Every finding on record at Plaza Healthcare Center

Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection prevention control program and practices designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. * The facility failed to maintain a separation of clean, newly washed residents' clothes and potentially contaminated items in the clean area of the laundry. * The facility failed to ensure resident specific urinals for Residents 95 and 151 were stored in a sanitary manner away from the resident's cups and water pitchers. * The facility failed to ensure the CNA 4 performed appropriate hand hygiene before getting the lunch tray from the cart to serve to the resident. * The facility failed to ensure the CNA 5 did not place a basin of moist wipes on top of the soiled linen/ trash bin in the hallway for her use to clean the residents assigned to her care. * The facility failed to ensure the staff followed the EBP by donning a gown while providing high-contact resident care activities to Resident 10. * The facility failed to ensure LVN 5 disinfected the call light after picking up from the floor and handed the call light to Resident 145. These failures put the residents at risk for infections and not control/prevent potential transmission of communicable diseases to other residents throughout the facility. Findings: 1. Review of the facility's P&P titled Laundry – Sorting, Washing and Drying dated 1/1/12, showed the facility uses proper and safe methods of handling linens in order to protect against the spread of infection. Review of the facility's P&P titled Laundry Services dated 1/1/12, showed the facility employs adequate staff to ensure linen is kept clean, in good repair, and in sufficient quantities to meet the needs of the residents and the laundry is maintained in a clean and sanitary condition. On 8/5/26 at 0857 hours, a laundry room inspection and concurrent interview was conducted with Laundry Staff 1. Laundry Staff 1 was observed folding clean, newly washed residents' clothes on top of a table. Several items including loose papers, a black cloth bag, a cloth bin, and a container of disinfecting wipes were observed on the right side of the table and were potentially contaminated. The clean, newly washed residents' clothes were observed touching these items while Laundry Staff 1 continued folding and organizing the garments. There was no barrier present to prevent the contact between the clean laundry and the surrounding items. Laundry Staff 1 was asked if it was okay to have the newly washed, clean residents' clothes touching the loose papers, a black cloth bag, a cloth bin, and a container of disinfecting wipes. Laundry Staff 1 responded it's okay, they are clean, and pointed at the papers and stated, that is my list of resident's names and rooms. On 8/5/26 at 0901 hours, an interview was conducted with the Maintenance Director. The Maintenance Director verified the clean, newly washed residents' clothes were observed touching the loose papers, a black cloth bag, a cloth bin, and a container of disinfecting wipes on the right side of the table in the laundry room. The Maintenance Director stated, those items should not be there, it should not touch the clean clothes. 2. Review of the facility's P&P titled Infection Prevention and Control Program Description dated 11/8/24, showed Implementation of Control Measures and Precautions includes: - basics such as hand hygiene, Standard and Transmission Based Precautions (including the use of personal protective equipment (PPE), cleaning/disinfecting equipment, and measures to protect persons (as listed above) from communicable diseases/infections; and - prevention of Infection which includes staff and resident and visitor education focusing on the risk of spreading or acquiring infection and practices to decrease that risk. Review of the facility's P&P titled Urinal and Bedpan – Offering and Removing dated 1/1/12, showed the residents who are unable to go to the bathroom are offered a bedpan or urinal and to store the bedpan or urinal after sanitizing. a. On 8/3/26 at 0801 hours, an initial tour of the facility was conducted in Resident 95's room. A urinal was observed on top of Resident 95's nightstand. The urinal was positioned on the left side of the Resident 95's nightstand, adjacent to a plastic cup and the water pitcher. The urinal was almost touching the plastic drinking straw inside the plastic cup. On 8/3/26 at 1214 hours, an observation and concurrent interview was conducted with LVN 3. LVN 3 verified the presence of a urinal on top of Resident 95's nightstand which was almost touching the plastic drinking straw inside the plastic cup, beside the water pitcher. LVN 3 stated the urinals should not be on top of the nightstand and should be placed on the side of the bed. Medical record review for Resident 95 was initiated on 8/4/26. Resident 95 was admitted on [DATE]. Review of Resident 95's H&P examination dated 7/22/26, showed Resident 95 was able to understand and make treatment decisions. Review of Resident 95's MDS dated [DATE], showed the following: - under section C for cognitive status: BIMS score was 13 (cognition is intact); and - under section GG for functional activities: toileting hygiene was coded as 01 - dependent, helper does all of the effort or the assistance of two or more helpers is required to complete the toileting activity, and toilet transfers was coded as 03 – partial/moderate assistance – helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half of the effort. b. On 8/3/26 at 0805 hours, a tour of the facility was conducted in Resident 151's room. A urinal was observed on the left side on top of Resident 151's nightstand. Resident 151's urinal was positioned beside an empty medication cup and an uncovered water pitcher. On 8/3/26 at 1214 hours, an observation and concurrent interview was conducted with LVN 3. LVN 3 verified the presence of a urinal on top of Resident 151's nightstand beside an empty medication cup and water pitcher. LVN 3 stated the urinals should not be on top of the nightstand, it should be on the side of the bed. Medical record review for Resident 151 was initiated on 8/4/26. Resident 151 was admitted on [DATE]. Review of Resident 151's H&P examination dated 7/28/26, showed Resident 151 was unable to understand and make treatment decisions due to psychosis. Review of Resident 151' MDS assessment dated [DATE], showed the following: -under section C for cognitive status: BIMS score of 9 (moderately impaired cognition). -under section GG for functional activities: toileting hygiene was coded as 03 - partial/ moderate assistance – helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half of the effort; toilet transfers was coded as 03 – partial/ moderate assistance – helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half of the effort. On 8/5/26 at 1456 hours, an interview with the ADON was conducted. The ADON acknowledged Resident 95's urinal was on top of Resident 95's nightstand almost touching the plastic drinking straw inside the plastic cup, beside the water pitcher and Resident 191's urinal on top of Resident 151's nightstand, positioned beside an empty medication cup and an uncovered water pitcher. The ADON stated the urinals should not be on the nightstand as it was not consistent with the facility's infection control standards. When asked where the urinals should be stored, the ADON responded it should be placed at the lower part of the side of the bed. On 8/6/26 at 1515 hours, an interview with the Administrator and DON was conducted. The Administrator and DON were informed and acknowledged the above findings for Residents 95 and 151. 3. On 8/3/26 at 1229 hours, during the dining observation, CNA 4 was observed removing a resident's lunch tray from the cart without performing hand hygiene. On 8/3/26 at 1230 hours, an interview was conducted with CNA 4. CNA 4 was informed of the above observation. CNA 4 acknowledged the observation and stated she did not to perform hand hygiene before getting the lunch tray from the cart to serve to the resident. On 8/6/26 at 1435 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 4. On 8/4/26 at 0441 hours, a basin of moist wipes was observed on top of the soiled linen/trash bin cart in the hallway. On 8/4/26 at 0446 hours, an interview was conducted with CNA 5. CNA 5 was informed of the above observation. CNA 5 acknowledged the observation and stated she would use the wipes to clean the residents under her care. CNA 5 further stated she placed the basin on top of the cart for her easy access to clean the residents. On 8/6/26 at 1432 hours, an interview was conducted with the DON. The DON was informed and acknowledged findings as above. 5. Review of the facility's P&P titled Enhanced Barrier Precautions (EBP) revised on 10/15/24, showed the following: - for residents for whom EBP are indicated, EBP employed when performing the following high-contact resident care activities for those at risk of transmission or acquisition of Multidrug-resistant organism (MDROs) includes dressing, bathing/showering, transferring within the resident room, providing hygiene, changing linens, changing briefs or assisting with toileting, devices care or use like central line, urinary catheter, or feeding tube, and wound care; - make PPE, including gown and gloves available outside of the resident room. Gowns and gloves are to be donned before each high contact task, not prior to entering the room. Medical record review for Resident 10 was initiated on 8/3/26. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 10's H&P examination dated 3/30/26, showed Resident 10 had no capacity to understand and make decisions. Review of Resident 10's Order Summary Report dated 8/5/26, showed physician's order dated 7/12/26, for EBP due to chronic right breast wound every shift. On 8/3/26 at 1016 hours, during the initial tour, Resident 10 was observed lying in bed and CNA 3 was providing the morning care. CNA 3 was observed with gloves on while changing Resident 10's briefs; however, CNA 3 was not wearing a gown. CNA 3 acknowledged the findings. On 8/3/26 at 1022 hours, an observation and concurrent interview was conducted with CNA 3. An EBP sign was observed outside Resident 10's room and a red sticker next to her name. CNA 3 stated Resident 10 was on EBP since she had a wound on her right breast. In addition, CNA 3 stated she must wear gloves and gown when providing high contact activities like changing linens and incontinence care. On 8/3/26 at 1031 hours, an interview was conducted with LVN 5. LVN 5 verified Resident 10 was on EBP for right breast wound. LVN 5 stated the nursing staff must wear gloves and gowns when providing high contact activities, which included providing the morning care, changing briefs, and wound care. 6. Review of the facility's P&P titled Cleaning and Disinfection of Resident Care Equipment revised on 1/1/12, showed the following: - resident-care equipment, including reusable items and durable medical equipment, is cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogen standard; - reusable items are cleaned and disinfected or sterilized between residents; and - reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturers' instructions. Medical record review for Resident 145 was initiated on 8/3/26. Resident 145 was admitted to the facility on [DATE]. Review of Resident 145's H&P examination dated 7/22/26, showed Resident 145 had no capacity to understand and make decisions. Review of Resident 145's MDS assessment dated [DATE], showed Resident 145's BIMS score was 14, indicating intact cognition. On 8/3/26 at 1258 hours, an observation and concurrent interview was conducted with LVN 5. Resident 145's call light was observed on the floor. LVN 5 was informed of Resident 145's call light. LVN 5 was observed picking up the call light from the floor with bare hand and handed the call light to Resident 145 without disinfecting the call light. LVN 5 verified the above findings. LVN 5 stated anything on the floor was dirty and she must have disinfect the call light prior to giving the call light to Resident 145. On 8/5/26 at 1126 hours, an interview was conducted with the ADON. The ADON stated anything dropped on the floor was considered dirty. In addition, the ADON stated if the item or device was reusable like the call lights and bed controls then the staff must disinfect the device first prior to giving the device for the residents use. The ADON stated the negative impact of not disinfecting reusable devices was the spread of infection. On 8/6/26 at 1427 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview and facility document review, the facility failed to ensure the Facility Assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) were complete. * The facility failed to ensure the Facility Assessment included the active involvement of the required individuals in developing the facility assessment and the resources necessary to care for the residents including weekends and contingency plan for staffing needs. These failures placed the residents at risk for unmet care needs if the assessed population's needs and resources were not comprehensively identified and addressed.Findings: Review of Facility Assessment (FA) dated 5/21/26, failed to show the direct care staff, direct care representatives, residents, residents' representatives, and family members were actively involved in developing the FA, resources necessary to care for residents including weekends, or include a contingency plan for staffing needs. On 8/9/26 at 1012 hours, an interview was conducted with the Administrator. The Administrator verified and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed. * Food preparation equipment and utensils were not clean or in good working condition. * Meal preparation equipment were not air dried. * One of 14 kitchen employees wore jewelry and had long fingernails during the food preparation. * One of 14 kitchen employees did not perform handwashing after picking up a paper towel from the floor. These failures posed the risk for food-borne illnesses in highly susceptible resident population of 134 facility residents who received food prepared in the kitchen.Findings: Review of the facility's matrix showed 134 of 140 residents consumed food prepared in the kitchen. 1. Review of the facility's P&P titled Food Storage and Handling revised on 2/29/24, showed the following:- label and date all food items;- label and date all storage products; and- rotate stock. According to the USDA Food Code 2022 Section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles shall be:B) Clean equipment and utensils shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. On 8/3/26 at 0807 hours, during the initial tour of the kitchen with Dietary Aide 1 and LVN 4, the following was observed and verified by Dietary Aide 1 and LVN 4:- one food slicer was not clean;- one serving spoon had melted handle;- two plate covers were not clean;- one washed plate was not clean;- one mixer with orange cloth inside was not clean and had rusted parts;- two cutting boards were heavily marred;- one container of nutmeg expired on 6/21/26; and- one box of cream cheese expired on 6/30/26. On 8/6/26 at 1427 hours, an interview was conducted with the Administrator, Dietary Manager, and DON. The Administrator, Dietary Manager, and DON were informed and acknowledged the above findings. 2. According to FDA Food Code 2022 Section 4-901.11 Equipment and Utensils, Air-drying required after cleaning and sanitizing shall be:(A) Shall be air-dried or used after adequate draining before contact with food. On 8/3/26 at 0807 hours, during the initial tour of the kitchen, an observation and concurrent interview was conducted with Dietary Aide 1 and LVN 4. Two clean blenders were observed red wet with the lid on. Dietary Aide 1 and LVN 1 verified the inside of the blender was not air-dried. Dietary Aide 1 stated it must be air-dried after it was washed. 3. Review of the facility's P&P titled Dietary Department Infection Control for Dietary Employees effective on 3/25/26, showed the following:- rings, bracelets, and watches are not permitted to be worn while working in the food service area or while preparing food with only exception is a plain band ring such as a wedding band. On 8/4/26 at 0851 hours, an observation and concurrent interview was conducted with Dietary Aide 2 and the Dietary Manager. Dietary Aide 2 was observed with long fingernails and wearing a brown metal bracelet. The Dietary Manager verified the above findings. The Dietary Manager stated the kitchen employees must have short and clean fingernails and no jewelries on hands and wrists except for a plain band ring. 4. Review of the facility's P&P titled Dietary Department Infection Control for Dietary Employees effective on 3/25/26, showed the following:- proper hand hygiene upon entering the kitchen;- before initially donning gloves for working with food; and- after engaging in any other activities that contaminate the hands. On 8/4/26 at 1120 hours, an observation and concurrent interview was conducted with Dietary Aide 3 and the Dietary Manager. Dietary Aide 3 was observed picking up a paper towel on the floor with bare hands, threw it in the trash, then held the fridge door handle and touched the brown cart. Dietary Aide 3 acknowledged the above findings. Dietary Aide 3 stated anything the floor was dirty and must wash hands after picking up anything from the floor. The Dietary Manager stated the negative impact was the risk of contamination of fridge door and food cart handles. The Dietary Manager stated all staff must wash their hands if they were soiled and especially after picking up anything from the floor. On 8/6/26 at 1427 hours, an interview was conducted with the Administrator, Dietary Manager, and DON. The Administrator, Dietary Manager, and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care was provided to prevent the development of pressure injuries for one of three final sampled residents (Resident 125) reviewed for pressure injury. * The facility failed to ensure Resident 125's LAL mattress was placed on the setting as prescribed by the physician. This failure had the potential for not providing the necessary care and services and effectively managing the resident's pressure injury.Findings: Review of the facility's P&P titled Pressure Injury Prevention revised 6/27/24, showed implement interventions identified in the plan of care which may include, but are not limited to pressure redistributing devices for bed and chair. Medical record review for Resident 125 was initiated on 8/3/26. Resident 125 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 125's MDS assessment dated [DATE], showed Resident 125 had severe cognitive impairment. Review of Resident 125's Order Summary dated 8/6/26, showed a physician's order dated 4/13/26, for LAL mattress for wound management to set on static mode when doing ADL and alternate mode when not doing ADL, and set at 1 bar below 200. Review of Resident 125's Care Plan Report dated 4/13/26, to address Resident 125's open ulcer on the left buttock from abscess formation. The interventions included to provide LAL mattress for wound management to set on static mode when doing ADL and alternate mode when not doing ADL and set at 1 bar below 200. On 8/5/26 at 0935 hours, an observation was conducted with Resident 125. Resident 125 was observed lying in bed with a LAL mattress. Resident's LAL mattress was observed on static mode and ADL care was not being provided to the resident. On 8/5/26 at 1008 hours, a follow up observation for Resident 125 and concurrent interview was conducted with LVN 7. LVN 7 verified Resident 125's LAL was set at the static mode. LVN 7 stated the LAL mattress should be in alternate mode setting when the ADL care was not being provided to the resident. On 8/6/26 at 1310 hours, an interview was conducted with the DON. The DON was informed and acknowledged the findings as above.

