Every finding on record at Rancho Seco Care Center

Based on observation, interview, and record review, the facility had 8 percent (%; a unit of measurement) error rate when two medication errors out of 25 opportunities were observed during a medication (med) pass for one of five residents (Resident 72). This failure resulted in medications not given in accordance with the prescriber's order and the potential to affect the residents' clinical conditions leading to health complications.Findings:During a med pass observation on 7/20/26 at 9:41 a.m., Licensed Nurse (LN) 5 was observed preparing seven medications for Resident 72 including docusate sodium (a medication to soften the stool) 100 milligrams (mg, a unit of measurement) one tablet, and 10 ml of carbamazepine (a medication to stabilize mood) 100 mg/5 milliliters (ml, a unit of measurement) suspension (a liquid medicine where tiny, fine bits of solid medicine are floating or mixed around in a liquid, but have not actually dissolved). LN 5 removed the cap from the carbamazepine bottle without shaking the suspension and poured the medication into a plastic medicine cup. LN 5 poured the dose in the cup to approximately 12.5 ml. When LN 5 had finished pouring the carbamazepine dose, she confirmed where she measured the dose to and drew a line between the 10- and 15-ml line. A review of Resident 72's medical record indicated the following physician's orders:- Docusate sodium 100 mg tablet: Give two tablets by mouth two times a day for bowel care. Hold for loose stool, ordered 3/28/26; and - Carbamazepine 100 mg/5 ml suspension: Give 10 ml by mouth three times a day related to personal history of transient ischemic attack (TIA, when a blood clot or narrowed artery briefly blocks blood flow to a part of the brain) and cerebral infarction without residual deficits (a past stroke or brain tissue death caused by interrupted blood flow where there is no long term damage), ordered 3/28/26. During a concurrent interview and record review on 7/20/26 at 12:55 p.m. with LN 5, Resident 72's docusate and carbamazepine orders were reviewed. LN 5 reviewed the docusate order and stated she should have given two tablets but had only given one. LN 5 acknowledged she did not shake the carbamazepine suspension before she measured the dose and stated it was important to shake a suspension well before pouring it because the medication settled at the bottom of the bottle. LN 5 confirmed she measured the carbamazepine between the 10- and 15-ml marks on the medicine cup and acknowledged she had not measured the 10 ml prescribed dose correctly. During an interview on 7/21/26 at 11:14 a.m. with the Director of Nursing (DON), DON expected nursing staff to follow the instructions in a physician's order when preparing medications and if a medication required shaking then nurses should do that. DON also expected nursing staff to pour medicine in a cup and measure it at eye level and to measure to the line for the dosage indicated in the physician's order. DON stated it was important to shake a suspension well prior to pouring it to ensure the correct dosage was prepared and administered. During a telephone interview on 7/22/26 at 1:46 p.m. with the Consultant Pharmacist (CP), CP stated carbamazepine suspension needed to be shaken well before pouring to ensure the correct dosage was prepared. A review of the drug labeling for carbamazepine suspension, revised 5/2024, indicated, Medication Guide . How should I take carbamazepine? . Shake the bottle well each time before use. A review of the facility's undated policy and procedure titled, Medication Administration, indicated, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . Policy Explanation and Compliance Guidelines . 10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation . 17. Administer medication as ordered in accordance with manufacturer specifications . b. 'Shake well' to mix suspensions .

Based on observation, interview, and record review, the facility failed to ensure professional standards of quality were followed for four residents out of a census of 92, when:1. Licensed Nurse (LN) 6 did not sign and date Resident 98's medicated patch;2. LN 5 did not wear appropriate personal protective equipment (PPE, equipment such as gloves, masks, or safety glasses worn to minimize exposure to hazards) while handling Resident 23's hazardous medication (medications that can cause serious effects including cancer, organ toxicity, fertility problems, genetic damage, and birth defects if not handled appropriately);3. LN 5 did not crush Resident 81's medications for administration; and 4. Resident 34's controlled substance medications (medications with a high potential for abuse and addiction) were not accurately accounted for on the medication administration record (MAR) and the Controlled Drug Record (CDR, an accountability record).These failures decreased the facility's potential to prevent residents from experiencing adverse effects from medicated patches applied not in accordance with physician's orders, unwanted exposure to hazardous medications leading to health complications, choking from administration of medications whole, abuse or misuse of medications, and to maintain accurate accountability of controlled medications.Findings: 1. During a medication (med) pass observation on 7/20/26 at 8:39 a.m., LN 6 was observed applying a lidocaine (an anesthetic to relieve pain) patch on Resident 98. LN 6 removed the patch from the packaging, removed the adhesive backing, and applied the patch to Resident 98's middle upper back. During an interview on 7/20/26 at 11:45 a.m. with LN 6, LN 6 confirmed she did not sign or date the lidocaine patch that she applied to Resident 98. During an interview on 7/21/26 at 11:27 a.m. with the Director of Nursing (DON), DON expected nursing staff to sign, date and put the time on a medicated patch when applied to a resident. DON stated it was important to write the information so nursing staff could see when it was applied and to prevent a patch from being left on the resident beyond what was indicated in an order. A review of the facility's undated policy and procedure (P&P) titled, Administration of Medication Transdermal Patch, indicated, Policy: It is the policy of this facility to ensure residents receive transdermal medication in accordance with professional standards of practice. Policy Explanation and Compliance Guidelines . 6. Administration . c. Write the date and initials on the patch. 2. During a med pass observation on 7/20/26 at 9:27 a.m., LN 5 was observed preparing four medications for Resident 23 which included finasteride (a medication to treat an enlarged prostate gland) five milligrams (mg, a unit of measurement) one tablet. The package had a sticker affixed to and indicated it was hazardous. LN 5 prepared the medications without wearing gloves. During an interview on 7/20/26 at 1:02 p.m. with LN 5, LN 5 confirmed she did not wear gloves when she prepared the hazardous medication for Resident 23. LN 5 stated she should have worn gloves when handling the medication because it was hazardous. During an interview on 7/21/26 at 11:25 a.m. with the DON, DON expected nursing staff to follow directions for special handling when preparing and administering medications. DON also expected nursing staff to wear gloves to protect themselves and the residents when handling hazardous medications. During a telephone interview on 7/22/26 at 1:46 p.m. with the Consultant Pharmacist (CP), CP stated if a medication was categorized as hazardous, the nurse who prepared the medication should wear gloves to protect themselves and to prevent cross contamination. A review of an article published by the Centers for Disease Control and Prevention (CDC, the national public health agency of the United States) titled, Hazardous Drugs Exposures in Healthcare, dated 3/3/26, indicated, Who is at risk? Healthcare workers who prepare or administer hazardous drugs . or who work in areas where these drugs are used may be exposed to these agents in the workplace . Published studies have shown that workplace exposures to hazardous drugs can cause both acute [short term] and chronic [long-term] effects such as: skin rash, adverse reproductive outcomes . and other cancers. A review of the facility's undated P&P titled, Hazardous Drug Handling, indicated, Purpose: To establish safe handling of hazardous drugs (HDs), promote patient safety, worker safety, and environmental protection. Handling HDs includes, but is not limited to, the receipt, storage, compounding, dispensing, administration . This system shall include policies and procedures to prevent the unintentional entry of HDs into the body due to the handling of HDs and/or touching contaminated surfaces. Scope: The facility must develop and maintain a health and safety management system which shall, at a minimum, include the following . 4. Safe work practices; 5. Proper use of appropriate Personal Protective Equipment (PPE) . A review of The National Institute for Occupational Safety and Health (NIOSH, the federal organization responsible for making recommendations for the prevention of work-related injury and illness) List of Hazardous Drugs in Healthcare Settings, dated 2024, indicated, The drugs in Table 2 meet the NIOSH definition of a hazardous drug . These drugs may exhibit one or more of the types of toxicity described in the NIOSH definition of a hazardous drug . Some of these drugs may also present an occupational hazard to those workers who are actively trying to conceive, who are pregnant or may become pregnant, and who are breastfeeding because the drugs may be excreted in breast milk . Table 2 . finasteride . Developmental and/or Reproductive Hazard. 3. During a med pass observation on 7/20/26 at 9:11 a.m., LN 5 was observed preparing medications for Resident 81 which included eye drops, tablets, and an oral (by mouth) liquid medication. LN 5 entered Resident 81's room with the prepared medications and tried to hand Resident 81 the oral liquid medication in the medicine cup, but Resident 81 did not move his hands. LN 5 administered Resident 81's liquid medication and he was observed having difficulty swallowing the medication. LN 5 offered Resident 81 sips of water between sips of the liquid medication, and he was observed repeatedly belching and clearing his throat. LN 5 then administered Resident 81's oral tablets with a plastic spoon, one by one, and offered him sips of water in between. Resident 81 continued to [NAME] and clear his throat and had labored breathing that sounded wet. Resident 81 was then observed chewing the medications and the crunching of multiple tablets was heard. A review of Resident 81's medical record indicated the following diet and physician orders:- Pureed (completely smooth, thick, and uniform like pudding or applesauce) texture, thin consistency, ordered 6/10/26; and- May crush all crushable medications and open capsules until contraindicated, ordered 6/10/26. During a concurrent interview and record review on 7/20/26 at 1:11 p.m. with LN 5, Resident 81's orders were reviewed. LN 5 stated Resident 81 had difficulty swallowing his medications during the observed morning med pass and if she had taken the time to really look through the record, then she would have known how Resident 81 normally took his medications. LN 5 further stated she did not think it was safe for Resident 81 to take his medications whole since he had orders for a pureed diet. During a concurrent interview and record review on 7/21/26 at 11:30 a.m. with the DON, Resident 81's orders and nursing notes were reviewed. DON confirmed there were orders placed by the physician that would allow nursing staff to crush a resident's medications and expected nursing staff to get the medication out of the resident's mouth so they did not choke or aspirate, then to check the resident's orders to see if the medications could be crushed if a resident was having difficulty swallowing their medications whole. DON acknowledged Resident 81's pureed diet order and stated, Different nursing notes say that he takes his pills crushed. DON further stated it was not acceptable to administer tablets wholes since Resident 81 took his pills crushed and expected the nurse to crush the medications. A review of the facility's undated P&P titled, Medication Administration, indicated, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . 4. A review of Resident 34's medical record indicated the following physician's orders:-Oxycodone (a potent pain medication) 10 mg tablet: Give one tablet by mouth every four hours as needed for mild pain; moderate pain, ordered 4/6/26; and-Oxycodone 20 mg tablet: Give one tablet by mouth every four hours as needed for moderate pain; severe pain if pain level 7-10 (a tool used by healthcare providers to help patients communicate the intensity of their physical discomfort where 0 represents freedom from pain, and 10 represents the worst, most excruciating pain imaginable), ordered 4/6/26.During a concurrent interview and record review on 7/21/26 at 12 p.m. with the DON, Resident 34's CDR and MARs dated May and June 2026 were reviewed. DON confirmed the CDR indicated oxycodone 10 mg was removed on the following dates and times, but their respective administrations were not documented on the MAR: one tablet on 5/29/26 at 5:31 p.m., and two tablets on 6/6/26 at 2:23 p.m. DON also confirmed the MAR indicated 20 mg (two tablets) were administered on 6/11/23 at 12:30 p.m. and 6/17/26 at 6 a.m. but the CDR indicated only one tablet was removed for each date. DON expected nursing staff to document on the CDR and the MAR whenever a controlled drug was removed and administered to a resident. DON stated it was important to maintain accuracy of controlled drug records to prevent possible medication overdose or misuse of the drugs.During an interview on 7/21/26 at 11:05 a.m. with the Assistant Director of Nursing (ADON), ADON expected nursing staff to check the CDR and compare it to the physical count when preparing controlled medications to verify that the counts match. ADON stated if the count was correct, then the dose could be prepared, administered to the resident, and documented in both the CDR and MAR.A review of the facility's undated policy and procedure titled, Medication Administration, indicated, 20. Sign MAR after administered. For those medications requiring vital signs, record vital signs onto the MAR. 21. If medication is a controlled substance, sign narcotic book.

Based on observation, interview, and record review, the facility failed to ensure:1. Unauthorized nursing staff did not have access to medications once their employment with the facility ended;2. Safe medication labeling practices in accordance with accepted professional standards when opened inhalers and biologicals were not properly labeled with sufficient information to clearly identify the specific residents for which they were prescribed in medication (med) carts A and D; and3. Unwanted or refused doses of medication were not stored in the med cart. These failures decreased the facility's potential to prevent diversion or misuse of medications, medication errors and preventable infections from cross-contamination of resident medications from accidental misadministration of similar or same drugs for a census of 92 residents.Findings: 1. During a concurrent observation and interview on 7/20/26 at 12 p.m. with the Director of Nursing (DON), med storage room [ROOM NUMBER] was inspected. An Automated Drug Dispensing System (ADDS, a computer-controlled medication storage cabinet used to dispense medication) was identified. DON stated access to the ADDS was granted and removed by the facility and supplier pharmacy. DON logged into the ADDS computer system to reveal a list of nursing staff who had authorization to access medications inside it. DON reviewed the list and identified the names of two nursing staff and stated they were no longer employed by the facility. DON further stated she had not followed up with the pharmacy after the employees ended their employment at the facility to terminate their access to the ADDS and there was no process in place to ensure nursing staff who no longer worked at the facility had their access to the ADDS removed in a timely manner. A review of an email sent by the Administrator on 7/20/26 at 5:36 p.m. indicated the last day worked for Licensed Nurse (LN) 7 and LN 8 was 11/19/25 and 6/4/26, respectively. A review of the facility's undated policy and procedure (P&P) titled, Storage of Medications, indicated, Policy . The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 2. During an inspection of med cart A on 7/20/26 at 12:24 p.m. with the DON, the following medications were identified inside their manufacturer boxes with pharmacy labels affixed to the box, but without resident specific labeling on the medications themselves:- One fluticasone/salmeterol (medication to treat asthma; a long-term lung disease that causes swelling, tightening, and mucus buildup in the airways) 100 micrograms (mcg, a unit of measurement)/50 mcg inhaler;-One umeclidinium/vilanterol Ellipta inhalation powder (a medication to treat chronic obstructive pulmonary disease [COPD], a long-term lung condition that makes it hard to breathe because of airway damage, swelling, or clogging, trapping old air inside) 62.5 mcg/25 mcg;-One fluticasone diskus (medication to treat asthma) 100 mcg inhaler,-One Breo Ellipta (medication to treat COPD) 200 mcg/25 mcg inhaler; and-One unlabeled Novolog (rapid-acting insulin used to control high blood sugar) 100 units/milliliter (u/ml, a unit of measurement) vial.DON stated the medications needed to be stored in the manufacturer's boxes which contained the pharmacy label to be able to correctly identify which residents they were for. During a concurrent observation and interview on 7/20/26 at 12:51 p.m. with LN 6, med cart D was inspected. LN 6 confirmed the following findings:-One budesonide/formoterol (medication to treat asthma) 160 mcg/4.5 mcg inhaler and one budesonide/formoterol 80 mcg/4.5 mcg inhaler were identified inside their manufacturer boxes with pharmacy labels affixed to the box, but without resident specific labeling on the medications themselves;-One Breyna (medication to treat asthma) 160 mcg/4.5 mcg inhaler in a box without a pharmacy label with the room [ROOM NUMBER]-A written on the box in blue marker; and-Three sterile saline vials for inhalation were identified in the med cart drawer without a pharmacy label. LN 6 stated the Breyna inhaler should have had a pharmacy label on the box. LN 6 further stated the supplier pharmacy did not open the boxes to label the inhalers, and the process was to store them in the labeled boxes to be able to identify which residents they were for. A review of the facility's undated P&P titled, Medications and Medication Labels, indicated, Policy . Medications are labeled in accordance with currently accepted professional principles . to promote safe medication use following state and federal law . Procedures . 4. The provider pharmacy permanently affixes label to the outside of prescription containers . For medications designed for multiple administration, (for example, inhaler or eye drops), a label is affixed to product to assure proper resident identification. A review of an article published by the Institute for Safe Medication Practices (ISMP, a nonprofit organization dedicated entirely to medication error prevention and safe medication use and who provide critical safety guidelines for healthcare worldwide) titled, Correct use of inhalers: Help residents breathe easier, dated 1/2017, indicated, Optimal use of inhalation devices . Dispensing and Consultant Pharmacists . Label the actual inhaler, not just the box in which it comes. 3. During a concurrent observation and interview on 7/20/26 at 9:10 a.m. with LN 5, LN 5 was observed exiting a resident's room holding a clear medicine cup with pills in it. LN 5 stated the resident did not take the medication and placed a second medicine cup on top of the pills so that the medication was sandwiched between the two cups and wrote the resident's room number with a marker on it. LN 5 stated she would dispose of it in a container located in the medication storage room later. LN 5 then placed the cups with the refused medications in them in the top drawer of the med cart. During an interview on 7/21/26 at 11:07 a.m. with the Assistant Director of Nursing (ADON), ADON expected nursing staff to document the refusal of medication, log the medication on the destruction log and then dispose of it in the designated bin in the medication storage room with another nurse to witness and cosign for the destruction. ADON also expected nursing staff to destroy the medication right then and there after resident refusal because some of the medications could be psychotropic medications. ADON stated it was not acceptable to store the refused medication in the med cart for later destruction because it was a concern for resident safety and could increase the chance for medication errors. ADON further stated it was also an infection control concern because the medication had entered and exited the resident's room. During an interview on 7/21/26 at 11:46 a.m. with the DON, DON expected nursing staff to immediately destroy refused doses of medication. DON stated it was not acceptable to store the medication in the med cart because doing so increased the potential for a medication error and was an infection control concern since the medication had entered the resident's room. A review of the facility's undated P&P titled, Disposal of Medications, indicated, Procedures 1. The director of nursing and the consultant pharmacist will monitor for compliance with federal and state laws and regulations in the handling of medications . 5. Medications not listed in Schedules II, III, IV and V (non-controlled medications) shall be destroyed by the nursing care center in the presence of a pharmacist or nurse and one other witness . 8. Outdated medications, contaminated or deteriorated medications, and the contents of containers with no label shall be destroyed according to the above policy.

Based on interview and record review, the facility failed to ensure informed consent was obtained prior to the administration of psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) for three of 26 sampled residents (Resident 2, Resident 20, and Resident 30). This failure increased the potential for residents or their responsible parties (RP, legal representative) to not be informed of the risks and benefits of the medications and possible treatment alternatives.Findings:A review of Resident 2's medical record indicated a physician's order for duloxetine (a medication used to treat depression and anxiety) delayed release Sprinkle 60 milligrams (mg; a unit of measurement) capsule, give one capsule by mouth one time a day related to depression, ordered 4/13/26.During a concurrent interview and record review on 7/22/26 at 1:11 p.m. with the Director of Nursing (DON), Resident 2's physician's order for duloxetine and consents were reviewed. DON stated an informed consent for duloxetine was not obtained.A review of Resident 20's medical record indicated a physician's order for Lamictal (a medication to treat bipolar disorder, a mental health condition marked by extreme, disruptive shifts in mood, energy, and activity levels) 50 mg tablet, give 50 mg by mouth two times a day related to bipolar disorder, ordered 12/25/25.During a concurrent interview and record review on 7/22/26 at 12:47 p.m. with the DON, Resident 20's physician's orders and consents were reviewed. DON confirmed she did not see an informed consent for Lamictal and expected nursing staff to ensure an informed consent was obtained by the doctor prior to administering the first dose of psychotropic medication. DON stated the informed consent was important to ensure a resident understood the reason for receiving the medication, the risks that could come with its use, and there was no misuse of psychotropic medications.A review of Resident 30's medical record indicated a physician's order for the following psychotropic medications:-Citalopram (a medication to treat depression) 10 mg tablet: Give one tablet via percutaneous endoscopic gastrostomy tube (PEG tube; a flexible plastic feeding tube placed through a small incision in the belly directly into the stomach) one time a day for repetitive counting, and clapping related to unspecified psychosis (a mental state where a person loses touch with reality where they have trouble telling what is real and what is not), ordered 2/3/26;-Depakote (a psychotropic medication to treat bipolar disorder) delayed release Sprinkle 125 mg capsule: Give two capsules via PEG tube two times a day for agitation related to depression, ordered 2/3/26;-Quetiapine (a psychotropic medication to treat bipolar disorder) 25 mg tablet: Give one tablet via PEG tube one time a day for generalized anxiety disorder (GAD; a mental health condition marked by constant, excessive, and hard-to-control worry) related to unspecified psychosis manifested by episodes of continuous yelling, ordered 2/24/26; and-Trazodone (a medication to treat insomnia and depression) 50 mg tablet: Give one tablet via PEG tube at bedtime for inability to sleep related to depression, ordered 2/3/26.During a concurrent interview and record review on 7/22/26 at 12:57 p.m. with the DON, Resident 30's physician's orders and consents were reviewed. DON confirmed she did not see an informed consent obtained for citalopram, Depakote or quetiapine. DON stated an informed consent was obtained for trazodone, but it was not complete because the dosage was not indicated and expected the dosage and frequency to be documented on the consent.A review of the facility's undated policy and procedure titled, Use of Psychotropic Medication(s), indicated, Policy Explanation and Compliance Guidelines . 9. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings [the strictest safety alert the United States Food and Drug Administration can mandate for a prescription or over-the-counter medication] for antipsychotic [a type of psychotropic medication] medications, in advance of such initiation or increase. 10. The resident has the right to accept or decline the initiation or increase of a psychotropic medication. 11. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc.)

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, a federally mandated resident assessment tool) was accurate for two of 26 sampled residents (Resident 29 and Resident 30), when:1. Resident 29's discharge assessment was not completed as required; and2. Resident 30's nutritional status assessment for two quarterly reviews did not indicate enteral feeding (a medical method of delivering liquid nutrients directly into the stomach or small intestine using a feeding tube).These failures increased the facility's potential for incorrect submission and reporting of residents' assessments. Findings: 1. A review of Resident 29's admission Record, indicated he was admitted to the facility on [DATE] with a diagnosis of acute and chronic respiratory failure with hypoxia (a condition when the body's tissues and organs do not get enough oxygen to work properly) and was discharged on 3/7/26. During a concurrent interview and record review on 7/21/26 at 2:20 p.m. with the Director of Nursing (DON), Resident 29's progress notes dated 3/7/26, change in condition transfer form dated 3/7/26, and MDS assessments were reviewed. DON stated Resident 29 was transferred to the hospital on 3/7/26 at 2:30 p.m. due to shortness of breath and labored breathing, despite receiving oxygen therapy. DON further stated the facility received a call from the hospital later that day indicating Resident 29 passed away. DON acknowledged the MDS assessment prepared and submitted for Resident 29 was an entry assessment only, and no discharge assessment was completed. DON also stated a discharge assessment should have been created to ensure proper reporting and compliance with regulations. 2. A review of an admission record indicated Resident 30 was admitted to the facility on [DATE] with a diagnosis of dysphagia (trouble or difficulty swallowing food, liquids, or even saliva). During a concurrent observation and interview on 7/23/26 at 10:45 a.m. with Licensed Nurse (LN) 1, Resident 30's feeding tube was observed as intact. LN 1 stated Resident 30 received medications and Glucerna (a specialized nutritional shake) bolus (a large dose of food or liquid given quickly into the body) through the feeding tube daily. A review of Resident 30's Order Summary Report, indicated Resident 30 had an order for Enteral feed as needed started on 7/25/25. The record further indicated Resident 30 had an order for Glucerna one time a day for supplement give eight ounces (oz; a unit of measurement) bolus via gastric tube (a feeding tube inserted through the abdomen directly into the stomach). During a concurrent interview and record review on 7/22/26 at 2:02 p.m. with MDS Coordinator (MDSC), MDSC confirmed MDS quarterly assessments dated 1/30/26, and 4/30/26, did not have enteral feeding triggered in those assessments. MDSC stated missing the enteral feeding could have been inaccurate MDS assessment. During a concurrent interview and record review on 7/22/26 at 2:16 p.m. with DON, Resident 96's quarterly MDS assessments were reviewed. DON confirmed the assessments dated 1/30/26 and 4/30/26 did not have enteral feeding triggered in those assessments. DON stated MDS should have been entered correctly otherwise; it could have been inaccurate MDS plan of care. A review of the facility's undated policy titled, Conducting an Accurate Resident Assessment, indicated, The purpose of this policy is to ensure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment by staff qualified to assess relevant care areas . The Administrator will ensure that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.

Based on observation, interview, and record review, the facility failed to protect and keep secure when not in use, confidential resident health records for a census of 92 residents, when Licensed Nurse (LN) 5 left medication boxes with confidential resident information unattended during medication (med) pass.This failure had the potential to expose and disclose the residents' personal and confidential health information to unauthorized individuals.Findings:During a med pass observation on 7/20/26 at 9:07 a.m. in Hall C, LN 5 was observed preparing medications for Resident 81. Another resident's prescription phenytoin (a medication to treat seizures; a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) suspension medication box with a pharmacy label affixed to it was observed on top of the med cart. LN 5 removed a prescription eye drop from the manufacturer's box to administer it to Resident 81 and set the box on top of the med cart. Both boxes had pharmacy labels affixed to them that contained confidential resident information. LN 5 entered Resident 81's room to administer the prepared medications and left the boxes unattended and visible to staff and residents who passed by.During a second med pass observation on 7/20/26 at 9:43 a.m. with LN 5, the box for phenytoin suspension was observed on the med cart, unattended.During an interview on 7/20/26 at 12:59 p.m. with LN 5, LN 5 confirmed she had left confidential resident information accessible and unsecure when the boxes with pharmacy labels were left unattended on the med cart during the morning med pass.During an interview on 7/21/26 at 11:40 a.m. with the Director of Nursing (DON), DON stated it was not acceptable to leave resident medication information unattended on the med cart.A review of the facility's undated policy and procedure titled, Confidentiality of Personal and Medical Records, indicated, Policy: This facility honors the resident's right to secure confidential personal and medical records. This includes the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record. Policy Explanation and Compliance Guidelines: 1. Personal and medical records include all types of records the facility might keep on a resident, whether they are medical, social, fund accounts, automated, or other. 2. 'Keep confidential' is defined as safeguarding the content of information . from unauthorized disclosure without the consent of the individual and/or the individual's surrogate or representative.

Based on interview and record review, the facility failed to confirm one of 26 sampled residents (Resident 96's) code status in an emergency, when Licensed Nurse (LN) 3 did not follow Resident 96's physician's order to do not attempt resuscitation (DNR). This failure resulted in delivering unwanted life-sustaining treatment that was inconsistent with Resident 96's wishes. Findings: A review of an admission record indicated Resident 96 was readmitted to the facility on [DATE] with a diagnosis of congestive heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).A review of Resident 96's Progress Notes, dated [DATE], indicated Resident 96 was found unresponsive on [DATE] and cardiopulmonary resuscitation (CPR; a life-saving emergency procedure performed on an individual who was found unresponsive, or showed no signs of breathing) was performed.A review of Resident 96's Order Summary Report (OSR), dated [DATE], indicated Resident 96 had an active code status order for DNR.A review of Resident 96's Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident 96's code status was DNR.A review of Resident 96's Physician/Provider Orders for Life-Sustaining Treatment (POLST), dated [DATE], indicated Resident 96 had chosen DNR and to allow natural death to occur.During an interview on [DATE] at 10:41 a.m. with LN 3, LN 3 stated CPR was performed on Resident 96 after he was found unresponsive on [DATE] at approximately 7:30 p.m. LN 3 further stated she reviewed Resident 96's physician's order at that time and confirmed Resident 96's code status was DNR.During a concurrent interview and record review on [DATE] at 2:02 p.m. with MDS Coordinator (MDSC), Resident 96's POLST and MDS assessment, dated [DATE] were reviewed. MDSC confirmed Resident 96's POLST and MDS assessment indicated DNR.During a concurrent interview and record review on [DATE] at 2:16 p.m. with Director of Nursing (DON), Resident 96's OSR dated [DATE], was reviewed. DON confirmed Resident 96's OSR indicated an active code status of DNR. DON expected Resident 96's physician's order and POLST to be carried out correctly otherwise; if not followed then Resident 96's wishes were not honored.A review of the facility's undated policy titled, Communication of Code Status, indicated, . this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information .