Based on observation, interview, medical record review, and P&P review, the facility failed to provide the necessary care and services related to the GT enteral feeding for one of two final sampled residents (Resident 2) reviewed for tube feedings.* The facility failed to ensure Resident 2 was provided with the GT enteral feeding formula as ordered by the physician. This failure had the potential for the resident's needs not met and place the resident at risk for weight loss.Findings: Review of the facility's P&P titled Enteral Feedings revised on 8/24/23, showed review order for the enteral feeding. Administer the enteral feeding formula per physician order. Medical record review for Resident 2 was initiated on 8/3/26. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2 had moderate cognitive impairment. Review of Resident 2's Order Summary dated 8/6/26, showed the physician's order dated 7/16/26, for the following:- enteral feed order to provide continuous water flush of 60 ml/hr for 10 hours to provide 600 ml of water, to start at 2000 hours and off at 0600 hours or until dose is complete; and- enteral feed order to provide Jevity 1.5 (enteral feeding formula) at 80 ml/hr for 10 hours to provide 800 ml, to start at 2000 hours and off at 0600 hours or until dose is met. On 8/3/26 at 0840 hours, during initial tour, Resident 2 was observed in the room lying in bed and the enteral feeding pump was off at bedside. On 8/5/26 at 0942 hours, an observation was conducted with Resident 2. Resident 2 was observed in the room lying in bed and the enteral feeding pump was off at bedside. On 8/5/26 at 0949 hours, a follow up observation of Resident 2 and concurrent interview was conducted with RN 1. Resident 2 was observed in the room lying in bed and the enteral feeding pump was off at bedside. When asked about Resident 2's GT feeding, RN 1 verified the enteral feeding pump was off; however, the enteral feeding pump showed the feeding was incomplete with 153 ml feeding left. On 8/5/26 at 0952 hours, an interview and concurrent record review was conducted with LVN 8. LVN 8 stated she turned off Resident 2's enteral feeding pump because it was ordered for 10 hours. LVN 8 verified Resident 2's physician's order for the enteral feeding and stated she did not wait for the enteral pump to complete the set dose. LVN 8 further stated she did not check if the prescribed volume was completed.

Based on interview, medical record review and facility P&P review, the facility failed to provide the necessary pain management care and services for one of 28 final sampled residents (Resident 40) reviewed for pain management. * The facility failed to administer the correct pain medication as per the physician's order for Resident 40's level of pain. This failure posed the risk for the Resident 40 not to receive the appropriate and necessary interventions to manage the residents' pain.Findings: Review of the facility's P&P titled Pain Management revised 5/25/23, showed the licensed nurse will the administer pain medication as ordered and document medication administered on the Medication Administration Record (MAR). The Licensed Nurse will assess the resident for pain and document results on the MAR each shift. Medical record review for Resident 40 was initiated on 8/3/26. Resident 40 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 40's MDS quarterly assessment dated [DATE], showed Resident 40's BIMS Summary Score was 15, indicating intact cognition. Review of Resident 40's Order Summary Report dated 8/5/26, showed the following physician's orders:- dated 10/15/25, to administer ibuprofen (pain medication) 400 mg, to give one tablet by mouth every six hours as needed for mild pain level of 1-4 (using the 0-10 pain scale, 0=no pain and 10=worst pain);- dated 10/23/25, to administer ibuprofen 600 mg, give one tablet by mouth every six hours as needed for moderate pain level of 5-7; and- dated 10/23/25, to administer tramadol (pain medication) 25 mg, give one tablet by mouth every eight hours as needed for severe pain level of 8-10. Review of Resident 40's MAR for June 2026 showed the resident was administered the following pain medications:- ibuprofen 600 mg for a pain level of 9 on 6/13/26 at 2350 hours; and- ibuprofen 400 mg for a pain level of 5 on 6/30/26 at 0900 hours. On 8/5/26 at 0844 hours, an interview and concurrent medical record review for Resident 40 was conducted with RN 1. RN 1 stated for the residents who reported pain, the licensed nurse would assess the resident's pain level prior to the administration of the pain medications. RN 1 further stated the pain medication would be administered as per the physician's order and within the parameters ordered. RN 1 verified Resident 40 was not given the correct pain medications according to the resident's reported pain level. On 8/6/26 at 1106 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of eight residents (Resident 96) observed for medication administration was free from the significant medication errors. * The facility failed to ensure Resident 96's divalproex sodium (medication to treat seizure disorder) DR (delayed release) medication was not crushed and administered to Resident 96. This failure had the potential to negatively impact on Resident 96's health outcomes.Findings: Review of the facility's P&P titled Medication Administration dated 10/2017 showed medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medication do so only after they have familiarized themselves with the medication. The facility has sufficient staff to allow administering of medications without unnecessary interruptions. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines.a. Long-acting or enteric coated dosages forms should generally not be crushed; an alternative should be sough. On 8/4/26 at 0919 hours, a medication administration observation for Resident 96 was conducted with LVN 1. LVN 1 prepared the following medications for Resident 96:- divalproex sodium DR 250 mg one tablet; - metoprolol tartrate (medication to treat high blood pressure) 25 mg one tablet, hold if the systolic blood pressure below 110 mmHg or pulse rate was less than 60 beats per minute;- multi-vitamins with minerals (supplement) one tablet;- deep sea nasal spray (nasal congestion) 0.65% one spray in the left and right nostril; and- fluticasone (for nasal congestion) 50 mcg nasal spray one spray in the left and right nostril. On 8/4/26 at 0927 hours, LVN 1 was observed crushing the tablet medication and mixing the medications in apple sauce. Resident 96 was observed taking the medication with apple sauce. Medical record review for Resident 96 was initiated on 8/3/26. Resident 96 was admitted to the facility on [DATE]. Review of Resident 96's H&P examination dated 7/10/26, showed Resident 96 had a medical history of seizure disorder. Review of Resident 96's MAR for July 2026 showed a physician's order dated 7/8/26, to administer divalproex sodium delayed release 250 mg, one tablet by mouth twice a day for seizure disorder. On 8/4/26 at 1421 hours, an interview was conducted with LVN 1. LVN 1 acknowledged Resident 96's divalproex sodium delayed release medication was crushed. 0n 8/5/26 at 1355 hours, a telephone interview was conducted with the Pharmacist. The Pharmacist was asked divalproex DR (delayed release) can be crushed. The Pharmacist stated DR in the medication meant delaying the release of medication and crushing the pills releases all the medicine at once which can severely upset your stomach and raise risk of bad side effect of the medication. The Pharmacist further stated there will be loss of effectiveness of the medication, damaging the tablet would ruin the delivery of the medication your body needs to control seizure disorder. On 8/6/26 at 1106 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner for two of 140 residents (Residents 110 and 150) in the facility. * Two containers of the wound cleanser spray were observed on top of the nightstand at Resident 150's bedside. * The facility failed to ensure one medication cup of triamcinolone (antifungal) cream was not left on Resident 110's bedside table unattended. These failures posed the risk of unsafe practices and unauthorized access to the medications. Findings: Review of the facility's P&P titled Medication Storage in the Facility dated January 2025 showed the medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier, The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. 1. On 8/3/26 at 840 hours, during the initial tour of the facility, two containers of wound cleanser spray were observed on top of the nightstand at Resident 150's bedside. Resident 150 stated I don't use them. On 8/3/26 at 1216 hours, an interview was conducted with LVN 3. LVN 3 acknowledged the presence of two containers of wound cleanser spray observed on top of the nightstand at Resident 150's bedside. LVN 3 stated No medications should be at bedside, I don't know who placed that there, maybe the treatment nurse. On 8/3/26 at 1600 hours, an interview was conducted with LVN 4. LVN 4 acknowledged two containers of wound cleanser spray was observed on top of the nightstand at Resident 150's bedside. LVN 4 stated We don't use those cleansers, we only use normal saline, it might be from the hospice patient. LVN 4 further stated Oh, I don't know; I know the resident does not have a wound. When asked why Resident 150 had the wound cleansers on his nightstand, LVN stated There should be no wound cleansers or any other medications at bedside. Medical Record review for Resident 150 was initiated on 8/4/26. Resident 150 was admitted on [DATE]. Review of Resident 150's H&P examination dated 7/13/26, showed Resident 150 was unable to understand and make treatment decisions due to dementia. Review of Resident 150's Self- Administration of Medication dated 7/27/26 showed Resident 150 was not capable of self-administration of medication. Review of Resident 150's Skin Check dated 7/30/26, showed Resident 150 did not have skin issues. Review of Resident 150's Order Summary Report for the month of August 2026 did not show wound care orders. On 8/6/26 at 1515 hours, an interview was conducted with the Administrator and DON. The Administrator and DON acknowledged the above findings. 2. Medical record review for Resident 110 was initiated on 8/3/26. Resident 110 was admitted to the facility on [DATE], and readmitted on [DATE]. On 8/3/26 at 0809 hours, during the initial tour of the facility, Resident 110 was observed sitting in bed. One medication cup which contained white cream was observed on top of the bedside table. When Resident 110 was asked, Resident 110 stated the nurse left the cup of medication on top of the bedside table and did not explain what the medication was for. Review of Resident 110' H&P examination dated 6/16/26, showed Resident 110 had no capacity to understand and make decisions. Review of Resident 110's Self-Administration of Medication assessment dated [DATE], showed Resident 110 was not capable of self-administration of medications. Review of Resident 110's Order Summary Report dated 8/5/26, showed the following physician's orders: - dated 7/17/26, to apply 0.1% triamcinolone acetonide cream to general body everyday shift for scattered rash; and - dated 7/17/26, to apply 0.1% triamcinolone acetonide cream to general body as needed for scattered rash. Further review of Resident 110's Order Summary Report failed to show a physician's order to self-administer triamcinolone cream, nor to keep the triamcinolone cream at the bedside. On 8/3/26 at 0817 hours, an observation, interview and concurrent medical record review for Resident 110 was conducted with LVN 1. LVN 1 verified the medication cup which contained white cream was triamcinolone cream and it was used for Resident 110's rash. LVN 1 verified Resident 110 was not capable to self-administer medication. LVN 1 further stated leaving medication at the bedside had the potential for other staff, visitors, or residents to access prescription medication at any time. On 8/6/26 at 1106 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure one of 14 dietary aides (Dietary Aide 4) had the skills and abilities to effectively provide sanitary utensils and equipment used for meal preparation in accordance with standards of practice. * The facility failed to ensure Dietary Aide 4 was competent in operating the dishwasher. This failure had the potential to jeopardize the health and well-being of the 134 residents who received food prepared in the kitchen.Findings: Review of the facility's matrix showed 134 residents consumed food prepared in the kitchen. Review of the facility's P&P titled Dietary Department Operational Manual revised on 6/10/14, showed the following:- the primary objectives of the dietary department include maintenance of standards for sanitation and safety; and- the Dietary Manager is responsible for the oversight of the dietary department Review of the facility's P&P titled Dish Machine Temperature Recording revised on 10/1/14, showed the following:- allow the dish machine to run through several cycles in order to bring the water temperature to the proper level by sending several empty racks through the machine;- read temperature gauges on the machine while the racks are in the machine;- washing temperature for low temperature dish machine must be 120-150 degrees Fahrenheit;- rinse temperature for low temperature dish machine must be 120-150 degrees Fahrenheit; and- any temperatures that are below required levels, outlines in the chart above must be brought to the attention of the Dietary Manager promptly. Review of Dietary Aide 4's job description dated 8/24/23, showed the following:- the Dietary Aide is responsible for assisting with food preparation, tray service, and sanitation. This role helps ensure residents receive safe, nutritious, and appealing meals in accordance with planned menus, standardized recipes, physician ordered therapeutic diets, and resident preference; and- maintains a safe and sanitary work environment by following infection control, food safety, and sanitation procedures. On 8/4/26 at 0857 hours, an observation and concurrent interview was conducted with Dietary Aide 4 and the Dietary Manager. Dietary Aide 4 was requested for dishwashing observation and he agreed. Dietary Aide 4 was observed turning on the dishwasher, placed the dirty dishes and covers in the dishwasher, then removed the dishes approximately after a minute. Dietary Aide 4 was asked how to check for the temperature and Dietary Aide 4 kept pointing at the dishwashing machine sticker label which showed minimum temperature for wash and rinse must be at 120 degrees Fahrenheit. Dietary Aide 4 failed to show the temperature gauge of the dishwasher. The Dietary Manager showed the temperature gauge to Dietary Aide 4 which he did not check. Dietary Aide 4 was asked to check the temperature gauge and he stated the temperature was 110 degrees Fahrenheit. The Dietary Manager stated Dietary Aide 4 must check the dishwasher's temperature gauge to make sure it was at 120 Fahrenheit prior to washing and rinsing to sanitize the dishes. The Dietary Manager further stated Dietary Aide 4 should make sure to follow the dishwasher's instructions and recommendations. The Dietary Manager acknowledged the above findings. On 8/6/26 at 1427 hours, an interview was conducted with the Administrator, Dietary Manager, and DON. The Administrator, Dietary Manager, and DON were informed and acknowledged the above findings.

Based on interview, medical record, and facility P&P review, the facility failed to ensure the person-centered care plan was developed for one of 28 final sampled residents (Resident 69). * The facility failed to ensure Resident 69's activity care plan included measurable goal and timeframes, and resident specific interventions. This failure had the potential for the resident's need not being met and negatively affect the residents' quality of life.Findings: Review of the facility's P&P titled Activities Program dated 5/22/25, showed the facility provides an Activity Program designed to meet the needs, interests, and preferences of each resident. The facility will be staffed and equipped to encourage the participation of each resident, to fully stimulate and support physical and mental capabilities, and to enable the resident to maintain the highest attainable social, physical and emotional functioning. Review of the facility's P&P titled Comprehensive Person- Centered Care Planning dated 5/22/25, showed the facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Review of the facility's MDS Coordinator Job Description (undated) showed the MDS Coordinator is responsible for coordinating and overseeing the completion of the MDS assessments and related care planning in accordance with federal and state regulations (including CMS and Title 22) to ensure accurate reimbursement, regulatory compliance, and optimal quality of care for residents. General duties and responsibilities include participating in care plan meetings, work closely with the interdisciplinary team on the development of individualized care plans, update individualized care plans based on MDS data and resident needs, and to ensure care plans reflect changes in resident condition, treatment goals, and preferences On 8/3/26 at 941 hours, an observation of Resident 69 and concurrent interview was conducted with CNA 2 assigned to Resident 69's 1:1 monitoring. Resident 69 was asleep in bed. CNA 2 stated Resident 69 would sleep on and off during the day. When asked if Resident 69 would go to activities, CNA 2 stated no, and have not seen the activities staff coming in to visit. Medical Record review for Resident 69 was initiated on 8/4/26. Resident 69 was admitted on [DATE]. Review of Resident 69's H&P examination dated 7/10/26, showed Resident 69's judgment and insight were impaired. Review of Resident 69's MDS assessment dated [DATE], showed Resident 69's BIMS score was 11 (moderate to mild cognitive impairment). Review of Resident 69's plan of care showed a focus care plan initiated on 6/4/23, to address Resident 69's impaired social interaction. The care plan goal included for Resident 69 to participate in social situations. The interventions initiated on 3/3/23, included the following: - consult facility activities coordinator;- determine underlying cause of self-esteem;- encourage the resident to be involved in self-care;- evaluate effect;- evaluate resident's ability to perform ADLs;- monitor for presence of negative thoughts;- monitor interactions with others;- monitor level of eye contact;- monitor speech; and- provide positive enforcement when resident participates in activities. Further review of the care plan did not show a measurable goal and timeframes and resident specific interventions. In addition, the care plan was not revised since 2023. On 8/4/26 at 1157 hours, an interview and concurrent record review was conducted with the Activity Director. The Activity Director stated Resident 69 would get out of her room to attend activities and the activity staff would do room visits. On 8/4/26 at 1235 hours, an interview and concurrent record review was conducted with the Activity Program Director. The Activity Program Director stated Resident 69 recently had not been getting out of the bed to participate in group activities and reported room visits were being provided and documented in Resident 69's notes. The Activity Program Director further stated Resident 69 liked to attend Catholic services, watch TV, and always came for nail spa. The Activity Program Director verified there was no activity care plan developed specific to Resident 69's needs and preferences. The Activity Program Director further stated he does not handle the care plans but would do the actual day to day activities. On 8/5/26 at 740 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator acknowledged the Resident 69's activity care plan did not have measurable goal, no time frame and resident-centered interventions. The MDS Coordinator stated the care plans were reviewed and revised during the care plan meetings. The MDS Coordinator verified Resident 69's activity care plan was not revised. On 8/6/26 at 1515 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and P&P review, the facility failed to provide the necessary care and services for one of 28 final sampled residents (Resident 24) reviewed for ADL care. * The facility failed to ensure nail care was provided to Resident 24. Resident 24 was observed to have long fingernails with black debris under the fingernails. This failure had the potential for the resident's need not met and for the resident to experience physical discomfort.Findings: Review of the facility's P&P titled Grooming care of the Fingernails and Toenails revised on 10/21/21, showed fingernails are trimmed by CNAs except for the residents with diabetes or circulatory impairments and this includes all toenails except high-risk residents. Review of the facility's P&P titled Activities of Daily Living effective on 6/9/26, showed the facility ensures that each resident receives appropriate assistance with ADLs to maintain or improve their highest practicable level of function while promoting dignity, independence, and safety. Medical record review for Resident 24 was initiated on 8/4/26. Resident 24 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 24's H&P examination dated 2/19/26, showed Resident 24 had fluctuating capacity to understand and make decisions. Review of Resident 24's MDS assessment dated [DATE], showed Resident 24's Self-care showed Resident 24 was dependent on the staff for personal hygiene. On 8/4/26 at 1053 hours, an observation and concurrent interview was conducted with Resident 24. Resident 24 was observed lying in bed awake, oriented to name and able to make needs known. Resident 24 stated to check his fingernails. Resident 24 was observed with long fingernails with black debris under the fingernails. On 8/4/26 at 1100 hours, an observation and concurrent interview was conducted with the Administrator and DSD. Resident 24 was observed with long fingernails and black debris under the fingernails. The DSD verified the above findings. The DSD stated the CNAs must check the residents' nails daily. If the fingernails were long and dirty, then the CNAs must check with the charge nurse if the residents did not have diabetes. In addition, if the residents did not have diabetes, the CNAs must provide nail care which includes cleaning and trimming of the fingernails and then document the provided care. The DSD stated the long and dirty fingernails were risk for infection and injury by scratching. On 8/6/26 at 1427 hours, an interview was conducted with the Administrator, Dietary Manager, and DON. The Administrator, Dietary Manager, and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurately documented for three of 28 final sampled residents (Residents 6, 13, and 27). * The facility failed to ensure Resident 6's IV MAR was complete and/or accurate. * The facility failed to ensure Resident 13's blood pressure access site was accurately documented in the medical record. * The facility failed to maintain an accurate and organized medical records by continuously conducting ongoing monitoring and documentation of the potential side effects for Resident 27 related to a medication that had been discontinued six months prior. These failures have the potential to result in the residents' care needs not being met due to inaccurate medical information. Findings: Review of the facility's P&P titled Medical Records, Licensed Nursing Staff, and Attending Physician dated 12/28/22, showed other orders will include a clear and complete description to provide clarity on the physician's plan of care. Review of the facility's P&P titled Medical Records - Completion and Correction dated 3/25/26, showed the medical record entries will be recorded in a timely manner and will be complete, legible and accurate. Documentation will reflect medically relevant information concerning the Resident and will be documented in a professional manner. 1. Medical Record review for Resident 27 was initiated on 8/6/26. Resident 27 was admitted to the facility on [DATE]. Review of Resident 27's MDS assessment dated [DATE], showed Resident 27's mental status as rarely/never understood. Review of Resident 27's H&P examination dated 12/9/25, showed Resident 27 with a history of CVA with left side weakness and dementia among other diagnoses. Review of Resident 27's Order Summary Report dated 12/1 to 12/31/25, showed: - a physician's order dated 12/5 and was discontinued 12/19/25, for temazepam (medication generally used to treat severe insomnia) oral capsule 15 mg (Temazepam) one capsule by mouth at bedtime for insomnia manifested by inability to sleep for 14 days; and - a physician's order dated 12/4/26, to monitor for the side effects of the hypnotic/sedative medication due to the use of the temazepam medication every shift- syncope, dizziness, confusion, nightmares, daytime anxiety, hallucinations, mania, fatigue, headache, and sedation. Review of Resident 27's Order Summary Report dated 1/1 - 1/31/25, showed a physician's order dated 12/4/25, to monitor for side effects of hypnotic/sedative medication due to use of temazepam every shift- syncope, dizziness, confusion, nightmares, daytime anxiety, hallucinations, mania, fatigue, headache, and sedation. Resident 27's Order Summary Report for January 2026 did not show an order for the temazepammedication. Review of Resident 27's Order Summary Report for active physicians' orders as of 8/6/26, showed a physician's order dated 12/4/25, to monitor for the side effects of the hypnotic/sedative medication due to use of the temazepam medication every shift, to include observation for syncope, dizziness, confusion, nightmares, daytime anxiety, hallucinations, mania, fatigue, headache, and sedation. The active physician's orders for Resident 27 did not show an order for the temazepam medication. Review of Resident 27's MARs for January, February, March, April, May, June, July, and August 2026 showed to monitor for the side effects of the hypnotic/sedative medication due to use of the temazepam medication every shift including syncope, dizziness, confusion, nightmares, daytime anxiety, hallucinations, mania, fatigue, headache, and sedation, scheduled to be monitored during the day and evening shifts. Resident 27's MARs for January, February, March, April, May, June, July, and August 2026 showed documentation that the monitoring was done with affixed initials of nurses and results of the monitoring - responses were all N for no, and the side effects for the temazepam medication were not observed. Review of Resident 27's MARs for January through August 2026 showed the resident was monitored during the day and evening shifts for potential adverse effects of the temazepam medication, including syncope, dizziness, confusion, nightmares, daytime anxiety, hallucinations, mania, fatigue, headache, and sedation. However, the temazepam medication had been discontinued on 12/19/25. On 8/6/26 at 1108 hours, an interview with concurrent medical record review for Resident 27 was conducted with LVN 6. LVN 6 stated he participated in reviewing the resident's orders along with the nurses, physicians, and MDS staff. LVN 6 further stated the monitoring for the temazepam medication side effects should also have been discontinued when the temazepam medication was discontinued. LVN 6 added, the nurses monitoring and documenting needed to be a little bit more aware of what they were monitoring and documenting, and call the physician to discontinue the order if needed; and need to make sure the active orders were reviewed during care plan meetings and update the changes that needed to be made. On 8/6/26 at 1614 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 stated, The temazepam monitoring should have been discontinued when the temazepam order was completed. RN 2 further stated The nurses have to look what they are signing for to check on discrepancies, the nurses are just signing it off without reading. 2. On 8/3/26 at 0900 hours, during the initial tour of the facility, Resident 6 was observed with PICC (Peripherally Inserted Central Catheter, is a long, flexible tube inserted into a large vein in the upper arm and threaded to a major vein near the heart) line catheter inserted on her right upper arm with a dressing dated 8/2/26. Medical record review for Resident 6 was initiated on 8/3/26. Resident 6 was admitted to the facility on [DATE], and was readmitted [DATE]. Review of Resident 6's Order Summary Report showed the following physician's orders dated: - 6/23/26, to flush lumen with 5 cc normal saline before and after medication administration - 7/10/26, to flush lumen with 5 cc normal saline before and after medication administration - 7/10/26, to flush PICC line lumen with 5 cc NS (normal saline) every shift until 9/1/26 - 7/10/26, to administer daptomycin sodium chloride (an antibiotic medication) 500 mg every 24 hours IV Review of Resident 6's IV MAR for July 2026 showed blank and/or missing initials for the following orders: - on 6/23/26, to flush lumen with 5 cc normal saline before and after medication administration for 7/9/26 evening shift; - on 7/10/26, to flush lumen with 5 cc normal saline before and after medication administration for 7/10/26 day shift, 7/15/26 evening shift, and 7/22/26 evening shift; - on 7/10/26, to flush PICC line lumen with 5 cc NS every shift until 09/01/26 for 7/15/26 evening shift, and 7/22/26 evening shift; and - on 7/10/26, to administer daptomycin sodium chloride (an antibiotic medication) 500 mg every 24 hours IV on 7/10/26. On 8/6/26 at 0959 hours, a medical record review for Resident 6 and concurrent interview was conducted with RN 2. RN 2 stated the assigned RN must have forgotten to document on the IV MAR. On 8/6/26 at 1335 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Review of the facility's P&P titled Dialysis Management revised 1/25/24, showed the facility must ensure the residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. No blood pressure, phlebotomy, or other pressure inducing procedures on the arm with an AV shunt (Arteriovenous). Medical record review for Resident 13 was initiated on 8/3/26. Resident 13 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 13's H&P examination dated 1/13/26, showed