Based on observation, interview, and record review, the facility failed to ensure proper infection control measures for one of 26 sampled residents (Resident 81), when Licensed Nurse (LN) 5 did not change gloves or perform hand hygiene between oral (by mouth) and eye medication administration for Resident 81.This failure decreased the facility's potential to prevent cross contamination and infections among vulnerable residents.Findings:During a medication pass observation on 7/20/26 at 9:11 a.m., LN 5 was observed preparing seven medications for Resident 81 which included tablets, an oral liquid, and an eye drop. LN 5 put on gloves and carried the prepared oral medications in plastic medicine cups and the eye drop into Resident 81's room. LN 5 administered Resident 81's liquid medication, followed by oral tablets. LN 5 held Resident 81's cup of water and assisted him with sips from a straw in-between each tablet that was administered. LN 5 then administered Resident 81's eye drops without changing gloves or performing hand hygiene in between.During an interview on 7/20/26 at 1:11 p.m. with LN 5, LN 5 stated nursing staff were expected to perform hand hygiene in between administering oral and eye medications. LN 5 confirmed she did not and should have performed hand hygiene after she administered Resident 81's oral medications and before instilling his eye drop.During an interview on 7/21/26 at 11:45 a.m. with the Director of Nursing (DON), DON stated nursing staff were expected to perform hand hygiene in between administering oral medications and eyes drops, and gloves should be worn to administer eye drops.A review of the facility's undated policy and procedure (P&P) titled, Hand Hygiene, indicated, Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice .A review of the facility's undated P&P titled, Administration of Eye Drops or Ointments, indicated, Policy Explanation and Compliance Guidelines . 3. Wash hands or utilize alcohol-based hand rub and apply gloves. A review of the facility's undated P&P titled, Medication Administration, indicated, Policy: Medications are administered by licensed nurses . in accordance with professional standards of practice, in a manner to prevent contamination or infection.A review of an article published by the Center for Disease Control (CDC) titled, Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, indicated, Know when to clean your hands . Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or patient's surroundings. After contact with blood, body fluids, or contaminated surfaces. (https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html; accessed 7/23/24)

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from abuse, when Resident 2 swung a stuffed animal at Resident 1, grabbed her right arm, kicked her right leg, and threatened her.This failure decreased the facility's potential to protect Resident 1 from physical and verbal abuse.Findings:A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility in November 2025 with a diagnosis of chronic obstructive pulmonary disease (COPD -a chronic lung disease causing difficulty in breathing).A review of Resident 1's Minimum Data Set (MDS -a federally mandated assessment tool), dated 2/11/26, indicated Resident 1's Brief Interview for Mental Status (BIMS -an assessment tool used by facilities to screen and identify memory, orientation and judgement status of the resident) score was 15 out of 15 with good memory.A review of Resident 1's SBAR Communication Form (a communication tool used by healthcare workers when there is a change of condition among residents), dated 2/14/26, indicated Resident 1 was accused of stealing Resident 2's stuffed animal and Resident 1 was scratched and kicked by Resident 2.A review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility in October 2023 with a diagnosis of dementia (a progressive state of decline in mental abilities).A review of Resident 2's MDS, dated [DATE], indicated Resident 2's BIMS score was three out of 15 with severe memory impairment.A review of Resident 2's SBAR Communication Form, dated 2/14/26, indicated Resident 2 was involved in a physical and verbal altercation with Resident 1.During a concurrent observation and interview on 2/19/26 at 12:50 p.m. with Resident 1 in her room, a scabbed wound measuring about 1/8 inch (a unit of measurement) in length with redness around the area was observed on Resident 1's right arm. Resident 1 stated the wound was from Resident 2's fingernail when Resident 2 grabbed her arm on 2/14/26 around 7:30 p.m. in the foyer. Resident 1 further stated she was going to return Resident 2's stuffed animal, but when Resident 2 saw her she got mad, then she grabbed Resident 1's arm and hit her with the stuffed animal.During an interview on 2/19/26 at 1 p.m. with Resident 1, Resident 1 stated Resident 2 waited for her in their room after they were separated and then kicked her on the right leg. Resident 1 further stated Resident 2 was cussing at her and told her, I'm going to kill you . Resident 1 added she felt bad, was sore on her right arm and leg and was also afraid for a few nights after the incident.During an interview on 2/19/26 at 2:18 p.m. with Licensed Nurse (LN) 1, LN 1 stated on 2/14/26 at around 9:30 p.m., LN 1 heard yelling coming from Resident 1 and Resident 2's room. LN 1 stated Resident 2 was threatening Resident 1 and Resident 2 told Resident 1 get out of my room . I want to kill you .During an interview on 2/19/26 at 2:43 p.m. with LN 2, LN 2 stated on 2/14/26 between 7:30 p.m. to 8 p.m., LN 2 was charting at the nurse's station (by the foyer) when he heard Resident 1 and Resident 2 arguing. LN 2 then looked up and saw Resident 2 swung a stuffed animal at Resident 1 and Resident 1 used her arm to block it. LN 2 further stated Resident 2 was cussing at Resident 1.During an interview on 2/19/26 at 4:57 p.m. with Director of Nursing (DON), DON expected residents to always be safe.A review of the facility's policy titled, Abuse Prevention Program, revised 12/2016, indicated, Our residents have the right to be free from abuse . This includes but is not limited to freedom from . verbal . or physical abuse . Protect our residents from abuse by anyone including . other residents .

Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled and safely stored for a census of 95 residents, when:1. Expired and discontinued medications were stored in medication cart (med cart) C;2. Two bottles of wound treatment solutions and one tube of wound ointment were found stored in the treatment cart at station 2, opened and undated; and3. Three packets of antibiotic ointment (a thick, greasy cream applied to the skin to prevent bacterial infections in minor cuts, scrapes, and burns) were found expired and stored in the treatment cart at station 2.These failures decreased the facility's potential to safely store medications for residents.Findings:1. During a concurrent observation and interview on [DATE] at 3:17 p.m. with Licensed Nurse (LN) 2 in station 2, med cart C was inspected. LN 2 confirmed one medication had an expiration date of 11/2025, and five discontinued medications belonged to a resident that was discharged from the facility. LN 2 stated expired and discontinued medications should not be stored in the med cart due to the risk of administering these medications to residents. 2. During a concurrent observation and interview on [DATE] at 10:18 a.m. with LN 1 in station 2, the treatment cart was inspected. LN 1 confirmed one bottle of wound cleanser, one bottle of povidone-iodine solution (a liquid medicine used to apply to the skin to prevent infection), and one tube of calmoseptine ointment (a moisture barrier cream that protects and helps heal skin irritations) were found opened and undated. LN 1 stated wound treatment solutions and ointments should have an open and discard date.3. During a concurrent observation and interview on [DATE] at 10:18 a.m. with LN 1 in station 2, the treatment cart was inspected. LN 1 confirmed three packets of antibiotic ointment were stored with an expiration date of 11/2025. LN 1 stated expired ointments should not be stored in the treatment cart and should have been discarded. During an interview on [DATE] at 11:26 a.m. with Director of Nursing (DON), DON stated expired and discontinued medications should not be stored in the med cart or treatment cart. DON further expected LNs to label opened medications with open and discard date. A review of the facility's policy titled, Storage of Medications, updated [DATE], indicated, Discontinued, outdated, or deteriorated drugs or biologicals are returned to the pharmacy or destroyed . Drugs shall not be kept in stock after the expiration date .A review of the facility's policy titled, Administering Medications, revised 4/2019, indicated, . When opening a multi-dose container, the date opened is recorded on the container.

Based on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented for a census of 95 residents, when:1. Licensed Nurse (LN) 1 did not disinfect the blood pressure (BP) monitor in between resident use;2. Five sterile wound dressings (a medical covering completely free of germs and contaminants, designed to protect open wounds from bacteria) were opened and stored in the treatment cart at station 2; and3. A housekeeper (HK) did not wear the required personal protective equipment (PPE, any gear to protect your body from germs, hazardous chemicals in a medical setting like gloves, gowns, and masks) while deep cleaning the room of a resident on Enhanced Barrier Precaution (EBP, infection control method).These failures had the potential to spread infection among residents, staff, and visitors.Findings: 1. During an observation on 1/6/26 at 8:55 a.m. LN 1 went into a resident's room, checked the resident's BP then placed the BP monitor on the medication cart without disinfecting it. During an observation on 1/6/26 at 9:13 a.m. in the hallway, LN 1 used the same BP monitor to check another resident's BP. LN 1 did not disinfect the BP monitor prior to checking the resident's BP. During an interview on 1/6/26 at 1:56 p.m. with LN 1, LN 1 confirmed she did not disinfect the BP monitor in between use. LN 1 stated BP monitors were supposed to be disinfected before and after use to prevent the spread of infection between residents. During an interview on 1/8/26 at 11:26 a.m. with Director of Nursing (DON), DON expected staff to disinfect BP monitors in between resident use to prevent possible transmission of infection. A review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 10/2018, indicated, Reusable items are cleaned and disinfected or sterilized between residents . 2. During a concurrent observation and interview on 1/7/26 at 10:18 a.m. with LN 4, in station 2, the treatment cart was inspected. LN 4 confirmed five sterile wound dressings were found opened and stored in the treatment cart. LN 4 stated sterile wound dressings should not be kept in the treatment cart once it was opened to maintain sterility. LN 4 further stated not maintaining the sterility of the wound dressings would not be safe for the residents' wounds and could introduce more bacteria that could affect the residents' health. During an interview on 1/8/26 at 11:26 a.m. with DON, DON stated if a sterile wound dressing was opened, even if it was not used then the wound dressing should be discarded and should not be stored in the treatment cart due to possible contamination when placed on the residents' wounds. A review of the facility's policy titled, Storage of Medications, updated 7/10/24, indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner . deteriorated drugs or biologicals are . destroyed. 3. A review of Resident 5's admission Record, indicated she was admitted to the facility in July 2025 with a diagnosis of osteomyelitis (an infection of a bone caused by bacteria) of vertebra (spine) and sacral region (triangular shaped bone at the bottom of the spine). A review of Resident 5's Order Summary Report (OSR), dated 12/31/25, indicated, Resident 5 was ordered to be placed on EBP due to the presence of wounds and the use of a urinary catheter. During an observation on 1/5/26 at 10:10 a.m., HK was observed cleaning Resident 5's room. HK was not wearing a gown while disinfecting the bedside table, and the bed rail. HK stated she did not understand the meaning of the EBP sign posted outside the room. During a concurrent observation and interview on 1/5/26 at 10:40 a.m. with LN 3 in Resident 3's room, LN 3 confirmed HK was not wearing a gown while cleaning Resident 5's room who was on EBP. During a concurrent interview and record review on 1/7/26 at 10:05 a.m. with the Infection Preventionist (IP), Resident 5's physician orders were reviewed. IP confirmed Resident 5 was on EBP due to her wounds. IP stated staff should adhere to infection control practices which include wearing the required PPEs to effectively implement infection control measures. During an interview on 1/8/26 at 9:26 a.m. with the DON, DON stated staff should be knowledgeable about the proper procedure on what to do before entering a resident's room under any precautions. DON also stated as per the facility's policy, the use of appropriate PPE was required not only when providing direct care but also during the cleaning/disinfecting of a room under precautionary measures, to prevent exposing other residents to potential infections. A review of the facility's policy titled, Enhanced Barrier Precautions: Additional Considerations for California Skilled Nursing Facilities, updated in June 2024, indicated, Use of EBP by Environmental Services (EVS) personnel in rooms with Resident(s) on EBP . a specific example of high-contact EVS activities for which EVS personnel should use gown and gloves while cleaning and disinfecting the environment around residents on EBP . cleaning and disinfecting high touch surfaces such as bed rails, remote controls, bedside tables or stands on or near the resident's bedspace.

Based on observation, interview, and record review, the facility failed to store and serve food in a sanitary manner for a census of 95 residents, when:The refrigerator and freezer temperature were not monitored on multiple dates of two months;An expired cinnamon stick bottle was available for use; andThe [NAME] did not serve food in sanitary manner during tray line.These failures had the potential to result in foodborne illnesses among vulnerable residents.Findings:1. During a concurrent interview and record review on 1/5/26 at 8:24 a.m. with Dietary Manager (DM), the October and November 2025 temperature record for the refrigerators and freezers were reviewed. DM confirmed there was no temperature monitoring for the walk-in and reach-in refrigerators and/or the walk-in and reach-in freezers in the p.m. shifts on 10/1/25, 10/25/25, 11/23/25, and 11/24/25.A review of the facility's policy titled, Procedure for Refrigerated Storage, dated 2019, indicated the refrigerator's temperature was 41-degree Fahrenheit (a unit of measure) or lower and the freezer's temperature was zero-degree Fahrenheit and lower.2. During a concurrent observation and interview on 1/5/26 at 8:59 a.m. with DM, the spices rack was observed. DM confirmed the cinnamon stick bottle was available for use and had an expiration date 11/30/25. A review of the facility's policy titled, Storage of Food and Supplies, dated 2020, indicated, Food and supplies will be stored properly and in a safe manner. No food will be kept longer than the expiration date on the product. 3. During a concurrent observation and interview on 1/7/26 at 12:05 p.m. during tray line with the [NAME] and Registered Dietician (RD). The [NAME] used gloved hands, touched the handles of scoops and plates, and then used the same gloved hand to crush ready-to-eat food (fish) into smaller pieces. RD expected the [NAME] not to use the same gloved hands, after touching multiple surfaces, to touch ready-to-eat food, which could lead to food contamination. A review of the facility's policy titled, Food Handling, dated 2018, indicated, Food will be prepared and served in a sanitary manner. A review of the facility's policy titled, Maintaining a Sanitary Tray Line, dated 2025, indicated, This facility priorities tray assembly to ensure food are handled safely. The policy further indicated, Use utensils such tongs, serving spoons, etc. to handle food as much as possible.