the resident had mental capacity to make decisions. Review of Resident 13's Order Summary Report showed the following physician order dated 12/3/24, for no blood pressure taking, no blood draw to left upper extremity AV shunt. Review of Resident 13's documentation of blood pressure for July and August 2026 showed the following: - on 7/16/26 at 0940 hours, a blood pressure reading of 142/78 mmHg on the left arm; - on 7/17/26 at 0953 hours, a blood pressure reading of 140/90 mmHg on the left arm; - on 7/17/26 at 1157 hours, a blood pressure reading of 136/82 mmHg on the left arm; - on 7/22/26 at 1002 hours, a blood pressure reading of 144/88 mmHg on the left arm; - on 7/22/26 at 1213 hours, a blood pressure reading of 120/74 mmHg on the left arm; - on 7/23/26 at 0950 hours, a blood pressure reading of 126/80 mmHg on the left arm; - on 7/24/26 at 1155 hours, a blood pressure reading of 138/90 mmHg on the left arm; - on 7/24/26 at 1902 hours, a blood pressure reading of 136/82 mmHg on the left arm; - on 7/24/26 at 2329 hours, a blood pressure reading of 136/74 mmHg on the left arm; - on 7/29/26 at 0945 hours, a blood pressure reading of 140/88 mmHg on the left arm; - on 7/30/26 at 1000 hours, a blood pressure reading of 136/82 mmHg on the left arm; - on 7/31/26 at 0952 hours, a blood pressure reading of 140/88 mmHg on the left arm; and - on 8/5/26 at 0927 hours, a blood pressure reading of 140/90 mmHg on the left arm. On 8/5/26 at 1140 hours, Resident 13 was observed awake, lying in bed, with AV shunt noted on the left arm. Resident 8 stated he went to dialysis every Monday, Wednesday, and Friday. Resident 13 stated that he did not allow the licensed nurses to take his blood pressure on the left arm. On 8/5/26 at 1155 hours, an interview and concurrent medical record review for Resident 13 was conducted with RN 1. RN 1 verified the BPs were not taken on Resident 13's left arm and the documentation for the BP readings for July and August 2026 were inaccurate. RN 1 further stated taking the BP on the access site will increase the resident's risk for infection and blood clot to the left AV shunt. On 8/6/26 at 1106 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the antibiotic stewardship process was accurately implemented. * The facility failed to ensure the physician was notified of Resident 150 not meeting the McGeer's criteria for infection. In addition, Resident 150's prescribed antibiotic (medication to treat infection) was continued without appropriate reassessment. These failures posed a risk for inappropriate use of the antibiotics including unnecessary continuation of antibiotics and potential inappropriate treatment. Findings: Review of the facility's P&P titled Antibiotic Stewardship dated 5/20/21, showed the following:- the facility will implement an Antibiotic Stewardship Program to promote appropriate use of antibiotics optimizing the treatment of infection, reducing the threat of antibiotic resistance, reducing adverse events associated with antibiotic use and improve outcomes for residents; - the IP will collect and analyze infection surveillance data, coordinate data collection and monitor adherence to infection control policies and procedures; - antibiotic time-outs (ATO - is a review process for all antibiotics prescribed in the facility) will be utilized when appropriate. ATO's prompt clinicians to reassess the ongoing need for an antibiotic after culture results are available; and- the IP will provide results of tracking antibiotic use, outcomes and adverse effects to the clinical staff. On 8/5/26 at 913 hours, an interview and concurrent medical record review for Resident 150 and facility document review was conducted with the IP. The Antibiotic Stewardship Tracking Report for May, June, and July 2026 was reviewed with the IP. The May 2026 Antibiotic Stewardship Tracking Report showed Resident 150's identified infection of conjunctivitis. Review of Resident 150's Infection Screening Evaluation dated 5/27/26, showed the following:- a current, active diagnosis of infection- no pain- no symptoms of infection- no eye complaints - no pus from one or both eyes, no new or increased eye redness, no new, or increased eye pain- infection analysis if Loeb/ Mc Geer's Criteria was met was left blank. The IP verified Resident 150's physician was not notified of the infection not meeting the clinical criteria in the Infection Screening Evaluation dated 5/27/26, and stated the physician's order was based on the Optometry Consult done on 5/27/26. Medical record review for Resident 150 was initiated on 8/5/26. Resident 150 was admitted to the facility on [DATE]. Review of Resident 150's H&P examination dated 5/11/26, showed Resident 150 had fluctuating capacity to understand and make medical decisions. Review of Resident 150's Order Summary Report for May 2026 showed a physician's order dated 5/27/26, for erythromycin (antibiotic) ophthalmic (eye) ointment 5 mg/gm, instill 0.25 strip in both eyes four times a day for blepharoconjunctivitis (common inflammatory disorder involving both the eyelid margins and conjunctiva- thin mucous membrane that lines the inside of the eyelids and covers the sclera -the white of the eye) for seven days. Review of 150's Optometry Consult dated 5/27/26, showed unspecified blepharitis (inflammation of the eyelids) to left and right eyes, upper and lower eyelids; bilateral conjunctival hyperemia (red eyes affecting both eyes) with plan to begin erythromycin ointment 5 mg four times a day for one week and monitor as needed. Review of Resident 150's MARs for May and June 2026 showed erythromycin ophthalmic ointment 5 mg/gm instill 0.25 strip in both eyes four times a day for blepharoconjunctivitis for seven days was administered from 5/28/26, and was completed on 6/4/26. Review of Resident 150's Nursing Progress Note dated 5/28/26, showed Resident 150 has no eye redness, no pain, to continue antibiotic as ordered. On 8/5/26 at 1558 hours, an interview and concurrent medical record review for Resident 150 was conducted with the ADON. The ADON stated Resident 150's eye infection with erythromycin ophthalmic ointment ordered on 5/27/26, did not meet the McGeer's Criteria; specifically, there was no eye redness, drainage, or pain; and Resident 150's physician was not notified of Resident 150's infection not meeting the McGeer's Criteria; and the resident's eye treatment continued without reassessment. On 8/6/26 at 1515 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility document review, the facility failed to provide the necessary care and services to ensure two of 28 sampled residents (Residents 3 and 40) attained and maintained their highest practicable physical well-being. * The facility failed to ensure to administer Resident 3's midodrine hydrochloride (a medication used to treat symptomatic low blood pressure) as per the physician's order. This failure had the potential to negatively affect the resident's well-being. * The facility failed to ensure the insulin administration sites were rotated for Resident 40. This failure had the potential to result in ineffective treatment, altered medication effectiveness/absorption, and tissue damage. Findings: 1. Medical record review for Resident 3 was initiated on 8/3/26. Resident 3 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 3's MDS assessment dated [DATE] showed resident's cognitive function was intact. Review of Resident 3's Order Summary Report dated 8/6/26, showed a physician's order dated 6/25/26, for midodrine hydrochloride 25 mg give one tablet by mouth three times a day and hold if systolic blood pressure (SBP) is more than 120 mmHg. Review of Resident 3's MAR for June, July, and August 2026 showed the midodrine hydrochloride was checked and initialed by a licensed nurse on the following dates, times and blood pressure readings: - dated 6/3/26 at 1700 hours, blood pressure reading was 128/79 mmHg; - dated 6/4/26 at 0900 hours, blood pressure reading was 130/80 mmHg; - dated 7/5/26 at 0900 hours, blood pressure reading was 125/76 mmHg; - dated 7/5/26 at 1300 hours, blood pressure reading was 129/78 mmHg; - dated 7/5/26 at 1700 hours, blood pressure reading was 129/78 mmHg; and - dated 8/4/26 at 1300 hours, blood pressure reading was 121/77 mmHg. On 8/6/26 at 0949 hours, an interview and concurrent medical record review for Resident 3 was conducted with LVN 6. LVN 6 verified the above findings. LVN 6 stated the midodrine medication should not have been given to Resident 3 when the SBP reading was more than 120 mmHg. On 8/6/26 at 1328 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 40 was initiated on 8/3/26. Resident 40 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 40's MDS quarterly assessment dated [DATE], showed Resident 40's BIMS score was 15, indicating intact cognition. Review of Resident 40's Order Summary Report showed a physician's order dated 3/28/26, to administer Lantus Solostar (a long-acting insulin designed to manage blood sugar levels) 16 units subcutaneously at bedtime. Review of Resident 40's Location of Administration Report for June and July 2026 showed the Lantus Solostar was administered at the same injection site on the following dates: - dated 6/4/26, the insulin was administered to the right arm; - dated 6/5/26, the insulin was administered to the right arm; - dated 6/23/26, the insulin was administered to the left arm; - dated 6/24/26, the insulin was administered to the left arm; - dated 6/28/26, the insulin was administered to the left arm; - dated 6/29/26, the insulin was administered to the left arm; - dated 7/20/26, the insulin was administered to the left arm; and - dated 7/21/26, the insulin was administered to the left arm. On 8/5/26 at 0844 hours, an interview and concurrent medical record review for Resident 40 was conducted with RN 1. RN 1 stated prior to administering the insulin injection, the licensed nurse should check the MAR to see where was the last administration site. RN 1 further stated the insulin injection sites should be rotated to prevent complications of the skin from repeated injections to the same site. RN 1 reviewed Resident 40's MAR for June and July 2026 and verified the above findings when the insulin administration sites were not rotated. On 8/6/26 at 1106 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and P&P review, the facility failed to ensure the recommendations from the Preadmission Screening and Resident Review (PASRR) Level II determination was incorporated into the resident care for one of two final sampled resident (Resident 12) reviewed for PASRR. * The facility failed to incorporate the PASRR Level II recommendation into the assessment and care planning for Resident 12. This failure had the potential for Resident 12 to not receive adequate care recommended by the state-designated authority.Findings: Review of the facility's P&P titled Preadmission Screening Level II Resident Review revised 9/2017 showed the facility will coordinate the recommendation from the PASRR Level II determination and the PASRR evaluation report with the resident's assessment, care planning and transitions of care. The IDT will review the Level II evaluation report to develop a care plan and arrange the Specialized Services recommended for the resident. Specialized Services are add-on to the facility services- they are a higher intensity and frequency than the services provided by the facility. Medical record review for Resident 12 was initiated on 8/3/26. Resident 12 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 12's H&P examination dated 5/4/26, showed Resident 12 had no capacity to make decisions. Review of Resident 12's PASRR Notice of Individual Determination dated 3/12/26, showed a SMI (serious mental illness) Level II documentation on the applicant's medical and social history, which revealed a significant medical condition with mental stressors that would require nursing care. The following were the recommended specialized add-on services, services and supports that supplement nursing facility care to address mental health needs:- Activities of Daily Living (ADL) Training/Reinforcement Skill training and support to improve day to day activities such as dressing, bathing, feeding, toileting, and grooming;- Supportive Services Interactions with facility staff that encourage problem solving, socialization, reality orientation or focus on therapeutic goals;- Psychotherapy/Counseling Individual and/or group and/or family treatment provided by a licensed mental health professional. Therapy may include a combination of strategies and techniques such as supportive, cognitive behavioral, psychodynamic, art/music, counseling, skills training, and existential therapies, among others; - Psychiatry Consultation and/or Follow-up Care Services to provide psychopharmacological intervention and monitoring of mental conditions. These providers will evaluate the efficacy and necessity of psychiatric medications, review lab profiles, make adjustments as needed, and address side effects.- Safety Monitors Safety monitors for risk of falling and harm to others; and- Behavior Monitors Behavior Monitors for physical aggression and verbal aggression. Additional Functional/Medical Recommendations:- Pharmacy Consultation Services to review pharmacological issues, such as drug interactions and black box warnings.- Physical Therapy Consultation Services to enhance and restore functional ability and quality of life to those with physical impairments.- Occupational Therapy Consultation Services to improve independence in activities of daily living.