Based on observation, interview, and record review, the facility failed to prepare food in a manner to conserve its nutritive value for a census of 95 residents, when the recipe was not followed for cooking carrot, pea, and fish. This failure had the potential for residents to experience decreased food intake and less nutrients in the served food. Findings: A review of the facility's menu served for lunch on 1/7/26 included oven crisp fish, tater tots, seasoned carrots, wheat roll, and apple hill cake. A review of the facility's recipe for seasoned peas, dated 2025, indicated the peas' cooking time was 10-15 minutes. A review of the facility's recipe for seasoned carrots, dated 2025, indicated the carrots' cooking time was 10-20 minutes. A review of the facility's recipe for oven crisp fish, dated 2025, indicated fish for 96 servings needed two cups of parsley flakes. The recipe also indicated to use thawed fillet fish of choice and coat both sides of the fish with ranch dressing. During an observation on 1/7/26 at 10:45 a.m., the [NAME] put carrots in a pot of water and peas in another pot of water and cooked them on the stove. The carrots were cooked until 11:20 a.m. and then placed on the steamer. The [NAME] added one teaspoon of salt and two ounces of butter in each pot of carrots. The peas were kept on the stove until tray line at 12 p.m. During an observation on 1/7/26 at around 10:30 a.m., the [NAME] opened frozen fillet fish, put it on the pan, spread one side of the fillet fish with ranch and some crushed potatoes chips. The [NAME] confirmed she did not use parsley. During an interview on 1/7/26 at 1:50 p.m. with the Registered Dietician (RD), RD stated it was important to follow the recipe regarding cooking time to maintain the food flavor and nutritive value. During an interview on 1/8/26 at 8:37 a.m. with Dietary Manager (DM), DM stated the [NAME] should have cooked carrots and peas for no more than 15-20 minutes as indicated in the recipe, because cooking more time might reduce the nutritive flavor of the vegetables and make it too soft. DM also stated the [NAME] should have followed the recipe and added parsley to the fish, thawed the fish fillet, and coated both sides of the fish with ranch dressing. A review of the facility's policy titled, Standardized Recipes, dated 2007, indicated, Standardized recipes shall be developed and used in the preparation of foods. A review of the facility's policy titled, Food Preparation, dated 2018, indicated, Serve vegetables promptly. Do not hold on the steam table for long period of time. (Maximum - 1 hour prior to serving). A review of the facility's policy titled, Food Preparation, dated 2020, indicated, Salt and season appropriately all meat, fish, and poultry according to the regular and special diets. Meats will be properly thawed.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5 percent (%) for one of 23 sampled residents (Resident 10), when three medications out of 34 opportunities were not given in accordance with the physician's orders and professional standards of practice. This failure resulted in a medication error rate of 8.82%.Findings:1. A review of Resident 10's admission Record, indicated Resident 10 was admitted to the facility in July 2018 with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and peripheral corneal degeneration (an eye condition where the outer edge of the cornea [the clear front layer of the eye] breaks down or changes over time). A review of Resident 10's Order Summary Report (OSR), dated 1/8/26, indicated, Resident 10 had an order for metformin (an oral medication that helps control blood sugar levels) 500 milligrams (mg, a unit of measurement), one tablet by mouth, two times a day.During a concurrent observation and interview on 1/6/26 at 8:33 a.m. with Licensed Nurse (LN) 1, LN 1 was preparing Resident 10's morning medications. LN 1 stated Resident 10 had an order for metformin, but it would not be given due to the medication not being available.During an interview on 1/6/26 at 1:43 p.m. with LN 1, LN 1 confirmed Resident 10's morning dose of metformin was not given because it was unavailable. LN 1 stated a missed dose of metformin could cause high blood sugar for Resident 10.During an interview on 1/7/26 at 12:28 p.m. with Director of Nursing (DON), DON stated metformin should have been given as ordered.2. A review of Resident 10's OSR, dated 1/8/26, indicated Resident 10 had an order for timolol (an eye drop medication used to lower high pressure inside the eye), one drop in right eye, two times a day and artificial tears (an eye drop used to lubricate dry eyes and help keep moisture on the outer surface of the eyes), one drop in both eyes, every two hours. During an observation on 1/6/26 at 8:41 a.m. in Resident 10's room, LN 1 administered one drop of timolol in Resident 10's right eye and then immediately administered artificial tears eye drop in both eyes.During an interview on 1/6/26 at 8:45 a.m. with LN 1, LN 1 confirmed both eye drops were administered consecutively.During an interview on 1/8/26 at 11:26 a.m. with DON, DON expected LNs to wait five minutes between administering different eyedrops. DON stated it was important to wait five minutes in between eyedrops to prevent the eyedrops from being less effective and to avoid potential side effects from administering them consecutively.During an interview on 1/8/26 at 1:07 p.m. with Consultant Pharmacist (CP), CP stated waiting five minutes between administering different eyedrops was important.A review of the facility's policy titled, Administering Medications, revised 4/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for one of 23 sampled residents (Resident 13), when the care plan did not address Resident 13's hospice (comfort-focused support for people with terminal illness) care and interventions.This failure decreased the facility's potential to address Resident 13's individualized care and specific needs.Findings:A review of Resident 13's admission Record, indicated she was admitted to the facility in June 2024 with diagnoses including hypertensive heart disease with heart failure (long-term high blood pressure causing the heart muscle to thicken and weaken which can lead to strokes).A review of Resident 13's hospice admission Order, dated 11/21/25, indicated she was admitted to hospice care in November 2025 with a diagnosis of cerebral atherosclerosis (hardening of the arteries in the brain which restricts blood flow raising risks for strokes).A review of Resident 13's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 11/26/25, indicated a significant change in status assessment was completed for Resident 13 following her admission under hospice care.During a concurrent interview and record review on 1/8/26 at 9:26 a.m. with the Director of Nursing (DON), Resident 13's admission order and care plans were reviewed. DON stated Resident 13 had been receiving hospice care since November 2025. DON confirmed there was no care plan in place for Resident 13's hospice care and further stated a care plan should have been developed by the nursing staff to ensure care was centered according to patient's wishes and necessary hospice care interventions were implemented effectively.A review of the facility's undated policy titled, Comprehensive Care Plans, indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . that includes . All services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on observation, interview, and record review, the facility failed to accommodate the needs and preferences for one of 23 sampled residents (Resident 94), when Resident 94 was not evaluated upon her request to use a motorized wheelchair at the facility.This failure decreased the facility's potential to maintain Resident 94's independent functioning, dignity, well-being and self-esteem.Findings:A review of Resident 94's admission Record, indicated she was admitted to the facility in February 2024 with diagnoses including muscle weakness and dystonia (a neurological disorder causing abnormal posture that can be painful).A review of Resident 94's Order Summary Report (OSR), dated 2/9/24, indicated Resident 94 was responsible for herself and could make her own healthcare decisions.A review of Resident 94's Minimum Data Set (MDS-a federally mandated assessment tool), dated 11/14/25, indicated Resident 94 was independent with bed mobility and only required set-up assistance for transfers. MDS also indicated Resident 94's Brief Interview of Mental Status score was 15 out of 15 with intact cognition and no memory issues.During a concurrent observation and interview on 1/5/26 at 10:35 a.m. with Resident 94 inside her room, Resident 94 stated she had a motorized wheelchair parked next to her bed, but she was not permitted to use it. Resident 94 further stated she was not assessed to determine if she could drive it safely and was simply told of the restriction without a clear explanation.A review of Resident 94's social services progress notes, dated 4/8/25, indicated, Resident 94 repeatedly requested assistance from the Social Services Director (SSD) to get permission to use her motorized wheelchair, but the request was always denied.During an interview on 1/8/26 at 9:40 a.m. with the Director of Rehab (DOR), DOR stated she recalled Resident 94 owning a motorized wheelchair and had expressed her desire multiple times to use it within the facility. DOR further stated an evaluation was not initiated because permission was denied by the previous administration.During a concurrent interview and record review on 1/8/26 at 9:26 a.m. with the Director of Nursing (DON), Resident 94's medical records were reviewed. DON stated there was no documentation indicating an evaluation was conducted for Resident 94 for the use of a motorized mobility device, which led to the decision to deny her the use of a motorized wheelchair.During an interview on 1/8/26 at 1:20 p.m. with the Regional Consultant (RC), RC confirmed an evaluation was not performed for Resident 94's request to use her own motorized wheelchair within the facility. RC expected staff to acknowledge and accommodate the residents' requests, provided they are safe for all the residents.A review of the facility's undated policy titled, Resident Rights, indicated, The resident has a right to be treated with respect and dignity including: the right to retain and use personal possessions . The right to receive services in the facility with reasonable accommodation of resident needs and preferences .

Based on observation, interview, and record review, the facility failed to provide necessary care and services for one of 23 sampled residents (Resident 48), when staff did not implement an appropriate communication system for Resident 48.This failure increased Resident 48's potential to experience delays in receiving necessary care and services.Findings:A review of Resident 48's admission Record, indicated he was admitted to the facility in October 2025 with a diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During an observation on 1/5/26 at 9:08 a.m. in Resident 48's room, Resident 48 was seated on his bed and was observed asking a question to Certified Nurse Assistant (CNA) 1 in Spanish. CNA 1 responded in English, informing Resident 48 to wait while she looked for a staff who speaks the same language. CNA 1 returned and informed Resident 48 that she could not find an available Spanish-speaking staff and asked him to wait a bit longer.During a concurrent observation and interview on 1/5/26 at 1:06 p.m. with Licensed Nurse (LN) 3, in Resident 48's room, Resident 48 was talking in Spanish and appeared to be anxious. LN 3 listened but stated he could not understand Resident 48. LN 3 went to look for a staff who can translate for Resident 48. After several minutes LN 3 returned with the Activities Driver (AD). AD explained to LN 3 that Resident 48 was asking about his medications. LN 3 stated finding staff who can translate was the usual method of handling residents who spoke different languages.During a concurrent observation and interview on 1/6/26 at 2:20 p.m. inside Resident 48's room, CNA 2 was observed talking with Resident 48. CNA 2 stated she could not understand what Resident 48 was saying so she decided to give him some snacks, stating Maybe he is hungry. CNA 2 also stated she usually try to find staff who could translate to help communicate with residents who spoke a different language.During an interview on 1/7/26 at 3:25 p.m. with the Social Services Director (SSD), SSD confirmed many residents at the facility, including Resident 48, spoke different languages. SSD stated she prepared communication boards/binders for each resident to facilitate better communication between staff and residents. SSD also stated posters with the phone number for the translation application (app) were placed in the staff breakroom and clock-in room to ensure staff were consistently reminded of this resource.During a concurrent observation and interview on 1/7/26 at 3:40 p.m. with SSD, SSD visited Resident 48's room and confirmed she could not find a communication board/binder for Resident 48. SSD then checked the staff break room for the translation app phone number and stated there was no translation app poster available by the break room.During a concurrent observation and interview on 1/7/26 at 4:15 p.m. with the Director of Nursing (DON) in the clock-in room, DON stated she could not find the poster with the translation app phone number.During an interview on 1/7/26 at 3:45 p.m. with the Director of Staff Development (DSD), DSD stated she did not provide an in-service training for staff in 2025 on how to address language barriers between staff and residents.During an interview on 1/8/26 at 9:26 a.m. with the DON, DON expected staff to use the appropriate tools to assist residents with limited language skills in better expressing themselves while they were at the facility and to ensure they received the necessary care in a timely manner without delay.A review of the facility's undated policy titled, Non-Discrimination-Language Assistance Service, indicated, It is the policy of this facility to ensure that individuals with Limited English Proficiency (LEP) . have access to language assistance services . The facility must not rely on staff other than qualified interpreters . All staff will be trained in effective communication techniques, including the effective use of an interpreter.

Based on interview and record review, the facility failed to review the pharmacist's recommendations for psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) for two of 23 sampled residents (Resident 19 and Resident 52), when:1. Resident 19's medication regimen review (MRR) for trazodone (a medication to treat depression) was not followed; and2. Resident 52's MRR for lorazepam (a medication to treat anxiety) was not followed.This failure increased the residents' potential to receive unnecessary medications.Findings:1. A review of Resident 19's admission Record, dated 1/8/26, indicated Resident 19 was admitted to the facility in 2019 with diagnoses including depression (mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress).A review of Resident 19's Order Summary Report, dated 1/8/26, indicated Resident 19 had an order, dated 9/7/23, for trazodone 25 milligrams (mg, a unit of measurement) by mouth at bedtime every Monday through Saturday for inability to sleep.A review of Resident 19's MRR titled, Note to Attending Physician/Prescriber, dated 11/13/25, indicated the Consultant Pharmacist (CP) recommended a gradual dose reduction (GDR, a tapering systematic steps to reduce dosage of medications) for trazodone 25 mg to every other night. MRR indicated no documentation of the physician/prescriber response of rationale, signature, and date.During a concurrent interview and record review on 1/8/26 at 10:34 a.m. with the Director of Nursing (DON), Resident 19's medical record was reviewed. DON confirmed Resident 19's order for trazodone 25 mg by mouth at bedtime every Monday to Saturday. DON stated the pharmacist's recommendation in November's MRR to reduce Resident 19's trazodone 25 mg to every other night was not followed, which might affect the resident's mental status.2. A review of Resident 52's admission Record, dated 1/8/26, indicated Resident 52 was admitted to the facility in 2025 with a diagnosis of depression.A review of Resident 52's Order Summary Report, dated 1/8/26, indicated Resident 52 had an order, dated 1/4/26, for lorazepam 0.5 mg by mouth as needed for anxiety for 14 days.A review of Resident 52's MRR titled, Consultant Pharmacist's Medication Regimen Review, dated 12/11/25, indicated CP requested clarification for the lorazepam order since there was no frequency in the order. MRR indicated no follow-up note documentation.During a concurrent interview and record review on 1/8/26 at 10:36 a.m. with the DON, Resident 52's medical record was reviewed. DON confirmed there was no frequency in the lorazepam order and stated without a frequency in the order, the nurse could have given an overdose.During an interview on 1/8/26 at 12:47 p.m. with CP, CP expected the facility to let the physician know and clarify the monthly MRR for Resident 19 and Resident 52. CP stated all orders should have a frequency and the MRR should have been updated as soon as possible.A review of the facility's policy titled, Medication Regimen Review and Reporting, dated 9/2018, indicated, Resident-specific MRR recommendations and findings are documented and acted upon by the nursing care center and/or physician. The policy further indicated, A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable format to nurses, physicians and the care planning team within 48 hours of MRR completion.