- Dietary Consultation Services to manage weight and/or special nutritional needs. Alternative Community Placement Settings and Features:- Accessibility Accommodations Accessibility accommodations address physical, sight, hearing, and/or communication impairment and must be provided in any alternative placement. A facility should provide bed rails, shower bars, walker access and wheelchair access. However, review of Resident 12's plan of care dated 3/17/26, failed to show an individualized care plan incorporating the above PASRR Level II recommendations. On 8/5/26 at 0935 hours, an interview and concurrent medical record review for Resident 12 was conducted with the MDS Coordinator. The MDS Coordinator failed to show a personalized care plan based on the PASRR Level II recommendation from the DHCS Psychologist for Resident 12. On 8/6/26 at 1106 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, and facility's P&P review, the facility failed to provide a safe and functional environment for the residents, staff, and visitors. * The facility failed to ensure the exit door in the dining room remained unobstructed. This failure had the potential to delay or prevent the residents, staff, and visitors from safely exiting the building during an emergency.Findings: Review of the facility's P&P titled Exits dated 1/1/12, showed a purpose to ensure sufficient and accessible exits to all for rapid, safe, and orderly evacuation of the facility. Exits are to be cleared at all times, exit doors are never blocked, even briefly, the facility staff is responsible for ensuring exits are kept clear. If a facility staff member discovers a blocked exit, he or she will clear it, if possible, and will report the finding to his or her immediate supervisor. On 8/3/26 at 1232 hours, a dining room observation was conducted. A door with a lighted exit signage was observed. The door was leading to the front lobby. However, the door was observed blocked by a dining table and there were two residents seated in the wheelchairs, positioned at the table across from each other, eating lunch, and preventing clear access to the exit door. On 8/3/26 at 1235 hours, an interview was conducted with RNA 1. RNA 1 was asked where the staff would usually exit the dining room. RNA 1 pointed to the door towards the hallway. When asked if they would use the exit door, RNA 1 stated they could use the exit door; however, the exit door had an alarm. RNA 1 verified there was a dining table in front of the exit door towards the main lobby with two residents eating lunch. RNA 1 further stated he was not aware they could not block the exit door. On 8/3/26 at 1247 hours, an interview was conducted with LVN 4. LVN 4 was asked where the staff with the residents exit in case of emergency, LVN 4 pointed at the two side doors with no exit signs. LVN 4 verified there was a table in front of the exit door towards the main lobby with two residents eating lunch. LVN 4 stated, the exit door was not in use and was an easy access for the residents to get out of the door, towards outside the lobby. LVN 4 further stated she was not aware they could not block the exit door. On 8/3/26 at 1300 hours, an interview was conducted with the Maintenance Director. The Maintenance Director was made aware and acknowledged there was a dining table blocking the exit door towards the main lobby. The Maintenance Director stated one resident had escaped from the exit door in the dining room so they put the dining table in the front for safety. The Maintenance Director further stated was aware the exit doors should not be blocked. On 8/6/26 at 1515 hours, an interview with the Administrator and DON was conducted. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents were free from unnecessary psychotropic drugs for one of 28 final sampled residents (Resident 37) and two of five residents (Residents 11 and 125) reviewed for unnecessary medications. * The facility failed to ensure Resident 11's was evaluated monthly related to the use of the Depakote (a medication used to treat seizure and acute manic or mixed episodes linked to bipolar disorder) medication. * The facility failed to ensure Resident 37's monthly behavior summary was accurate according to the total numbers of behavior episodes for the use of olanzapine (antipsychotic) medication in MAR. * The facility failed to ensure Resident 125's monthly psychotherapeutic drug monitoring summary was recorded accurately related to the use of mirtazapine (antidepressant) medication. In addition, the facility failed to monitor Resident 125's orthostatic blood pressure as ordered by the physician related to the use of antipsychotic medication. These failures had the potential for the residents to experience adverse effects from the psychotropic medications due to not providing the correct data to the prescriber to adjust the dosage of the medications and negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Behavior/ Psychoactive Medication Management dated 1/30/26, showed when a resident is prescribed an antipsychotic medication(s), the resident's orthostatic blood pressure is monitored weekly. The Behavior Management/Psychoactive Review Committee will review the following and make recommendations based on resident's need: 1. The effectiveness of non-medication interventions; 2. Continued use of Psychoactive medication; and 3. Possible nonpharmacological alternative. 1. Medical record review for Resident 11 was initiated on 8/3/26. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's MDS assessment dated [DATE], showed the resident's cognitive function was moderately impaired. Review of Resident 11's Order Summary Report dated 8/6/26, showed the following physician's orders: - dated 6/23/26, to monitor the target behavior for use of the Depakote medication to stabilize mood as manifested by being calm to sudden irritability and to monitor for side effects of Depakote every shift; and - dated 6/30/26, to administer Depakote sprinkles 125 mg, give two capsules by mouth two times a day to stabilize mood as manifested by being calm to sudden irritability. Review of Resident 11's medical record failed to show the resident was evaluated monthly and had the psychotherapeutic summary completed related to the use of the Depakote medication. On 8/6/26 at 0917 hours, an interview and concurrent medical record review for Residents 11 was conducted with LVN 6. LVN 6 verified the above findings for Residents 11. LVN 6 stated Resident 11 should have the Psychotropic Summary Sheet form completed every month to evaluate Resident 11's use of the Depakote medication. On 8/6/25 at 1435 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 125 was initiated on 8/3/26. Resident 125 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 125's MDS assessment dated [DATE], showed Resident 125 had severe cognitive impairment. a. Review of Resident 125's Order Summary Report dated 8/6/26, showed the following physician's orders: - dated 2/16/26, to monitor for side effects related to the use of the mirtazapine medication every shift; - dated 2/17/26, to monitor target behaviors for use of the mirtazapine medication for depression as manifested by poor meal intake less than 50%. Indicate the number of behavior of occurrences; and - dated 6/23/26, to administer Remeron (mirtazapine) 7.5 mg by mouth at bedtime for depression manifested by poor meal intake less than 50%. Review of Resident 125's Psychotropic Summary Sheet Form for June 2026 for the Remeron 7.5 mg medication dated 7/5/26, showed the documentation of Resident 125's behavior episodes of depression as manifested by poor oral meal on the following shifts: - 0700 to 1900 hours (day shift) no episode of depression as manifested by poor oral meal; and -1900 to 0700 hours (evening shift), Resident 125 had two episodes of depression as manifested by poor oral meal. Review of Resident 125's MAR for June 2026 showed Resident 125's behavior monitoring for the use of the mirtazapine medication for depression as manifested by poor meal intake less than 50%. The MAR monitoring further showed Resident 125 had 15 episodes of poor meal intake less than 50% for June 2026. b. Review of Resident 125's Order Summary Report dated 8/6/26, showed a physician's order dated 2/16/26, to monitor the orthostatic blood pressure while lying and sitting weekly on Sundays during the morning shift for antipsychotic medication. Review of Resident's MAR for June 2026 failed to show the blood pressure readings while lying and sitting was completed on Sundays to monitor Resident 125's orthostatic blood pressure. Further review of Resident's medical record failed to show the blood pressure reading while lying and sitting was recorded every Sundays to monitor Resident 125's orthostatic blood pressure. On 8/6/26 at 0936 hours, an interview and concurrent medical record review for Residents 125 was conducted with LVN 6. LVN 6 verified the documented episodes of Resident 125's poor meal intake in Psychotropic Summary Sheet Form and MAR for June 2026 did match. LVN 6 stated Resident 125's orthostatic blood pressure should have been monitored as ordered by the physician. On 8/6/25 at 1315 hours, an interview was conducted with the DON. The DON was informed and acknowledged the findings as above. 3. Review of the facility's P&P titled Behavioral and Psychoactive Medication Management effective date 1/30/26, showed the following: - the IDT will reassess the effectiveness of the psychoactive medication at least quarterly during the IDT care plan meeting or psychoactive behavioral management committee; - any order for psychoactive medications must include a specific behavior manifestation; - the behavioral and psychoactive review committee will review the following and make recommendations based on resident's need such as the effectiveness of the non-medication interventions, continued use of psychoactive medication, and possible nonpharmacological alternatives. Medical record review for Resident 37 was initiated on 8/3/26. Resident 37 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 37's H&P examination dated 6/20/26, showed Resident 37 had no capacity to understand and make decisions. Review of Resident 37's MDS assessment dated [DATE], showed Resident 37's BIMS score was four, indicating severely impaired cognition Review of Resident 37's Order Summary Report dated 8/5/26, showed a physician's order dated 6/21/26, for olanzapine 10 mg oral tablet, give one tablet by mouth three times a day for schizophrenia as manifested by unprovoked verbal outbursts without reason. On 8/5/26 at 1447 hours, an interview and concurrent medical record review for Resident 37 was conducted with LVN 2. Reviewed of Resident 37's medical records showed the following: - Review of Resident 37's Psychotropic Summary Sheet for May 2026 showed zero behavioral episodes for unprovoked verbal outbursts without reason. However, review of Resident 37's MAR for May 2026 showed two behavior episodes of unprovoked verbal outbursts without reason on 5/16/26 during evening shift (1900-0700 hours); and - Reviewed of Resident 37's Psychotropic Summary Sheet for June 2026 showed six behavioral episodes of unprovoked verbal outbursts without reason. However, review of Resident 37's MAR for June 2026 showed zero behavior episodes of unprovoked verbal outbursts without reason. LVN 2 verified the above findings. LVN 2 stated the assigned licensed nurse must count episodes of behavior in the resident's MAR every month then the total will be documented in the Psychotropic Summary Sheet. LVN 2 verified the monthly numbers of episode of unprovoked verbal outbursts without reason in the summary sheet and MAR did not match. On 8/5/26 at 1518 hours, an interview and concurrent medical record review was conducted with the DON. The DON reviewed Resident 37's Psychotropic Summary Sheet and the MAR for May and June 2026. The DON verified the sum (total number) of the behavioral episodes documented on the Psychotropic Summary Sheet were inaccurate. The DON stated the Psychotropic Summary Sheet must be accurate; if not, it would affect the physician's orders and recommendations. On 8/6/26 at 1427 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the informed consent for the psychotropic medications and treatments were complete for one of 28 final sampled residents (Residents 3) reviewed for psychotropic/opioid medications side effects. * The facility failed to ensure Resident 3's informed consent for the clozapine (antipsychotic medication) medication included the behavioral manifestation related to the use of the medication as per the physician's order. This failure had the potential for Resident 3 to not be fully informed of the psychotropic medication use and the potential side effects of the medication. Findings: Review of the facility's P&P titled Informed Consent revised 1/30/26, showed the licensed nurse will confirm that the healthcare practitioner obtained informed consent and will document the verification in the Resident's medical record, before administering the first dose or first increased dose of psychoactive medications, applying physical restraints or medical devices. Documenting of the verification of informed consent may be done by contacting the resident or decision-maker (including Surrogate IDT) to verify that the healthcare practitioner obtained informed consent for the order. The licensed nurse will contact the healthcare practitioner to request the practitioner obtain the informed consent, if the licensed nurse is unable to verify that the healthcare practitioner obtained informed consent from the resident or decision-maker. The informed consent will be placed in the resident's medical record. Review of the AFL 25-38.1 titled Notice of Release of Psychotherapeutic Drug Informed Consent Form dated 2/3/26, showed the facilities may use the CDPH (California Department of Public Health) Psychotherapeutic Drug Informed Consent Form or use their own in-house form as long as the in-house form contains all the data elements on the CDPH form. The form must be in use by 1/1/26, for new residents, residents being prescribed a new psychotherapeutic drug, and residents having a psychotherapeutic drug dosage change. Review of the CDPH 9168 document titled Psychotherapeutic Drug Informed Consent Form dated 12/2025 showed to include the following psychotherapeutic drug information: drug category, drug name, dosage prescribed, frequency, duration, administration method, caution and warning summary, reason for use of the psychotherapeutic drug and benefits, the probable side effects and significant risks associated with the use of the psychotherapeutic drug, and the reasonable alternative mode(s) of treatment or possible non-pharmacological approaches that could address the resident's needs. Medical record review for Resident 3 was initiated on 8/3/26. Resident 3 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 3's Psychotherapeutic Drug Informed Consent Form dated 5/29/26, for the Clozaril medication under the Reason for Use of Psychotherapeutic Drug and Benefits section, showed the form did not include the behavior manifestation related to the use of Clozaril medication. Review of Resident 3's MDS assessment dated [DATE], showed resident's cognitive function was intact. Review of Resident 3's Order Summary Report dated 8/6/26 showed a physician's orders dated 6/25/26, to administer clozapine (Clozaril) 300 mg one tablet by mouth at bedtime for paranoid manifested by auditory hallucinations as evidenced by responding to internal stimuli. Review of Resident 3's MAR for June, July, and August 2026 showed Resident 3 was administered with the clozapine medication on the following dates and time:- 6/1 to 6/30/26 at 2100 hours;- 7/1 to 7/30/26 at 2100 hours; and- 8/1 to 8/5/26 at 2100 hours. On 8/6/26 at 0957 hours, an interview and concurrent medical record review for Residents 3 was conducted with LVN 6. LVN 6 verified the above findings for Residents 3. On 8/6/25 at 1325 hours, and interview was conducted with the DON. The DON stated the informed consent for the psychotropic medication should include the indications, frequency, and duration for the use of the medication as per the physician's order. The DON was informed and acknowledged the above findings.