Based on interview and record review, the facility failed to ensure one of 23 sampled residents (Resident 53) was free from unnecessary medications, when Resident 53's lorazepam (an anti-anxiety medication) was prescribed without a stop date.This failure increased Resident 53's potential to receive an unnecessary medication.Findings:A review of Resident 53's admission Record, indicated he was admitted to the facility in October 2025 with a diagnosis of anxiety disorder.A review of Resident 53's Order Summary Report (OSR), dated 12/13/25, indicated an order for lorazepam 0.5 milligrams (mg; a unit of measurement) to be given every eight hours as needed (PRN) for anxiety with agitation with no stop date.A review of Resident 53's Medication Administration Record (MAR), dated 12/25 and 1/26, indicated Resident 53 received lorazepam 13 times in 12/25 and twice in 1/26.During a concurrent interview and record review on 1/8/26 at 9:26 a.m. with the Director of Nursing (DON), Resident 53's OSR and MARs were reviewed. DON confirmed Resident 53's order for PRN lorazepam did not indicate a stop date. DON stated lorazepam should have been ordered for a limited duration of 14 days only as per facility's policy to ensure the medication was used for specific symptoms only and not for staff convenience.A review of the facility's undated policy titled, Psychotropic Medications Policy, indicated, Psychotropic medications used on a PRN basis . is subject to the limitations as noted: PRN orders for psychotropic medications, shall be limited to no more than 14 days .

Based on interview and record review, the facility failed to ensure three of three sampled residents (Resident 1, Resident 2, and Resident 3) were free from abuse when:1a. Resident 1 and Resident 3 were observed slapping each on the arms on 11/9/25; and 1b. Resident 1 and Resident 2 were observed slapping each other on the arms on 11/11/25.This failure resulted in Resident 1 and Resident 2 sustaining abrasions on their arms. Findings:1a. During a review of Resident 1's clinical record, the clinical record indicated she was admitted to the facility on [DATE] with diagnoses that included dementia with other behavioral disturbance, cognitive communication deficit, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities), and unspecified psychosis (psychotic symptoms such as hallucinations, delusions or disorganized thinking not aligned with a specific psychotic disorder or mental illness). During a review of Resident 1's Quarterly Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 8/15/25, indicated Resident 1's BIMS (a brief screening that aids in detecting cognitive impairment) score was 2 out of 15 which indicated severe memory impairment.During a review of Resident 1's Progress Notes (PN) dated 11/9/25 at 3:54 p.m., the PN indicated, Nurse was walking by common area when nurse heard Resident C bed [Resident 3] was arguing with resident A bed [Resident 1] about sitting her in walker and escalated to a physical altercation. Nurse witness resident in A bed [Resident 3] slapped Resident C bed [Resident 1] on the arms. Resident C bed [Resident 1] slapped resident A bed [Resident 3] back on arms. Nurse separated residents, did a room change, moved resident C [Resident 3] to a different hallway. Did vitals and head to toe assessment. Residents have no injuries noted or reported.During an interview on 11/17/25 at 11:49 a.m. with Resident 1 she was unable to recall or provide details of the incident on 11/9/25.During a review of Resident 3's clinical record indicated she was admitted to the facility 1/6/23 with diagnoses that included anxiety disorder and Schizophrenia disorder (mental disorder characterized by hallucinations, delusions, disorganized thinking or behavior).During a review of Resident 3's Quarterly MDS, dated [DATE] Resident 3's BIMS score was 12 indicating she was cognitively intact.During an interview on 11/17/25 at 11:50 a.m. with Resident 3 when asked about the incident on 11/11/25, resident stated, I don't remember.1b. During a review of Resident 1's SBAR (situation, background, assessment, recommendation- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 11/11/25 at 7:57 p.m., indicated Resident 1 and Resident 2 were sitting at the same table in the dining room. Resident 1 grabbed the belongings of Resident 2. Resident 2 reached back for them and both residents started hitting each other. Both Resident 1 and Resident 2 sustained abrasions with bleeding. A housekeeper separated them and informed the nurses.During an interview on 11/17/25 at 11:49 a.m. with Resident 1 she was unable to recall or provide details of the incident on 11/11/25.A review of Resident 2's clinical record indicated she was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD- chronic condition caused by damage to the lungs that causes difficulty in breathing) and hypertension (high blood pressure).During a review of Resident 2's Quarterly MDS dated [DATE], Resident 2's BIMS score was 13 indicating she was cognitively intact.A review of Resident 2's SBAR form dated 11/11/25 at 8 p.m. indicated Resident 2 was watching television in the dining room and had some of her belongings with her. Resident 1 reached back to take Resident 2's belongings. The residents started hitting each other and Resident 2 sustained an abrasion, with bleeding, on her right foreman.During an interview on 11/17/25 at 12:03 p.m. with Resident 2, she stated the other resident grabbed her right arm. Resident lifted her sleeve showing bruising on right her forearm. Resident 2 further stated it doesn't hurt.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, copyright 2023, indicated, The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports.

Based on interview and record review, the facility failed to protect nine out of 97 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8 and Resident 9) from sexual abuse and the potential to affect all residents in the facility when the facility knowingly employed Certified Nursing Assistant 1 (CNA 1) with a history of a criminal misdemeanor (an offense punishable under criminal law). This failure led to nine residents ' (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8 and Resident 9) being sexually assaulted (sexual contact upon a person without their consent or on a person who is incapable of providing consent. Includes rape, unwanted sexual touching, oral sex and exposure) by CNA 1, with the potential to affect all residents in the facility who received care. On 2/21/25 at 7:25 p.m. an Immediate Jeopardy (IJ, a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility ' s Administrator (ADM) and the Regional Director of Operations (RDO). The IJ began on 12/10/24 when the facility hired CNA 1 with a known criminal history of abuse. The ADM and RDO were informed of the facility ' s failure to have systems in place to ensure all residents were protected from sexual abuse when the facility hired CNA 1 with a history of assault/intent to harm to care for a vulnerable population. This caused residents to have fear, anxiety, inability to sleep, to feel ashamed, embarrassed and at risk for long term psychosocial trauma such as social isolation, emotional instability, post-traumatic stress disorder and suicidal risk. On 2/24/25 at 3:35 p.m. during an onsite visit, the Department verified and confirmed through observation, interview and record review the IJ was removed after the facility presented an acceptable plan of action (POA, interventions to correct the deficient practice) on 2/21/25 at 9:21 p.m. which included the following: -Immediate suspension of CNA 1 on 1/24/25 -Audit of all current employee files to review background investigations - RDO in-serviced ADM to not hire employees with background/history of abuse. -ADM and/or designee to review applicant backgrounds -Director of Staff Development (DSD) and/or designee will contact listed references for new hires. Findings: During an interview on 1/30/25 at 1:42 p.m. with the ADM and Director of Nursing (DON), the ADM stated on 1/24/24 at 9:15 p.m. CNA 1 was suspended and removed from the building after allegations of sexual abuse toward Resident 1 were brought forward by CNA 2. The ADM stated CNA 1 was hired 12/10/24. The ADM stated, We do an initial interview, we check references and do a background check. The ADM stated CNA 1 ' s background check was completed, and she believed the DSD (Director of Staff Development) checked references. During a concurrent interview and record review on 1/30/25 at 2:30 p.m. with the ADM of CNA 1 ' s BACKGROUND SCREENING REPORT [BSR], dated 12/3/24 the BSR indicated, County Criminal History in [name of county] .INFORMATION FOUND .Charge KNOWLINGY TOUCH WITH INTENTION TO INJURE/INSULT/PROVOKE PERSON .Crime Type MISDEMEANOR .Disposition PLEA OF GUILTY OR RESPONSIBLE; SENTENCE IMPOSED Filing date 10/23/2019 . The ADM confirmed she was aware of the BSR prior to CNA 1 being hired and stated, He did explain to the DSD [Director of Staff Development] that it was a fight between he and his husband . During an interview on 1/30/25 at 3:08 p.m. with the ADM, the ADM was asked if the staff had voiced any concerns regarding CNA 1 and stated, .he came in to work one day with a black eye . During an interview on 1/30/25 at 3:18 p.m. with the DSD, the DSD stated, .On Friday the 24th he had been late to his shift .He did have two blackened eyes and a small cut on his cheek . When asked about CNA 1 ' s BSR misdemeanor, the DSD stated, [CNA 1] came forward on 12/3/24 about the information on his BSR incident dated 2019. He mentioned that he had several job opportunities and had no problem getting them after he explained what happened . During an interview on 2/3/25 at 10:28 a.m. with the DSD, the DSD stated she did not contact CNA1 ' s previous employer [skilled nursing facility] she was not able to reach them .called and left messages, but they did not return the call. During a concurrent interview and record review on 2/4/25 at 10:45 a.m. with the DSD of text message between the DSD and CNA 1, the DSD was asked what reference she called and stated, There are no specifics of who I call .I will do personal and professional . The DSD provided a document which contained CNA 1 ' s text message on 12/3/24 to the DSD which indicated, .I [CNA 1] received an email for the background check .It ' s a long story, to shorten it down called the cops on myself. Due to the nature of the situation, I was arrested and later charged. It was involving me and my husband . The DSD stated she brought the information to the ADM on 12/3/24 and the ADM and DSD called CNA 1 on 12/3/24 who gave further details of the charges. During an interview on 2/4/25 at 2:30 p.m. with the ADM and DON, the ADM confirmed she was aware of CNA 1 ' s previous charges and chose to hire him and stated, . [CNA 1] explained it as a domestic abuse. The ADM stated her expectations, Residents are treated with dignity and respect. They are not to be abused. During a review of the facility ' s policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, dated 2023, the P&P indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse . ' Abuse ' means the willful infliction of injury . ' Physical Abuse ' includes, but is not limited to hitting, slapping .Potential employees will be screened for a history of abuse .Background, reference, and credentials ' checks shall be conducted on potential employees .

Based on observation, interview, and record review, the facility failed to protect the residents ' right to be free from sexual abuse by a staff member for nine of ten sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, and Resident 9) when Certified Nursing Assistant 1 (CNA 1) sexually assaulted (sexual contact upon a person without their consent or on a person who is incapable of providing consent. Includes rape, unwanted sexual touching, oral sex and exposure) Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, and Resident 9. This failure caused the residents fear, anxiety, inability to sleep, to feel ashamed, embarrassed and at risk for long term psychosocial trauma such as social isolation, emotional instability, post-traumatic stress disorder and suicidal risk. On 2/21/25 at 7:25 p.m. an Immediate Jeopardy (IJ, a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility ' s Administrator (ADM) and the Regional Director of Operations (RDO). The IJ began on 12/10/24 when the facility hired CNA 1 with a known criminal history of abuse. The ADM and RDO were informed of the facility ' s failure to have systems in place to ensure all residents were protected from sexual abuse. On 2/24/25 at 3:35 p.m. during an onsite visit, the Department verified and confirmed the IJ was removed after the facility presented an acceptable plan of action (POA, interventions to correct the deficient practice) on 2/21/25 at 9:21 p.m. which included: -Immediate suspension of CNA 1 on 1/24/25 -Physician visits to residents subjected to abuse - Activity Director visits to residents subjected to abuse - Psychosocial assessments, and trauma assessment completed for all victims -Every shift monitoring of victims by nursing staff, reviewed by ADM or designee -Audit of all current employee files for history of abuse, adverse actions on background -In-service on preventing abuse and reporting abuse -Physical assessment and interview of all victims Findings: During an interview on 1/30/25 at 1:42 p.m. with the Administrator (ADM) and Director of Nursing (DON), the ADM stated she first learned of the incident with CNA 1 and Resident 1 during the evening of 1/24/25. The ADM stated they suspended CNA 1, and he left the building at 9:15 p.m. on 1/24/25. The ADM stated CNA 1 was hired 12/10/24. During a concurrent interview and record review on 1/30/25 at 2:30 p.m. with the ADM of CNA 1 ' s BACKGROUND SCREENING REPORT [BSR], dated 12/3/24 the BSR indicated, County Criminal History in [name of county] .INFORMATION FOUND .Charge KNOWLINGY TOUCH WITH INTENTION TO INJURE/INSULT/PROVOKE PERSON .Crime Type MISDEMEANOR .Disposition PLEA OF GUILTY OR RESPONSIBLE; SENTENCE IMPOSED Filing date 10/23/2019 . The ADM confirmed she was aware of the BSR prior to CNA 1 being hired and stated, He did explain to the DSD [Director of Staff Development] that it was a fight between he and his husband . A review of Resident 1 ' s clinical record indicated Resident 1 was admitted to the facility in early 2022 with diagnoses which included muscle weakness, encephalopathy (a medical condition that affects the brain ' s function), and intracranial injury (injury to the brain). During a review of Resident 1 ' s Minimum Data Set (MDS, federally mandated resident assessment tool) dated 11/23/24, the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 4/15, which indicated severe cognitive impairment. During a review of Resident 1 ' s Order Summary Report [OSR], order date 3/28/22, the OSR indicated, Resident is incapable of making health care decisions . During a review of Resident 1 ' s Progress Notes [PN], dated 1/27/25 at 6:56 p.m. the PN indicated, On 1/24/25 at approximately [8:30 p.m.] CNA [CNA 2] notified this nurse that a male CNA [CNA 1] assigned to the resident has no shirt on when doing care to the resident . During a review of the police report (Interview of CNA 1), dated 1/28/25, the report indicated CNA 1 confirmed he had [sexually assaulted] Resident 1. During a review of Resident 1 ' s PN, dated 1/29/25 at 7:15 a.m. the PN indicated, Resident is noted to keep one hand in his brief covering his private area. CNA ' s [Certified Nursing Assistant] are having trouble with ADL [Activities of Daily Living: basic tasks such as bathing, toileting] care. They are able to do care but takes reassurance. During an interview on 2/3/25 at 9:30 a.m. with Police Officer (PO 1) in the police department, PO 1 confirmed CNA 1 admitted to [sexual assault] on Resident 1. During a concurrent observation and interview on 2/3/25 at 1:12 p.m. with Resident 1 in his bedroom, Resident 1 was sitting in a reclining wheelchair, he was unable to reposition himself or stand. Resident 1 was unable to have any meaningful conversation. During an interview on 2/3/25 at 3:19 p.m. with CNA 2, CNA 2 stated, I was doing my rounds [evening shift of 1/24/25] .I saw that Resident 1 ' s door was closed, and I was confused because I was his CNA .the curtain was all the way closed [around Resident 1 ' s bed] .I saw heels of shoes from under the curtain like they were kneeling .I saw [CNA 1] with Resident 1 ' s bed all the way to the floor. [CNA 1 ' s] shirt was off. Resident 1 ' s brief [adult incontinence undergarment] was all the way off. [CNA 1 ' s] hands were on [Resident 1 ' s] [groin area] . During an interview on 2/4/25 at 11:23 a.m. with CNA 3, CNA 3 stated since the incident with CNA 1 she has had difficulty providing care for Resident 1 [Resident 1] would cover his penis with his hands when I am assisting him with his brief. This is new behavior. During an interview on 2/4/25 at 11:43 a.m. with CNA 4, CNA 4 stated Resident 1 ' s appetite has not been the same . [Resident 1] has been constantly trying to hold and cover himself [indicated to groin], even when he is eating. A review of Resident 2 ' s clinical record indicated Resident 2 was admitted to the facility in late 2023 with diagnoses which included cerebral infarction (occurs when blood flow to the brain is interrupted, causing brain cells to die), cerebral edema (brain swelling), and depression. During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated a BIMS score of 13/15, which indicated intact cognition. During a review of Resident 2 ' s OSR, order date 9/9/24, the OSR indicated, Resident is incapable of making his/her own health decisions . During a review of Resident 2 ' s PN dated 1/24/25 at 7:36 p.m. the PN indicated, A CNA informed me that [CNA 1] was sitting on his knee near the resident bed. the curtain was close (sic). when I went in, I asked the CNA 1what he was doing and he said, ' I was giving the resident urinal ' . During a review of Resident 2 ' s PN dated 1/24/25 at 9 p.m. the PN indicated, Resident verbalized that [CNA 1] [sexually assaulted him]. Resident stated the situation happened twice, but he did not mention it. He also said that the (sic) CNA entered his room to change him and [sexually assaulted him] . During a review of untitled facility document dated 1/25/25, the document indicated, [Resident 2] . Do you have any issues you would like to let us know of? Last week it happened twice, one male CNA entered my room to change me and [sexually assaulted him]. I told him [CNA 1] to stop. I had a hard time sleeping last night thinking he will come back in my room . During a review of the police report (Interview with CNA 1) dated 1/28/25, the report indicated CNA 1 confirmed he had [sexually assaulted] Resident 2. During an interview on 2/3/25 at 9:30 a.m. with PO 1 in the police department, PO 1 confirmed CNA 1 admitted to [sexual assault] on Resident 2. During a concurrent observation and interview on 2/3/25 at 12:45 p.m. with Resident 2 in his bedroom, Resident 2 was sitting in his wheelchair, and provided two instances of [sexual assault] by CNA 1. Resident 2 stated, Sometimes I hear a noise in the night I wake up and wonder if it could be him. After I wake up sometimes, I can ' t go back to sleep . During an interview on 2/3/25 at 1:33 p.m. with Licensed Nurse (LN 1), LN 1 confirmed she was working 1/24/25 and stated, .My CNA came to me and said CNA 1 [was in Resident 2 ' s room] and was kneeling on the floor with the curtain closed. I went to [Resident 2 ' s] room .Resident 2 ' s brief was open, and CNA 1 had a urinal in his hand . During an interview on 2/4/25 at 11:43 a.m. with CNA 4, CNA 4 stated Resident 2 had been upset, crying and told CNA 4 God is never going to forgive me for that . A review of Resident 3 ' s clinical record indicated Resident 3 was admitted to the facility in mid-2024 with diagnoses which included muscle weakness, and need for assistance with personal care. During a review of Resident 3 ' s MDS dated , 1/26/25 the MDS indicated a BIMS score of 9/15, which indicated moderate cognitive impairment. During a review of Resident 3 ' s OSR, the OSR did not indicate Resident 3 ' s capacity to make health care decisions. During a review of Resident 3 ' s PN dated 1/25/25 at 11:15 a.m., the PN indicated, Resident is verbalizing that when male CNA [CNA 1] was giving them (sic) shower yesterday .CNA took his shoes off .Then when the Resident opened his eyes, he said thatthe (sic) CNA was down to his underwear .Resident said he was shocked. Then the resident said the CNA became fully naked and started washing the resident. Resident said that the CNA proceeded to [sexually assault him]. Resident said he was embarrassed and shocked . During a review of the police report interview of Resident 3 dated 1/25/25, the report indicated Resident 3 stated, I was kind of embarrassed .this has been an ongoing thing basically since [CNA 1] got here .Things like exposing himself .[CNA1] [sexually assaulted Resident 3] .I am just embarrassed. I fear for my life in here. I couldn ' t believe how blatant he was . During a review of the police report (Interview of CNA 1) dated 1/28/25, the report indicated CNA 1confirmed he had [sexually assaulted] Resident 3. During an interview on 2/3/25 at 9:30 a.m. with PO 1 in the police department, PO 1 confirmed CNA 1 admitted to [sexual assault] on Resident 3. During an interview on 2/3/25 at 3:19 p.m. with CNA 2, CNA 2 stated on 1/24/25 Resident 3 had told her CNA 1 had taken him into the shower (evening of 1/24/25), taken his clothes off and [sexually assaulted him]. During an interview on 2/24/25 at 1:48 p.m. with Resident 3 in his bedroom, Resident 3 was asked about the incident on 1/24/25 with CNA 1, Resident 3 stated that when CNA 1 took him to the shower the CNA 1 took his own clothes off and was naked. Resident 3 said that CNA 1 put his privates in [Resident 3 ' s] face and Resident 3 said he kept jerking his head back. Resident 3 further stated that when CNA 1 put him back to bed he sexually assaulted him. Resident 3 stated, I was so upset that night I went to the hospital . A review of Resident 4 ' s clinical record indicated Resident 4 was admitted to the facility in late 2024 with diagnoses which included cognitive communication deficit, phocomelia (a congenital condition that causes malformation of the arms and legs), depression, dementia, schizophrenia (a disorder that affects a person ' s ability to think, feel and behave), anxiety disorder and adult failure to thrive (a syndrome in older adults characterized by a decline in overall health). During a review of Resident 4 ' s MDS dated [DATE], the MDS indicated a BIMS score of 9/15, which indicated moderate cognitive impairment. During a review of Resident 4 ' s OSR, order start date of 12/19/24, the OSR indicated, Resident is Capable Of Understanding Rights . During a review of Resident 4 ' s PN dated 1/29/25 at 4:37 p.m. the PN indicated, While in police, (sic) the abuser confessed that he sexually abused the resident. Staff interviewed the resident, and he states that the abuser [sexually assaulted him]. During a review of the police report (Interview of CNA 1) dated 1/28/25, the report indicated CNA 1 confirmed he had [sexually assaulted] Resident 4. During a review of the police report interview of Resident 4, dated 1/29/25, the report indicated Resident 4 stated, .this happened to me three times. [CNA 1] [sexually assaulted Resident 4] .I was scared when the nurse was [sexually assaulting him] .I never said anything to him and he never said anything to me .I did not want him to do this to me . Resident 4 stated in his interview that he felt scared when the nurse [CNA 1] was working at the care center. During an interview on 2/3/25 at 9:30 a.m. with PO 1 in the police department, PO 1 confirmed CNA 1 admitted to [sexual assault] on Resident 4. During a concurrent observation and interview on 2/3/25 at 11:33 a.m. with Resident 4 in his bedroom, Resident 4 was lying in bed. Resident 4 stated, He [CNA 1] came three or four times. The first time he [CNA1] masturbated himself and [sexually assaulted Resident 4]. The second time he [CNA 1] took off all his clothes. He [CNA 1] was masturbating himself and [sexually assaulted Resident 4] .I am afraid he has friends here that will do things to me .I did not tell him to stop because I was afraid and ashamed . Resident 4 stated he did not really feel safe in the facility. During an interview on 2/4/25 at 11:35 a.m. with CNA 6, CNA stated, [Resident 4] does have a change in behavior [since the incident] .As I start to wipe him he gets an erection, when I turn him he started to touch me .its new behavior. A review of Resident 5 ' s clinical record indicated Resident 5 was admitted to the facility in early 2023 with diagnoses which included need for assistance with personal care, traumatic brain injury (brain dysfunction cause by an outside force, usually a violent blow to the head), cognitive communication deficit, muscle weakness, and paraplegia (loss of motor function in the legs). During a review of Resident 5 ' s MDS dated [DATE], the MDS indicated a BIMS score of 11/15, which indicated moderate cognitive impairment. During a review of Resident 5 ' s OSR, the OSR did not indicate Resident 5 ' s capacity to make health care decisions. During a review of an untitled facility document dated 1/25/25, the document indicated, [Resident 5] . Do you have any issues you would like to let us know of? Yesterday, a male with [description of CNA 1] entered in my room, pulled his pants down and showed me his butt, and started masturbating in front of me. I told him to get out of my face and my room. This incident happened another time with the same male in my room . During a review of Resident 5 ' PN dated 1/27/25 at 1:47 p.m. the PN indicated, Resident appeared worried and anxious. Expressed his worries about alleged abuser returning to the building . During a review of Resident 5 ' s PN dated 1/27/25 at 6:38 p.m. the PN indicated, On 1/24/25 at approximately [8 p.m.], According to charge nurse resident was upset that the resident (sic) pants fell down, and he [Resident 5] saw his [CNA1 ' s] butt . During a review of the police report (Interview of CNA 1) dated 1/28/25, the report indicated CNA 1 confirmed he had [sexually assaulted] Resident 5. During an interview on 2/3/25 at 9:30 a.m. with PO 1 in the police department, PO 1 confirmed CNA 1 admitted to [sexual assault] on Resident 5. During a concurrent observation and interview on 2/3/25 at 1:40 p.m. with Resident 5 on the outside patio, Resident 5 stated, [CNA 1] came into my room and [sexually assaulted him]. I hollered and hit the wall and the call button. He did not leave the room . Resident 5 began to cry, visibly shake and stated, I get scared in my room. I ' m afraid he is going to come back and do it again .I don ' t feel safe. During an interview on 2/4/25 at 11:43 a.m. with CNA 4, CNA 4 stated, He [Resident 5] called me in to stay in his room [after the incident] because his roommate had walked out of the bathroom and was walking toward his bed and [Resident 5] was freaking out because he thought ' the guy ' was coming back. I stayed with him .he kept crying . A review of Resident 6 ' s clinical record indicated Resident 6 was originally admitted to the facility in early 2024 with diagnoses which included muscle weakness, dementia, and depression. During a review of Resident 6 ' s MDS, dated [DATE], the MDS indicated a BIMS score of 9/15, which indicated moderate cognitive impairment. During a review of Resident 6 ' s OSR order date 1/21/25, the OSR indicated, Resident is incapable Of Understanding Rights, Responsibilities, And Informed Consent . During a review of Resident 6 ' s PN dated 1/29/25 at 4 p.m. the PN indicated, While in custody, the abuser confessed that he sexually abuse (sic) the resident. Staff went to interview the resident, but the resident cannot communicate d/t [due to] mental condition. However, during the interview he became very tense . During a review of the police report (Interview of CNA 1) dated 1/28/25, the report indicated CNA1 confirmed he had [sexually assaulted] Resident 6. During an interview on 2/3/25 at 9:30 a.m. with PO 1 in the police department, PO 1 confirmed CNA1 admitted to [sexual assault] on Resident 6. During a concurrent observation and interview on 2/3/25 at 11:53 a.m. with Resident 6 in his room, Resident 6 was lying on his bed. He was unable to sit up or use his call light. Resident 6 closed his eyes, and his respirations increased when asked questions. He did not verbally respond to any questions. A review of Resident 7 ' s clinical record indicated Resident 7 was admitted to the facility mid-2023 with diagnoses which included need for assistance with personal care, depression, and anxiety. During a review of Resident 7 ' s MDS, dated [DATE], the MDS indicated a BIMS score of 15/15, which indicated no cognitive impairment. During a review of Resident 7 ' s OSR, order date 5/14/24, the OSR indicated, Resident is [Capable Of Understanding Rights, Responsibilities, And Informed Consent]. During a review of the department ' s On-Line Health Facility Complaint form, anonymously submitted, dated 1/31/25, the form indicated, Patient [Resident 7] confined (sic) in me and told me he has been a victim of sexual abuse by a CNA .CNA name is [CNA 1] . During a review of Resident 7 ' s PN dated 2/3/25 at 4:10 p.m., the PN indicated, Resident alleges that last month, a male CNA went into his room and [sexually assaulted] him and his roommate . During a concurrent observation and interview on 2/3/25 at 2:45 p.m. with Resident 7 in his bedroom, Resident 7 stated, I was talking to one of the CNAs about it .she said she had to report it. What happened was [CNA 1] walked into the room, he set my water down and touched my legs, rubbing them as he walked by. [Resident 7 demonstrated by running his hand down his upper thing from groin toward his knee] I told him not to do that, then he [CNA 1] pulled his pants down and [sexually assaulted him]. No underwear. It was very shocking to be honest . A review of Resident 8 ' s clinical record indicated Resident 8 was admitted to the facility mid-2024 with diagnoses which included depression, schizophrenia, bipolar disorder (a disorder associated with episodes of mood swing), and anxiety. During a review of Resident 8 ' s MDS, dated [DATE], the MDS indicated a BIMS score of 15/15, which indicated no cognitive impairment. During a review of Resident 8 ' s OSR, order date 5/14/24, the OSR indicated, Resident is [Capable Of Understanding Rights, Responsibilities, And Informed Consent]. During a review of Resident 8 ' s PN dated 2/3/25 at 4:17 p.m. the PN indicated, Resident alleges that last month one male CNA had [sexually assaulted him] in his room in front of himself and his roommate . During an interview on 2/3/25 at 3:02 p.m. with Resident 8 in his bedroom, Resident 8 stated, He [CNA 1] came into the room .he walked over to my bed and lifted his shirt up all the way to his chest, and then pulled his pants down, he was not wearing anything .I did not say anything .I felt shocked, I did not expect that . During an interview on 2/4/25 at 12:31 p.m. with LN 2, LN 2 stated, We have to do STD [sexually transmitted disease] testing on all the residents. It ' s a lot for the residents. During an interview on 2/4/25 at 2:30 p.m. with the ADM and DON, the ADM confirmed she was aware of CNA 1 ' s previous charges and chose to hire him. The ADM stated her expectations were, Residents are treated with dignity and respect. They are not to be abused. A review of Resident 9 ' s clinical record indicated Resident 9 was admitted to the facility late 2020 with diagnoses which included muscle weakness, anxiety disorder, and depression. During a review of Resident 9 ' s MDS, dated [DATE], the MDS indicated a BIMS score of 15/15, which indicated no cognitive impairment. During a review of Resident 9 ' s OSR, order date 9/27/24, the OSR indicated, Resident is Capable Of Understanding Rights, Responsibilities, And Informed Consent. During a review of Resident 9 ' s PN dated 2/18/25 at 12:36 p.m. the PN indicated, .the male CNA [CNA1] had exposed himself inappropriately by Pulled (sic) his pants down in (sic) dining room. [Resident 9] was able to describe she was closed (sic) to piano .I was able to see his blue underwear, then he pulled his pants up and left. During a review of Resident 9 ' s PN dated 2/24/25 at 9:48 p.m. the PN indicated, .[Resident 9] stated, ' I can still see the incident, I am not able to get over it, but I am working on it ' . During an interview on 2/18/25 at 11:08 a.m. with Resident 9 in her bedroom, Resident 9 stated, He [CNA 1] was standing across the room .It was evening time .He [CNA 1] took his pants and pulled them down so I could see his whole blue bikini underwear in the front. He hooked his thumbs into the waistband of his pants and pulled them down . I think it mentally hurt us . During a review of the facility ' s policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, dated 2023, the P&P indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .[Criminal sexual abuse] . serious bodily also includes sexual intercourse with a resident who is incapable of declining to participate in the sexual act or lacks the ability to understand the nature of the sexual act .[Sexual abuse] is non-consensual sexual contact of any type with a resident .Possible indicators of abuse include, but are not limited to: sudden unexplained changes in behavior and/or activities such as fear of a person or place, or feelings of guilt and shame . During a review of the facility ' s P&P titled, Resident Rights, dated 2/21, the P&P indicated, Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to .a dignified existence .be free from abuse .