Based on observation, interview, and facility P&P review, the facility failed to ensure the safe handling and collection of regular waste for two of four trash receptacles. * The facility failed to ensure the gray plastic trash receptacle and blue dumpster were not left open. These failures posed the risk of safety and pest contamination.Findings: Review of the facility's P&P titled Garbage and Trash Can Use and Cleaning revised on 10/1/14, showed the following:- food waste will be placed in covered garbage and trash cans; and- garbage and trash cans are cleaned at least daily and more often as necessary. According to FDA Food Code 2022 Section 5-501.113 and 115 Covering Receptacles and Maintaining Refuse areas and enclosures shall be:- proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents; and- outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. On 8/5/26 at 0732 hours, an observation was conducted at the back parking lot. One gray plastic trash receptacle was left open and observed with a wooden stick preventing the green color lid to close. In addition, the lid on the left side of the blue dumpster was not completely closed. The white trash bags were placed above the maximum loading level label and could be visually seen. On 8/5/26 at 0918 hours, an interview was conducted with the Dietary Manager. The Dietary Manager was made aware and acknowledged the above findings. The Dietary Manager stated garbage dumpsters, receptables, or cans must be closed at all times to prevent roaches or insects. On 8/6/26 at 1427 hours, an interview was conducted with the Administrator, Dietary Manager, and DON. The Administrator, Dietary Manager, and DON were informed and acknowledged the above findings.

Based on observation and interview, the facility failed to maintain a homelike environment for one of 28 final sampled residents (Resident 2) and one nonsampled resident (Resident 157). * Resident 2 resided in Room A. The walls adjacent to Resident 2's bed were observed with scrapes and chipped paint. * Resident 157 resided in Room B. The closet doors were observed with scrapes and chipped paint. Additionally, the wall adjacent to Resident 157's bed was observed with scrapes and unpainted areas. These failures had the potential to negatively impact the residents' quality of life.Findings: 1. Medical record review for Resident 2 was initiated on 8/4/26. Resident 2 was admitted to the facility on [DATE]. On 8/5/26 at 0920 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 was observed lying in her bed. The walls adjacent to Resident 2's bed were observed with scrapes and chipped paint. Resident 2 stated she believed the facility was in the process of making the repairs. 2. Medical record review for Resident 157 was initiated on 8/4/26. Resident 157 was admitted to the facility on [DATE]. On 8/5/26 at 0915 hours, an observation was conducted of Resident 157. Resident 157 was observed lying in his bed. The closet doors were observed with scrapes and chipped paint. Additionally, the wall adjacent to Resident 157's bed was observed with scrapes and unpainted areas. On 8/6/26 at 1420 hours, an interview was conducted with the DON. The DON was made aware of the closet door and/or walls with scrapes and chipped paint in residents' Rooms A and B. The DON verified and acknowledged the findings. The DON stated the facility would repair the damaged areas.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 1) was protected from sexual abuse. * On 5/30/26, Resident 2 was found on top of Resident 1, in Resident 1's room. Residents 1 and 2 were face to face in bed and Resident 2 was observed humping on top of Resident 1. Resident 1 lacked the cognitive capacity to provide informed consent or make reasonable decisions regarding personal safety. Considering Resident 1's cognitive ability, a reasonable person would consider this as severe emotional trauma and may go through post traumatic issues, violation of personal rights, and potential physical injury due to the unsafe positioning of Resident 2 on top of Resident 1. * The facility failed to ensure the facility's P&P for abuse protocols were followed when the CNA changed the resident's diaper after the alleged abuse incident and prior to the police officers being onsite to conduct an abuse investigation. This failure prevented the preservation of possible evidence, hinder the investigative process, and violating the established abuse response procedures. Findings: Review of the facility's P&P titled P-AN01 Abuse Prevention and Management revised 5/30/24, showed the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. Abuse is defined as the willful, deliberate infliction of injury, unreasonable confinement, involuntary seclusion, and physical or chemical restraint not required to treat symptoms, and/or imposed for the purposes of discipline or convenience, intimidation, exploitation, misappropriation of resident's property, mistreatment, and injuries of unknown source or punishment with resulting physical harm, pain, or mental anguish. Sexual abuse is defined as non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault. Willful, as related to abuse, is defined as the individual acting deliberately (not inadvertent or accidental) and not that the individual must have intended to inflict injury or harm. Further review of the P&P showed the purpose of the policy is to address the health, safety, welfare, dignity, and respect of residents. Reports of resident abuse, mistreatment, neglect, exploitation, injuries of an unknown source, and any suspicion of crimes are promptly reported and thoroughly investigated. The P&P further showed Sexual abuse is defined as non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault. Immediate actions included: If the suspected perpetrator is another resident, separate the resident so they do not interact with each other until the circumstances of the reported incident can be clarified. The resident will be assessed by the licensed nurse for any physical injuries or emotional distress. Notify the physician and provide treatment as ordered, if applicable. Notify the responsible party of the incident and results of assessment finding. If an abuse allegation involves forced sexual penetration, the Administrator or designated representative will notify the Attending Physician to promptly examine the resident or obtain an order to transfer the resident to the acute care hospital for examination. Immediately notify law enforcement. Do not bathe the resident or wash the resident's clothes of linen. Do not take items from the area in which the incident is alleged to have occurred. On 6/1/26, CDPH received an SOC 341 (Report of Suspected Dependent Adult/Elder Abuse) from the facility dated 5/30/26. The SOC 341 showed Resident 2 was found in female resident's room (Resident 1) in her bed. On 6/11/26 at 1220 hours, CDPH initiated an onsite investigation regarding the allegation of sexual abuse involving Residents 1 and 2. Review of the facility's summary of findings dated 6/4/26, showed on 5/30/26 at approximately 1100 hours, the Maintenance Director saw Resident 2 in Resident 1's room, on top of Resident 1. Resident 2's pants were pulled down towards his knees. Resident 1's gown was half off, chest exposed. Residents 1 and 2 were face to face and Resident 2 was moving in a humping motion. The Maintenance Director pulled Resident 2 off Resident 1 and yelled into the hallway, to the nurses' station approximately 10 feet away. The RN supervisor and LVNs in the station immediately went to assist. Upon approaching Resident 1's room, Resident 2 was observed exiting the room wearing his pants. The LVNs directed Resident 2 out of Resident 1's room. The RN supervisor visually assessed Resident 1 and was observed with the left side of the brief undone. Resident 1 was noted to be calm with no signs of distress noted. The facility's summary showed Resident 2 was in the activity room from 1005 to 1050 hours and had attended activities with the other residents and left the dining room to go for the 1100 hours smoke break with no unusual behaviors noted. Further review of the facility's summary of findings showed the Maintenance Director who was the witness to the alleged incident was interviewed on 5/30/26. The Maintenance Director reported as he walked by Resident 1's room, he saw Resident 2 on top of Resident 1, with his pants down. Resident 2 was moving in a humping motion. The Maintenance Director attempted to pull Resident 2 off from the waist, who was hugging Resident 1. Resident 2 attempted to push the Maintenance Director away. The Maintenance Director called into the hallway for help; not leaving the residents in the room. By that time, Resident got off the bed and pulled on his pants. The Maintenance Director reported that Resident 1 was exposed at the chest area, saw brief on for Resident 1, but did not notice if the brief was removed or not. In addition, facility's summary of findings also showed Officers B and C came to the facility on 5/30/26 at approximately 1755 hours, to conduct an investigation regarding the incident, interviewed Resident 2, and interviewed Resident 1 at bedside. Following the interview, a skin assessment was completed in the presence of Officer 3, who was a female officer, and contacted the forensic RN to discuss their findings; and based on their assessment and investigation findings, Resident 1's transfer to the acute hospital was not indicated to avoid further trauma to the resident. The PA for Resident 1's primary physician was notified and the order for transfer was discontinued. The facility's summary failed to show if a sexual abuse was committed by Resident 2 against Resident 1. a. Medical record review for Resident 1 was initiated on 6/11/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 1/6/26, showed Resident 1 had no mental capacity to make decisions, and had a diagnosis of Traumatic Brain Injury (TBI) with spastic hemiparesis. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 was dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity) with self-care which included eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Review of Resident 1's eINTERACT Change in Condition Evaluation - V 5.1 dated 5/30/26, showed the staff reported a male resident (Resident 2) was found in the resident's room (Resident 1) in the resident's bed. The staff immediately responded and found the resident (Resident 1) lying supine in her bed, with her button up pajama blouse unbuttoned exposing her chest area and wearing her diaper. Resident 1 was immediately covered with a blanket and privacy curtains closed. Resident 1 was not able to state the event, with no signs or symptoms of emotional distress such as crying, facial expressions of fear or pain. The PA for Resident 1's primary physician was notified and noted with orders for may transfer to an acute hospital setting for further evaluation and treatment, and bed hold for seven days if admitted . Police Department A was notified through Officer A and stated an officer will be dispatched to the facility to investigate the incident. Closed medical record review for Resident 2 was initiated on 6/11/26. Resident 2 was readmitted to the facility on [DATE], and was transferred to an acute care hospital on 5/30/26. Review of Resident 2's H&P examination dated 5/7/26, showed Resident 2 had the mental capacity to make decisions. Review of Resident 2's Plan of Care showed a care plan problem focus initiated on 5/11/26, which showed Resident 2 was observed with flashlight, aiming light towards female CNA's buttocks; speaking to licensed nurse stating, I want to take you out, marry you, and I want you to move in with me. The interventions included to monitor inappropriate behavior towards female residents, to educate the resident regarding respecting a female residents' personal boundaries, inappropriate behavior was not acceptable in the facility, and to notify and responsible party. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2 was independent on ambulation. Further review of Resident 2's MDS assessment showed Resident 2 had no functional limitation in range of motion on upper extremities and lower extremities. On 6/11/26 at 1220 hours, an interview was conducted with the Administrator. The Administrator stated Resident 2 was transferred to the acute care hospital shortly after the incident and the facility would not be accepting Resident 2 back to the facility. On 6/11/26 at 1315 hours, an interview and concurrent observation was conducted with Resident 1. Resident 1 was observed lying down in bed with head slightly elevated, and her body was covered with a blanket. Resident 1 stated there were good days and bad days in the facility. When asked to describe what the bad days were, Resident 1 stated nothing. Resident 1 further stated she did not remember the incident which occurred on 5/30/26. On 6/11/26 at 1346 hours, an interview was conducted with the Maintenance Director. When asked about his knowledge of the alleged incident involving Residents 1 and 2 on 5/30/26, the Maintenance Director stated the resident in Room A asked him for a closet lock and he did not have anything at the time that was compatible for Room A's closet. The Maintenance Director stated he went and searched in different rooms which included Resident 1's room where the door was partially closed and privacy curtains were partially drawn; and when he entered the room, he saw Resident 2 on top of Resident 1 with the arms around Resident 1's upper torso and was doing humping motion. Resident 2's bottom was exposed, and his pants were down and was wearing a shirt. The Maintenance Director stated he attempted to pull Resident 2 from Resident 1, but Resident 2 was resistant and wanted to hit him. The Maintenance Director further stated he yelled for help and the staff immediately came and assisted. When the staff came in, Resident 2 got off from Resident 1 and walked away from the room. Resident 1's upper torso was exposed with her breast exposed. Resident 1's diaper was lowered down with the front diaper down, her genital was exposed. There was no reaction noted from Resident 1. On 6/12/26 at 0910 hours, an interview and concurrent medical record review for Residents 1 and 2 was conducted with the SSD. The SSD stated Resident 1 was not cognitively intact and Resident 1 was dependent with the staff on ADLs. The SSD stated Resident 2 was independent on ADLs and Resident 2 was walking independently. The SSD further stated Resident 2 had behavior of verbal aggression toward the staff and wrote inappropriate things on the wall. When asked about the incident that happened on 5/30/26, as witnessed by the Maintenance Director, the SSD verified the incident was considered sexual abuse. On 6/12/26 at 1039 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 1 was dependent with the staff on ADLs and had weaknesses on her left