Based on interview and record review, the facility failed to implement measures to safely transfer one of three sampled residents (Resident 1) when staff did not follow facility Policy and Procedures (P&P) for safe resident handling/transfers and the Physical Therapy (PT) recommendations for the use of a sit to stand lift (a device designed to assist patients who have some mobility but need help to rise from a sitting position) with (2) staff assistance. This failure resulted in a fracture (break) of the bone in the lower leg and increased pain for Resident 1. Findings: A review of Resident 1's clinical record included the following documents: Resident'1s face sheet, indicated Resident 1 was admitted [DATE] with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body), Cerebral Infarction (a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause part of the brain to die) and the need for assistance with personal care. The Minimum Data Set (MDS, an assessment tool), dated 2/24/24, indicated Resident 1 was cognitively intact. A PT evaluation and treatment plan, dated 2/19/24, indicated Patient will safely perform functional transfers with Substantial/Maximal Assistance for correct hand/foot placement in order to perform functional mobility with reduced risk of falls. A Fall Risk Care Plan (CP), initiated 2/20/24, indicated Resident 1 was at risk for falls related to use of medications and osteomyelitis of vertebra (an infection of the spine) .resident will be free of .injury .follow facility protocol. A Therapy Note, dated 3/7/24 at 12:14 p.m., written by the Director of Rehabilitation indicated, PT [Resident 1] is able to tolerate a stand lift [sit to stand lift]. Suggest 2 person. A Change in Condition (COC) nursing evaluation, dated 3/8/24 and completed by Licensed Nurse (LN) 3, indicated at 8 a.m. Nursing observations, evaluation, and recommendations are:@0800 the resident complains about pain level 8 on L sheen [shin] and L ankle, with movement, cannot handle having the skin in the area being touched, no swelling or skin color or temperature changed at both sites, she can move her toes on L foot but with pain, resident received Oxycodone (narcotic pain medication)15 mg (milligram, a meaurement) 1 tab PO @0400, and Morphine (strong narcotic pain medication) 20 mg 1 tba[tablet]PO @0900,still c/o pain level 8, she states pain medications does not work, I want to go the hospital. Review of a General Note written by a LN on 3/8/24 at 10:07 a.m., indicated, Resident was sent to [name of hospital] for uncontrolled pain leveled 8 in L sheen [shin] and L ankle. A nursing note dated 3/8/24 at 2:54 p.m. stated, Called [name of hospital] to follow up sending resident for unrelieved pain to left leg. [name of hospital] nurse reported that resident was being discharged this afternoon. She has a fracture in left tibia and left fibula [broken bones in lower leg] and has a splint .follow up to be done with surgeon. During an interview on 3/13/24 at 12:50 p.m. with Resident 1, Resident 1 stated, It was last Thursday, after dinner, was sitting in wheelchair, needed to get back to bed, the CNAs were helping me to bed, I couldn't help much but they told me, 'You have to help us,' pulling on my arms, one on each side stood me up from wheelchair (wheelchair was facing bed), left leg slid forward - I had no socks on - my slippers are over there (Resident 1 pointed to shelf where red slip on shoes were visible) . heard a crack . they got me in bed, moved my legs over and I heard another crack but I was in excruciating pain. Resident 1 identified one Certified Nursing Assistant (CNA) by name and stated, She was holding my arm and shoulder and the other CNA had my left arm. They kept telling me, 'You have to help us,' but I couldn't. Resident 1 stated the CNAs did not use a lift [sit to stand lift] when they helped her to bed. During an interview on 3/13/24 at 2:40 p.m. with CNA 3, CNA 3 confirmed a sit to stand lift was not used per PT safe transfer recommendations for a resident transfer from wheelchair to bed. CNA 3 stated, along with CNA 4 .a two-person transfer was used to move Resident 1 from her wheelchair to bed. CNA 3 confirmed Resident 1 complained of pain to her left leg after the transfer was completed. During an interview on 3/13/24 at 3 p.m. with CNA 4, CNA 4 confirmed a lift [sit to stand lift] was required when transferring Resident 1 .there was one outside the room .but Resident 1 declined. CNA 4 stated Resident 1 complained of left leg pain after two-person transfer from wheelchair to bed. During an interview on 3/13/24 at 3:30 p.m., with the Director of Nursing (DON), the DON stated, The following morning, after Resident 1 was transferred without the lift, Resident 1 was still complaining of pain to her left leg .her doctor was notified, and Resident [1] was transferred to the hospital for further evaluation of left leg pain. The DON further confirmed, Resident 1 needed a lift [sit to stand lift] (per PT safe transfer recommendations and the facility P&P) for transfer and staff should not have transferred the resident without the use of the sit to stand lift. Residents requiring lift transfers are not safe with just a 2-person transfer .residents can be harmed if proper equipment is not used for transfers. During an interview on 3/13/24 at 3:55 p.m. with the Administrator, the Administrator stated her expectation is for staff to transfer residents safely which requires following the treatment plan and transfer recommendations. The Administrator further stated that residents can be harmed if proper equipment is not used. During a review of the P&P titled Safety and Supervision of Residents, dated 2001 MED-PASS, Inc, (Revised July 2017), the P&P indicated, Facility strives to make the environment as free from accident hazards as possible .Resident safety and supervision and assistance to prevent accidents are facility wide priorities . The care team shall target interventions to reduce individual risks . including adequate supervision and assistive devices. During a review of the facility P&P titled Fall Prevention Program,, dated October 2022 Revision, the P&P indicated, [The facility will] .provide additional interventions as directed by the resident's assessment, including but not limited to .Assistive devices [lifts]. During a review of the facility P&P titled Safe Resident Handling/Transfers, dated 2023, the P&P indicated, .The use of mechanical lifts are a safer alternative and should be used .Staff members are expected to maintain compliance with safe handling/transfer practices .Resident lifting and transferring will be performed according to the resident's individual plan of care.

Based on observation, interview and record review, the facility failed to protect one of five residents (Resident 1) from neglect, when a severe left leg injury of unknown origin was originally observed by facility staff on 5/23/23, but not assessed, treated and reported until 5/27/23. This failure resulted in Resident 1 experiencing prolonged, under-treated and unnecessary pain. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility in the winter of 2013 with diagnoses which included dementia, (problems with memory, language and other thinking abilities), osteoarthritis (joint disease), and chronic pain syndrome (pain lasting 3-6 months or longer associated with depression and anxiety). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 4/30/23, the MDS indicated the BIMS (Brief Interview for Mental Status, an assessment tool), was 2 out of 15, which reflected severe knowledge and memory impairment. During an interview on 6/1/23, at 11 a.m., with the Director of Nurses (DON), the DON indicated he was notified on 5/27/23, at 10:28 p.m., by Licensed Nurse 2 (LN 2), that Resident 1's x-ray results reflected fractures of the left lower tibia and fibula (both bones of the lower leg) and that Resident 1 needed to be transported to the emergency department. During an observation on 6/1/23, at 11:45 a.m., of Resident 1, Resident 1 was lying in bed awake, alert and verbally responsive. Resident 1 was observed to be moaning and crying out. During a continued observation, Resident 1's left leg was observed to be yellow from knee to toes. Additional purple discoloration was observed around the heal and ankle. The left leg was observed to be swollen, with a possible deformity around the middle calf area extending to the ankle. During an interview on 6/1/23, at 11:45 a.m., Resident 1 indicated They hurt me. Resident 1 further indicated, People are mean. When asked to elaborate, Resident 1 repeated, They hurt me, indicating the door to the hallway. Resident 1 was not able to give further information but continued to moan and cry out. Tears were observed on Resident 1's face. It was further observed that there was not a splint on Resident 1's leg but that the splint was lying in a wheelchair, which was against a wall. During an interview on 6/1/23, at 11:55 a.m., with LN 1, LN 1 indicated he was not aware of what had happened to Residents 1's leg, other than Resident 1 refused to wear the splint provided by the acute care facility. LN 1 indicated he had not notified the physician that Resident 1 refused to wear the splint. When asked about pain medication for Resident 1, LN 1 indicted Resident 1 had received her routine hydrocodone at 8 a.m. and that he would give her some [brand name] acetaminophen if she was in pain. During an interview on 6/1/23, at 1:10 p.m., with CNA 1, CNA 1 indicated she had noticed a little swelling to Resident 1's left ankle on 5/23/23, and had reported it to LN 1. CNA 1 indicated she had again reported the bruising and pain to LN 1 on 5/26/23. CNA 1 further indicated that on 5/27/23, while providing care to Resident 1, she noticed Resident 1's left lower leg was bruised and painful to touch or move. CNA 1 indicated the bruises were yellow and purple, mostly purple close to the ankle. CNA 1 indicated she had reported the bruising and pain to LN 1. During a follow-up interview on 6/1/23, at 2 p.m., with LN 1, LN 1 indicated he had not medicated Resident 1 for pain and was waiting for a return call from the physician. During a subsequent interview and observation on 6/1/23, at 2:05 p.m., Resident 1 was observed moaning and crying while moving about in her bed and the splint remained laying in the wheelchair. The DON was summoned to the bedside, at which time he indicated he believed Resident 1 was in severe pain and rated it as 10/10 on the pain scale (zero represented no pain while ten represented the worst imaginable pain). Resident 1 was subsequently transported via ambulance to the emergency department at 3:05 p.m., on 6/1/23. During an interview on 6/12/23, at 2:17 p.m., with CNA 2, CNA 2 indicated she had observed Resident 1's left lower leg on 5/25/23 at change of shift. CNA 2 indicated that Resident 1's left lower leg was swollen and bruised and purple and green color. During an interview on 6/12/23, at 2:30 p.m., with LN 3, LN 3 indicated that she assessed Resident 1's left lower leg on 5/26/23, early in her shift (night shift) after overhearing the CNAs discussing Residents 1's leg. LN 3 indicated Resident 1's left lower leg appeared bruised, purple and blue, mostly around the lower leg and ankle. LN 3 further indicated she did not notify the Administrator (ADM) or the DON of her assessment. During an interview on 6/12/23, at 2:45 p.m., LN 2 indicated she was made aware about 9:30 p.m., on 5/26/23, of swelling to Resident 1's left lower leg. LN 2 indicated she did not assess Residents 1's left lower leg until the following day, 5/27/23, at the start of her shift (about 3 p.m.). LN 2 further indicated Resident 1's left lower leg appeared bruised purple and pink and deformed above the ankle. During an interview on 6/14/23, at 1 p.m., with the emergency room Physician ([NAME]), the [NAME] indicated he had cared for Resident 1 in the early morning hours of 5/28/23 for complaints of left leg pain. The [NAME] indicated Resident 1 was miserable and had a makeshift support on her left lower leg that was wrapped too tight. The [NAME] further indicated, based on the yellow bruising, he believed the injury was at least a week old. The [NAME] indicated he suspected a ground level fall. During a review of Resident 1's Emergency Department Report (EDR), dated 5/28/23, the EDR indicated Resident 1 was admitted to the emergency department on 5/28/23, at approximately 1 a.m., with complaints of pain in her left ankle and skin tears of her right elbow. EDP indicated left lower leg extensive bruising with yellowing of bruising, swelling present. During a review of Resident 1's radiology exam (RE), the RE indicated an angulated fracture [ends of broken bones are at an angle to each other] of the left lower tibia and fibula. Further record review indicated Pt [patient] here with .fracture likely days old, based on coloring of bruising .Do have concerns about timeliness of care and fact that wound looked old and progressive bruising . During a review of Resident 1's ED Provider Notes dated 6/1/23, at 9 p.m., the Provider Notes indicated .pain improved after the reduction and splint placement . During a review of a facility policy titled, Abuse Prevention Program, revised December 2016, the policy indicated, 'Neglect' is defined as failure to provide .services necessary to avoid physical harm, mental anguish .'Injury of unknown source' is defined as an injury that meets both of the following conditions: (1) .the source of the injury could not be explained by the resident; and (2) The injury is suspicious because of the extent of the injury, the location of the injury .

Based on observations, interviews and document reviews, the facility failed to provide care and services to prevent pressure ulcers from developing and to promote healing once a pressure ulcer has developed for 1 of 19 sampled residents (Resident 46) when: 1) The facility failed to obtain initial wound treatment orders from the physician on 7/21/17; 2) The facility failed to conduct Weekly Wound Evaluations which included measurements, decribing exudate, describing the wound bed and periwound after the Wound Care RN completed her last weekly Wound Evaluation on 8/30/17; 3) The facility failed to accurately assess and/or correctly document the location of the left ischium wound care site (incorrect measurements were conducted on 2/6/18 and incorrect location documented on 7/21/17); and 4) The facility failed to provide a pressure redistribution device (such as a gel mattress, air fluidized, or a low air loss mattress) based on Resident 46's high risk factors and the need to offload pressure to the left side (offloading as recommended by the Wound Care RN). These failures resulted in Resident 46 obtaining a facility acquired open wound which was found initially as a Stage III pressure ulcer (a wound that develops from pressure on the tissue that cuts off blood circulation and is full thickness tissue loss) on the left ischium (the curved boney area that forms the base of each half of the pelvis) area. Findings: Resident 46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no documentation of pressure ulcers or open wounds for Resident 46 upon admission. The Admission MDS (Minimum Data Set-an assessment tool) dated 12/15/15 indicated that Resident 46 was severely impaired for cognitive skills for daily decision making. Resident 46 required extensive assistance with all Activities of Daily Living with one or two person assistance. Resident 46 was assessed as always incontinent (loss of bladder or bowel control) for both urinary and bowel. This MDS indicated on Section M0150. Risk of Pressure Ulcer a No for the question, Is this resident at risk of developing pressure ulcers? Review of a facility document titled Braden Scale for Predicting Pressure Sore Risk dated 12/8/15 indicated a score of 10 (10-12 is considered High Risk for developing a pressure sore/ulcer). Review of a Nursing Care Plan titled, Resolved: Resident with open area to left gluteal brief fold was dated with an initiation date of 2/24/16 and a resolved date of 4/1/16. A Nursing Progress Note dated 7/21/17 revealed a .wound to the right buttock fold 1.5 cm (centimeters-a unit of measure) x 1.7 cm x UTD (unable to determine) .Resident is incontinent with history of intermittent loose and formed stools. Wound cleansed with NSS, pat try, TAO ointment, non-stick dressing, and [MEDICATION NAME] dressing to keep wound clean and dry. MD and RP notified. LM for Kaiser wound nurse . Review of the Order Listing Report for the date range of 7/1/17-2/28/18 revealed there was no documented evidence that the licensed nurses had obtained wound treatment orders for the treatment of [REDACTED]. The first Physician order [REDACTED]. There was no documented evidence that a treatment was provided on 7/22/17. A review of Physician order [REDACTED]. Cleanse with wound cleanser. Apply [MEDICATION NAME] to wound bed then cover with [MEDICATION NAME]. Change every Monday, Wednesday, and Friday. A Nursing Care Plan dated 7/21/17 indicated, RESOLVED: Pressure ulcer to right gluteal fold. An interview was conducted with the Director of Nursing (DON) on 2/8/18 at 12:30 p.m. The DON confirmed there was a mistake with the type and location of the wound in the care plan. The DON further stated, the location of the wound was missed when the care plan was revised. A Progress Note from the Wound Care RN (from Kaiser) dated 7/24/17 revealed the location of the wound to the left ischium (not to the right buttock fold as documented by the licensed nurses on 7/21/17) and was a pressure ulcer staged as unstageable and measured at 1.8 cm x 1.4 cm x UTD (undetermined depth). The wound bed appearance was described as desiccated wound bed-full thickness loss, slough filled. The Wound Care RN further documented that This is a ischial pressure ulcer-unstageable. Family indicated to the staff that she has had this wound previously but I do not see any documentation of this. She has scar tissue over both ischial prominences. The right is intact but the left is dry and filled with slough .It appears that she leans to the left side, increasing the pressure over this bony prominence. Her dementia may prevent her from realizing the source of any discomfort she may have, therefore she does not weight shift for pressure relief .MUST be offloaded. Needs a high quality seating cushion or to be shifted to the right. This is not without risk and she must be monitored for right ischial pressure as she has had ulcers there in the past .Incontinence and moisture may be an influence but the ulcer etiology is pressure . Review of the Progress Notes from The Wound Care RN (from Kaiser) indicated that there were weekly assessments after the initial evaluation on 7/24/17 on the following dates: 8/2/17, 8/9/17, 8/16/17, 8/23/17, and 8/30/17. After the 8/30/17 assessment, the Wound Care RN began making monthly assessments on the following dates: 9/20/17, 10/18/17, 12/7/17, and 12/27/17. The only dates that the licensed nurses at the facility completed a Weekly Wound Evaluation which included taking measurements of the left ischial site, describing the wound bed and exudate, and the periwound was on 7/21/17 and 8/8/17 (per review of the Wound Evaluation Flow Sheet). There was no documented evidence that the licensed nurses at the facility conducted Weekly Wound Evaluations after 8/30/17 when the Wound Care RN began conducting monthly visits instead of weekly visits to Resident 46. An interview was conducted with the Director of Nursing (DON) on 2/6/18 at 10:35 a.m. The DON confirmed wound assessments/measurements for Resident 46 was done only twice by licensed nurses at the facility on 7/21/17 and 8/8/17. A review of the annual MDS (Minimum Data Set- an assessment tool) dated 12/13/17 indicated Resident 46 was severely impaired for cognitive skills for daily decision making. Resident 46 required extensive assistance with all Activities of Daily Living with one or two person assistance. Resident was assessed as always incontinent for both urinary and bowel continence. This MDS indicated Resident 46 had one Stage 3 pressure ulcer. A review of a Progress Note from the Wound Care RN (from Kaiser) dated 12/7/17 indicated, Left ischial wound is pinpoint and almost resurfaced. Found with no dressing. Periwound scarred but soft. Will protect with [MEDICATION NAME] as patient is incontinent and should be protected as the newly [MEDICATION NAME] skin gains tensile strength. Continue to limit time in chair, weight shift and prevent leaning to the left side as this increases pressure over the ischium . A review of a Progress Note from the Wound Care RN (from Kaiser) dated 12/27/17 indicated, Left ischium resurfaced. An interview was conducted with the Wound Care RN (from Kaiser) on 2/7/18 at 2:43 p.m. She stated that resurfacing does not mean healed. It means the wound is dried, not necessarily healed but had maturation. Review of the most recent Braden Scale dated 1/26/18 indicated a score of 13 (13-14 was Moderate Risk). The assessment further indicated the following: .Occasionally moist, chair-fast, completely immobile, and nutrition was adequate. Friction and Shear were a problem: requires moderate to maximum assistance in moving . Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance . A review of a Nursing Progress Note dated 2/5/18 revealed, SBAR-Change of Condition. It indicated, .left ischial wound reopened measuring 1.4 cm x 1.4 cm. Wound whitish borders, pink wound bed, 80% granulation and 20% slough . A Nursing Progress Noted dated 2/6/18 revealed, Dr was informed via fax regarding reassessment of wound today with an increase in size 3.25 x 3.25 x .25. 70% granulation and 30% slough . Review of a care plan for Resident 46 dated 12/8/15 with a revision on 12/28/17 indicated interventions to include; Complete Braden Scale on admission, quarterly and prn (as needed), Conduct weekly skin inspections, Provide pressure relieving wheelchair cushion, Provide pressure reduction/relieving mattress, Provide skin care after incontinent episodes and apply skin barrier cream, and Turning and Repositioning. An interview was conducted with the Director of Nursing (DON) on 2/6/18 at 8:40 a.m. She stated that the mattress that Resident 46 has now is a pressure reducing mattress and since all of their residents are at risk of pressure ulcer, they use this type of mattress. An interview was conducted with the Wound Care RN on 2/7/18 at 3:12 p.m. confirmed that the type of mattress that Resident 46 currently was on was a foam mattress. The facility staff provided a document that had information for the type of mattresses the facility is currently using, the Carroll Thera Max HFS Mattress Series. The pictures describing these mattresses reveal that they are a white type of foam mattress. The information of this type of mattress revealed it is not a pressure redistribution device (such as a gel mattress, air fluidized mattress, or a low loss air mattress). A pressure redistribution device would be beneficial for Resident 46 based on her high risk for pressure ulcers, inability to assume a variety of positions without bearing weight on the affected left side, and being contracted to both upper and lower extremities. During an interview and concurrent observation was conducted on 2/6/18 at 2:07 p.m. with Licensed Nurse 1. LN 1 stated the wound had reopened and the treatment was changed today from two times a week to three times a week (for Resident 46). LN 1 stated the wound was on the left ischium. He further confirmed Resident 46 was positioned on her left side with pillows relieving pressure on her right hip. Certified Nurse's Aide 1 (CNA 1) assisted LN 1 with the dressing change. Continued observations of Resident 46 indicated bilateral contractures to both hands, both feet, and she was unable to verbally communicate. During an observation on 2/6/18 at 2:23 p.m. at the bedside of Resident 46 the LN 1 removed the soiled 4 x 4 dressing and confirmed the Stage III pressure ulcer on the left ischium. LN 1 began measuring the wound and was unfamiliar with the wound measurements. LN 1 stated he just started taking care of wounds on Friday (less than 1 week ago). He further stated he had no training. LN measured the wound outside of the wound bed and included the scarred skin area on the far outside of the wound. The measurements were documented as: 3.25 cm x 3.5 cm (centimeter) and a depth of .25 cm, approximately 30% slough and 70% granulation. On 2/6/18 at 4:03 p.m. an interview was conducted with the Director of Staff Development (DSD). The DSD stated there was no depth to the wound and the measurement was 1.2 cm x 1.4 cm. A request was made for documents of the nurses' competencies for review when the wound measurements were so different. The request was made with the DSD. On 2/7/18 at 8:22 a.m. an interview was conducted with the Wound Care RN (from Kaiser). The Wound Care RN stated she had first assessed (Resident 46) in (MONTH) (YEAR). The Wound Care RN stated she noted a Stage III pressure ulcer to the left ischium of (Resident 46) on 7/24/17. Stated she had requested a gel pad for (Resident 46)'s chair. The Wound Care RN stated she did not recall a pressure relieving mattress on the bed at the time she assessed (Resident 46) in (MONTH) (YEAR). On 2/7/18 at 2:43 p.m. an interview with the Wound Care RN was conducted. The Wound Care RN stated she communicates with the Charge Nurses or the DON as she does not have access to the facility charting. Stated she does not update care plans and she does not come to the facility on a regular basis. The Wound Care RN stated she sees the residents on an as needed basis. Stated there had been no involvement with the Medical Director in the facility. During an observation on 2/7/18 at 3:09 p.m. the Wound Care RN started changing the dressing on (Resident 46). The Wound Care RN reported the wound measurements were 1.5 cm x 1.8 cm and corrected LN 1 on his measuring technique. The Wound Care RN stated the wound on (Resident 46) was currently confirmed as a Stage III pressure ulcer and the facility needed to minimize friction and pressure for Resident 46. An interview was conducted with LN 2 on 2/8/18 at 8:57 a.m. LN 2 stated about 2-3 weeks ago there was a training done on wound care. Stated she had not had any training prior to that date. When asked if she was comfortable with wound care, LN 2 stated she did not feel like an expert and she was not certified to be a wound nurse. A facility policy dated 5/25/16 and titled Pressure Ulcer Review indicated, Process: .should include an assessment of the Resident's skin condition on admission, readmission, quarterly, and with any significant change in status . For residents with pressure ulcers that are being treated, if weekly documentation shows no improvement in the ulcer, there should be documentation that the physician has been notified. Review of a facility policy undated and titled Skin Integrity Guideline indicated, Residents will be assessed or observed for risk of skin breakdown within 24 hours of admission or readmission, quarterly .Residents will be observed by the CNA daily for reddened/open areas, [MEDICAL CONDITION] of feet or sacrum. Changes will be reported to the licensed nurse and documented. Licensed Nurse will be responsible for performing a skin evaluation/observation weekly, utilizing the weekly Skin Review.