arm. CNA 1 stated in the morning of the alleged incident, CNA1 put on button up pajama blouse, a diaper, and a pair of shorts to Resident 1. CNA1 further stated it would not be possible for Resident 1 to unbutton her pajama blouse and lower her shorts by herself. On 6/12/26 at 1233 hours, a telephone interview was conducted with LVN1. When asked about her knowledge of the alleged incident on 5/30/26, involving Residents 1 and 2, LVN 1 stated the maintenance man (referring to the Maintenance Director) came out of the hall and asked for help. Resident 2 was coming out of Resident 1's room. Resident 1's breast was exposed, and her diaper was exposed. Resident 1's left diaper strap was undone and can see her pubic area because the diaper was folded on the side. LVN 1 stated she asked Resident 1 if she was OK; however, Resident 1 cannot really say what happened. LVN 1 further stated she and LVN 4 conducted visual check on Resident 1 and they did not see any blood or bodily fluids. According to LVN 1, the CNA changed Resident 1 but not immediately and the police took some time before they came to the facility at around 1800 hours. Resident 1 was already changed by the time the police officers arrived at the unit. They were informed by the police officers that due to the resident's condition, they did not want to traumatize Resident 1 and did not order a rape kit. They were told by the police officers they did not feel there was penetration. LVN 1 further stated it did not make sense to her what was told to them by the police officers. On 6/12/26 at 1353 hours, an interview was conducted with the Administrator. When asked about the outcome of the facility's investigation, the Administrator stated the facility's investigation report did not substantiate the incident on 5/30/26; however, the Administrator stated the incident happened on 5/30/26, was considered sexual contact occurred. Hence, the Administrator wanted Resident 1 to have a rape kit test to be done but the local police department stated it was not necessary as it might traumatize Resident 1. On 6/12/26 at 1530 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings. On 6/12/26 at 1622 hours, a telephone interview was conducted with RN 1. RN 1 stated the Maintenance Director called them (staff) into the room of Resident 1 because Resident 2 was inside the room as well. When they got into Resident 1's room, Resident 2 was already standing at the door. RN1 stated Resident 1's blouse was open, exposing her chest, but her diaper was still on. Resident 2 stated he got lost and was talking to Resident 1 and he fell asleep. When asked why he was on top of Resident 1, Resident 2 stated nothing happed. When Resident 1 was asked by RN 1 about the alleged incident, RN 1 stated she tried asking Resident 1, but the resident did not remember anything and was just saying, No, Mama. RN1 stated this was a statement Resident 1 always said. On 6/25/26 at 0730 hours, a follow-up visit was conducted by the CDPH surveyor. The facility was requested for a copy of the police report with the investigation conducted by Officers 2 and 3 from Police Department A on 5/30/26, for Residents 1 and 2 regarding the allegation of sexual abuse. The CDPH surveyor was provided with a copy of the request from the facility to Police Department A, dated 6/2/26. The request was made by the Administrator for the police report and any reports from the forensics team, from the incident reported on 5/30/26. There was no document to show whether sexual abuse occurred for Resident 1. The Administrator verified the findings. On 7/7/26 at 1436 hours, a telephone interview was conducted with Physician A. When asked about his knowledge about the alleged incident of sexual abuse involving Residents 1 and 2, Physician A stated they had a system in place, a team to handle calls. Physician A stated he was aware of the alleged incident and there was a standard protocol to inform the physician or the team on call. In this case, Physician A stated the police was notified and the police stated there was no penetration. Physician A stated his PA was called and the psychiatrist was called. Physician A stated if the police said there was no need to transfer the resident to the acute care hospital, then there was no need to transfer Resident 1 to the acute care hospital. When asked if a forensic nurse can adequately assess the resident, not being onside, and if there was penetration or not, Physician A stated he was not aware the forensic nurse was not in the facility. Physician A emphasized the facility communicated with his PA, and he was officially informed at the Quality Assurance meeting. On 7/8/26 at 1217 hours, a concurrent telephone interview and P&P review was conducted with the Administrator and DON. When asked how the forensic nurse was able to assess Resident 1 if she was not onsite, the DON stated the male and female police officers were assisted by the LVN from the facility. The forensic nurse was on the phone and was asking questions to guide the investigation and what to look for. Based on the information provided to the forensic nurse, the forensic nurse determined there was no need for Resident 1 to be transferred to the acute care hospital since the police and forensic nurse felt there was no penetration between Residents 1 and 2. When asked if an RN in the facility was involved with the investigation, the DON stated during the police assessment, the RN was busy assisting Resident 2 therefore the LVN assisted the police officers and the forensic nurse. When asked if a discussion between the facility and the PA for Resident 1 agreed with the decision not to transfer Resident 1, the DON stated the PA agreed with the decision from the police and forensic nurse not to transfer Resident 1 to prevent further trauma and not having identified signs of penetration occurred between Residents 1 and 2. The P&P regarding abuse prevention was reviewed with the Administrator and DON over the phone. Page 3 of 4 showed.Do not bathe the resident or wash the resident's clothes or linen. Do not take items from the area in which the incident is alleged to have occurred. When the Administrator was asked if she was aware the alleged victim was changed prior to the police officers being onsite, the Administrator stated she was not aware of the situation and she has conducted several interviews, and nothing was mentioned Resident 1 was changed prior to the police officers' arrival to the facility. The Administrator further stated she instructed the staff not to change Resident 1 prior to the police officers' arrival to the facility to conduct the investigation. The Administrator further stated the facility assessed Resident 1 immediately after the incident occurred, and days post the incident. Resident 1 did not have signs of trauma, distress, and skin injuries. Resident 1 was at her baseline and did not complain of anything. Resident 1 was not transferred to an acute care hospital based on the decision/recommendation from the police officers and forensic nurse who conducted their investigation post notification of the alleged incident and felt there was no penetration occurred between Residents 1 and 2 and was not necessary to avoid further trauma to Resident 1. The Administrator and DON acknowledged the findings.

Based on interview and medical record review, the facility failed to protect the residents' (Residents 1 and 3) right to be free from physical abuse by Residents 2 and 4. * Resident 2 had episodes of aggressive behaviors and refused the antipsychotic medications ordered by the physician. The facility failed to notify the psychiatrist that Resident 2's refusal as ordered which resulted in Resident 2's increase in agitation. Resident 2 struck Resident 1 on the face with a pitcher which resulted in Resident 1 sustaining head trauma and injuries on her face, arms, and legs. * Resident 4 punched Resident 3 in the face when Resident 3 refused to turn off a room light. This caused injuries to Resident 3's nose and upper lip. Findings: 1. Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 11/19/23, showed Resident 2 hit Resident 1 causing bleeding on Resident 1's face, arms, and legs. a. Medical record review for Resident 1 was initiated on 11/29/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1 had moderately cognitive impairment. Review of Resident 1's Change in Condition Evaluation dated 11/19/23 at 2141 hours, showed at 1615 hours, at Room A, the front door was closed with Resident 2 (Resident 1's roommate) holding the door shut with her body. When the front door was opened, Resident 1 was found crying, stating .she hit me, she hit me . with bleeding from her face, bilateral arms, and legs. Resident 1 was transferred to the acute care hospital for evaluation. Resident 2 was asked why she hit Resident 1, and Resident 2 stated .because I love her so much. Under the skin status evaluation, it showed Resident 1 had skin tears and abrasions on the top of her scalp, face, right and left elbows, and bilateral lower extremities. Review of Resident 1's medical record from the acute care hospital dated 11/19/23, showed Resident 1 was assessed to have multiple facial and body scratches and abrasions after an alleged assault. Resident 1 was admitted to the acute care hospital with diagnoses of blunt head trauma, facial contusion, abrasions of multiple sites and multiple contusions post alleged assault. b. Medical record review for Resident 2 was initiated on 11/29/23. Resident 2 was admitted to the facility on [DATE]. Review of Resident 's MDS dated [DATE], showed Resident 2 was cognitively intact. Review of Resident 2's care plan dated 8/16/23, showed a care plan problem addressing Resident 2 was at risk for harm: self-directed or other-directed related to schizoaffective disorder, anxiety disorder, depression, and insomnia. The interventions were to notify the provider if Resident 2 posed a potential threat to injure self or others, monitor sign and symptoms of agitation, and monitor for cognitive, emotional, or environmental factors contributing to violent behaviors. Review of Resident 2's Order Recap Report from 8/1/23 to 12/31/23, showed the following physician's orders: - dated 8/15/23, to administer one tablet of olanzapine (an antipsychotic that can treat schizophrenia and bipolar disorder) 20 mg by mouth two times a day for schizophrenia manifested by talking to unseen others, discontinued on 10/18/23; - dated 8/19/23, to administer two tablets of vortioxetine (an antidepressant used to treat major depressive disorder) 10 mg by mouth in the morning for depression manifested by verbalization of sadness; - dated 10/17/23, to inject Invega Sustenna (medication that can treat schizophrenia and schizoaffective disorder) 234 mg intramuscularly (in the muscle) one time a day starting on the 17th and ending on the 17th of every month for manifested by aggressive behavior and paranoid delusion. Review of Resident 2's physician's order dated 9/9/23, showed the order to notify the psychiatry NP if Resident 2 was refusing the medications. Review of Resident 2's Medication Administration Record for October 2023 showed Resident 2 had refused to take the following medications on the following dates: - olanzapine 20 mg on 10/1 at 0800 hours, 10/5 at 1700 hours, 10/9 at 0800 and 1700 hours, 10/10 at 0800 hours, and 10/16/23 at 0800 hours; and, - vortioxetine 10 mg on 10/1, 10/9, 10/10, 10/16, 10/20, 10/21, 10/22, 10/27, and 10/28/23. Review of Resident 2's Medication Administration Record for November 2023 showed Resident 2 had refused to take the following medication on the following dates: - Invega Sustenna 234 mg on 11/17/23; and, - vortioxetine 10 mg on 11/3, 11/5, 11/11, 11/17, 11/18, and 11/19/23. Review of Resident 2's medical record failed to show Resident 2's psychiatric team was notified of Resident 2 refusing to take the above medications. Further review of Resident 2's medical record failed to show Resident 2 was being monitored for aggressive behaviors and paranoid delusions. Review of Resident 2's Change in Condition Evaluation dated 9/28/23 at 1535 hours, showed Resident 2 was agitated towards the staff and other residents. When the staff attempted to deescalate Resident 2, Resident 2 continued to yell and walked towards the staff to hit them. Review of Resident 2's Progress Notes dated 10/18/23 at 0405 hours, showed Resident 2 was yelling at people in her room all throughout the night. Resident 2 was reminded she was alone in her room, but Resident 2 insisted there were spirits with her. Resident 2 was progressively getting louder and more aggressive, used slurred speech, and was slamming on doors. Review of Resident 2's Change in Condition Evaluation dated 11/19/23 at 2156 hours, showed at 1615 hours, a CNA reported residents (Residents 1 and 2) were fighting. When walking to Resident 2's room, the front door was closed with Resident 2 holding the door shut with her body. When the front door was pushed opened, Resident 1 was found crying, stating .she hit me, she hit me . with bleeding to the face, bilateral arms, and legs. Resident 1 was transferred to the acute care hospital for evaluation. Resident 2 was asked why she hit Resident 1, and Resident 2 stated .because I love her so much. On 11/29/23 at 1210 hours, an interview was conducted with the ADON. The ADON stated CNA 1 came to her asking for help. When they walked to Resident 2's room, the door was closed, Resident 2 held the door shut. When the door was pushed open, Resident 1 was found with bleeding on her face, arms, and legs. Resident 2 admitted to the police that she had hit Resident 1 with a pitcher. On 11/30/23 at 0936 hours, an interview was conducted with CNA 1. CNA 1 stated he heard Resident 1 screaming. When he walked into the room, CNA 1 saw Resident 2 standing next to Resident 1's bed. Resident 1 was lying in bed and could not get up. Resident 1 appeared hurt with scratches all over her face, arms, and legs. On 12/4/23 at 1055 hours, an interview and medical record review was conducted with LVN 1. LVN 1 stated Resident 2 was unpredictable, could be polite; however, she had sudden outbursts. LVN 1 was asked if Resident 2's psychiatrist was notified of Resident 2's multiple episodes of refusing her medications ordered by the physician. LVN 1 stated he called and texted Resident 2's medical physician, however, failed to notify the psychiatry health practitioners or psychiatrist regarding Resident 2's episodes of refusing the medications. Cross reference F758. 2. Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 11/28/23, showed Resident 3 got punched by his roommate. LVN 2 heard a noise from the room and saw Resident 3 was standing in front of Resident 4. Resident 4 had his left hand balled up and was observed bleeding. Resident 3 was also observed bleeding from his nose and upper lip. a. Medical record review for Resident 3 was initiated on 11/29/23. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's History and Physical Examination dated 11/22/23, showed Resident 3 could make his needs known but could not make medical decisions. Review of Resident 3's Change in Condition Evaluation dated 11/27/23 at 2115 hours, showed LVN 2 heard a loud commotion inside the room while the door was closed. When LVN 2 entered room, he saw Resident 4 standing in front of Resident 3 in between resident beds. Resident 4 was standing with his fist balled up and bleeding. Resident 3 was noted with his nose bleeding and a small scratch to the upper lip measuring 0.2 cm x 0.2 cm. When LVN 2 asked residents what happened, Resident 3 stated, . he [Resident 4] hit me because of the light. b. Medical record review for Resident 4 was initiated on 11/29/23. Resident 4 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 4's MDS dated [DATE], showed Resident 4 was cognitively intact. Review of Resident 4's Progress Note dated 11/27/23, showed at 11/27 at approximately 2115 hours, a facility staff member heard a loud noise coming from Residents 3 and 4's room. When the facility staff entered the closed room, Resident 4 had his left fist balled up and bleeding from that hand. Resident 4 stated he repeatedly requested for Resident 3 to turn off the light; however, Resident 3 refused and insisted the light would stay on all the time. Resident 4 stated he went to Resident 3's side of the room to turn off the light; however, Resident 3 did not let him. Resident 4 stated Resident 3 attempted to punch him; however, Resident 4 punched Resident 3 first. The Progress Note showed Resident 4 suffered a left-hand abrasion measuring 2.5 cm x 0.2 cm, from the altercation. Review of Resident 4's Progress Notes dated 11/28/23, showed Residents 3 and 4 had an altercation when Resident 4 punched Resident 3 in the face after Resident 3 refused to turn off the light in the room they share. Resident 4 sustained a laceration to the left hand after punching Resident 3. On 12/4/23 at 1520 hours, an interview and medical record review was conducted with RN 1. RN 1 stated LVN 2 reported Resident 3 wanted to turn his room light on; however, Resident 4 wanted the light off. Resident 4 then went to Resident 3's bed to turn off the light. Resident 3 did not want Resident 4 to turn off the light. Resident 3 wanted to hit Resident 4, but before he could hit Resident 4, Resident 4 punched him instead.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to protect Resident 1 who was known to have wandering and behaviors of taking other people's foods and on 1:1 supervision from the physical abuse by Resident 2. Resident 2 had struck Resident 1 in the face during an altercation whenResident 1 had wandered into Resident 2's room and attempted to take Resident 2's milk. This failure resulted in Resident 1 suffering a left nasal bone fracture, blunt head and facial trauma, a cerebral concussion (a type of traumatic brain injury caused by a bump, blow, or jolt to the head which may cause damage to brain cells). Findings: Review of the facility's P&P titled Abuse-Prevention, Screening, and Training Program revised 7/2018 showed in part, the facility does not condone any form of resident abuse .and develops facility P&Ps, training programs, and screening and prevention systems to promote an environment free from abuse .and mistreatment. Review of the SOC-341 (Report of Suspected Dependent Adult/Elder Abuse) dated 11/6/23, showed Resident 1 sustained a laceration to his left eye with swelling. Resident 1 was sent to Acute Care Hospital 1 for evaluation. Resident 2 stated Resident 1 took his milk and he hit him in the eye. 1. Medical record review for Resident 2 was initiated on 11/8/23. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's care plan dated 12/8/22, showed a care plan focus addressing Resident 2 was at risk for harm: self-directed or other-directed. Review of Resident 2's Health Status Note dated 11/6/23, showed Resident 1 snatched Resident 2's milk from his hand. The note showed Resident 2 stated when Resident 1 resisted from letting go of the milk, Resident 1 punched Resident 2 on his face, then Resident 2 proceeded to punch Resident 1 on his face. 2. Medical record review of Resident 1 was initiated on 11/8/23. Resident 1 was admitted to the facility on [DATE], with diagnoses including paranoid schizophrenia (a brain disorder which causes people to interpret reality abnormally) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Review of Resident 1's History & Physical examination dated 10/18/23, showed Resident 1 could make his needs known but could not make medical decisions. Review of Resident 1's Health Status Note dated 10/18/23, showed Resident 1 was newly admitted and noted by the staff that Resident 1 kept entering other residents' rooms and eating other people's foods. Review of Resident 1's care plan dated 10/18/23, showed a care plan focus addressing Resident 1 was a risk for wandering/elopement. The care plan interventions included to clearly identify the resident's room and bathroom; engage the resident in the purposeful activity; identify if there was certain time of the day wandering/elopement attempts occurred; implement a scheduled toileting program; provide clear, simple questions; provide reorientation to surroundings; and schedule time for regular walks or appropriate activities. Review of Resident 1's Health Status Note dated 11/6/23, showed at 1100 hours, Resident 1 was seen walking into other residents' rooms. Resident 1 was placed on 1:1 supervisionwith the RNA due to the resident constantly going into everyone's rooms. At 1500 hours, Resident 1's room was changed due to needing a 1:1 sitter, and the sitter was in the room with Resident 1. At 1805 hours, Resident 2 was standing by the doorway with the seemingly extremely angry facial expression and noted with blood on his gown. Resident 1 was a few feet away bleeding from his left side of face. Resident 1 noted with a laceration to the left side of the face with swelling and bleeding noted. Resident 1 stated,That guy punched me. Review of Resident 1's Change in Condition Evaluation dated 11/6/23, showed upon notification of the altercation, Resident 1's provider recommended for Resident 1 to be sent to the acute care hospital via 911 for further evaluation and treatment. Review of Resident 1's medical record from Acute Care Hospital 1 showed Resident 1 was admitted to Acute Care Hospital 1 on 11/6/23. Review of Resident 1's Admission History and Physical, Adult assessment from Acute Care Hospital 1 dated 11/6/23, showed Resident 1 reported being hit 11 times. Resident 1 was assessed to have nasal swelling with dried blood in his nares; left periorbital ecchymosis and swelling, and a left upper eyelid superficial laceration. Review of Resident 1's Progress Notes from Acute Care Hospital 1 dated 11/7/23, showed Resident 1 suffered from the blunt head and facial trauma, a traumatic brain injury/cerebral concussion, a left nasal bone fracture, and left periorbital (around the eye) soft tissue swelling. On 11/8/23 at 1535 hours, an interview was conducted with RN 1. RN 1 verified Resident 1 would wander into other residents' rooms often and stated Resident 1 was placed on 1:1 supervision on that day. RN 1 stated the 1:1 sitter had two residents (Residents 1 and 4) to watch 1:1 and went to bring Resident 4 out to smoke when Resident 1 got hit by Resident 2. On 11/8/23 at 1334 hours, an interview was conducted with LVN 3. LVN 3 was asked about the events that took place on 11/6/23, between Residents 1 and 2. LVN 3 stated he was the first responder to the incident after an RNA yelled for help. LVN 3 stated he saw Resident 2 standing outside a resident's room door and Resident 1 was walking out with his eye covered. LVN 3 described Resident 1 had his eyes closed and was trying to wipe off the blood from his face. LVN 3 also observed Resident 1 with swelling, discoloration, and skin tear on the eyelid. On 11/8/23 at 1607 hours, an interview was conducted with CNA 2. CNA 2 stated on 11/6/23, she was assigned to Resident 1 as a 1:1 supervision, but the facility also assigned her to care for three other residents. CNA 2 stated Resident 1 had dementia and went all the time to each room and took things from other residents. CNA 2 stated at 1750 hours, Resident 4 (one of the CNA's other assigned residents) went to the line to smoke, and she had to follow Resident 4. CNA 2 stated no one was covering for her to watch Resident 1 when she left the room. CNA 2 added within 10 minutes, she heard an RNA screaming for help from the residents' room due to the altercation. On 11/16/23 at 1036 hours, the Administrator was informed of and acknowledged the above findings. The Administrator acknowledged Resident 1 was placed on a 1:1 monitoring; however, Resident 1 was left unattended and wandered into Resident 2's room, which resulted in Resident 2 striking at and causing injury to Resident 1 with hospitalization .

Based on interview, medicalrecord review, facility document review, and facility P&P review, the facility failed to protect Resident 1 to be free from the physical abuse by Resident 2. Resident 2 had pushed Resident 1 during an altercation while standing in line waiting to smoke. This failure resulted in Resident 1 suffering a broken right hip, significant pain, required the resident to be sent to the acute care hospital, and underwent a major surgical surgery. Findings: Review of the facility ' s P&P titled Abuse-Prevention Program revised 9/2017 showed the facility does not condone any form of resident abuse and develops facility P&Ps , training programs, and systems to promote an environment free from abuse and mistreatment. Review of the SOC-341(Report of Suspected Dependent Adult/Elder Abuse) dated 5/23/23, showed Resident 1 reported Resident 2 had pushed him causing him to fall. 1. Medical record review of Resident 2 was initiated on 5/26/23. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2 ' s MDS dated [DATE], showed Resident 2 was cognitively intact. Review of Resident 2 ' s Progress Notes dated 5/23/23 at 1633 hours, showed Resident 2 had pushed Resident 1 causing him to fall to the ground while they were waiting in line to smoke. Resident 2 stated Resident 1 attempted to cut the line in front of him while he was in line to smoke. Resident 2 then pushed Resident 1 and Resident 1 fell to the ground 2. Closed medical record review for Resident 1 was initiated on 5/26/23. Resident 1 was admitted to the facility on [DATE], and was transferred to an acute care hospital on 5/22/23. Review of Resident 1 ' s History and Physical Examination dated 5/31/23, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1 ' s MDS dated [DATE], showed Resident 1 was cognitively intact and used a walker and a wheelchair as mobility devices. Resident 1 needed supervision and one-person physical assistance when walking in the room and in corridor and when moving to and from off-unit locations. The document also showed Resident 1 was not steady but able to stabilize without human assistance for walking, moving from the sitting to standing position, and turning around and facing opposite direction while walking. Review of Resident 1 ' s IDT Progress Notes-Behavior Management dated 5/23/23 at 1626 hours, showed Resident 1 was involved in a resident-to-resident altercation with Resident 2 and was assessed to have a pain level of nine out of 10 on a pain scale of 0 to 10 (with 0 = no pain, 4-5 = moderate pain, and 10 = excruciating pain). Resident 1 was also assessed to have difficulty with range of motion on the right lower extremity. The document showed Resident 2 had pushed Resident 1 causing Resident 1 to fall to the ground. Review of Resident 1 ' s eInteract Change in Condition Evaluation dated 5/21/23 at 1828 hours, showed Resident 1 complained of the right inner thigh pain. Resident 1 rated his pain to be seven out of 10 on a pain scale of 0 to 10 (with 0 = no pain, 4-5 = moderate pain, and 10 = excruciating pain). The document showed Resident 1 ' s medical provider was notified on 5/21/23 at 1800 hours; however, the nursing staff was waiting for a response from the medical provider. Review of Resident 1 ' s Medication Administration Record for May 2023 showed Resident 1 was administered 650 mg of acetaminophen on 5/21/23 at 1700 hours, for a pain level of seven. Review of Resident 1 ' s Progress Notes dated 5/22/23 at 1109 hours, showed Resident 1 was complaining of right hip pain, could not get out of bed, and refused the physical therapy. The document also showed Resident 1 reported he was pushed by another resident. Further review of Resident 1 ' s Progress Notes dated 5/22/23 at 1209 hours, showed Resident 1 was sent out to Acute Care Hospital 1 ' s emergency department. Review of Resident 1 ' s medical record from Acute Care Hospital 1 showed Resident 1 was admitted to Acute Care Hospital 1 on 5/22/23, for the right thigh and hip pain for two days after he reported he was pushed by another resident while standing, falling on his right side. The right thigh pain was sharp and worse with weightbearing. The document also showed Resident 1 had tenderness on the medial right thigh with limited range of motion of the right hip due to pain. Review of Resident 1 ' s Acute Care Hospital 1 ' s right hip x-ray result dated 5/22/23, showed Resident 1 had a right subcapital femoral neck (the neck of the thigh bone) fracture (a break of the bone). The document also showed Resident 1 had soft tissue swelling in the area. Further review of Resident 1 ' s Acute Care Hospital 1 ' s medical record showed Resident 1 had undergone a right total hip arthroplasty (a major surgical procedure to replace a damaged joint with an artificial joint). On 5/25/23 at1439 hours, an interview was conducted with Resident 2. Resident 2stated Resident 1 accused him of trying to remove Resident 1 from his place in the smoking line when Resident 1 put his fists in front of Resident 2 ' s face and attempted to pull Resident 2 from his place in line. Resident 2 then pushed Resident 1 who fell to the ground. Resident 2 stated facility staff responded by asking about the altercation. On 6/1/23 at 1105 hours, an interview was conducted with the DON. The DON stated a facility staff (LVN 1) witnessed the altercation between Residents 1 and 2. On 6/1/23 at 1155 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated she witnessedthe altercation between Residents 1 and 2. LVN 1 recounted the altercation occurred on 5/20/23 at approximately 2000 hours. LVN 1 statedshe observed Resident 1 attempting to shove or punch Resident 2 and Resident 2 responded by swinging his left arm at Resident 1 causing him to lose his balance and fall to the ground. LVN 1 asked Resident 2 why he swung his arm at Resident 1 knocking him to the floor. Resident 2 replied that Resident 1 tried to push him. Cross reference to F609 and F684.