Every finding on record at Reo Vista Healthcare Center

Based on observations, interviews, and record reviews, the facility failed to ensure staff provided necessary supervision (1:1 supervision to monitor continuously and not left unattended) according to the care plan to prevent falls for one of six sampled residents (Resident 1) who had a known history of falls, impaired safety awareness, and an identified need for ongoing staff presence to prevent unsafe self-transfers and falls. As a result, Resident 1 fell in her room, sustained bruises to the forehead, facial swelling, and bruising on arms associated with pain. Resident 1 was subsequently transferred to the hospital for medical evaluation and treatment. Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Cerebral Infarction (when a blood clot or blockage stops blood from reaching a part of the brain) affecting right dominant (stronger) side and unsteadiness of feet.A record review of Resident 1's Minimum Data Set (MDS- nursing facility assessment tool) dated 3/24/26 indicated, Resident 1 was rarely or never understood with moderate cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits with poor decisions and supervision required.A record review of Resident 1's quarterly fall assessment, dated 3/2/26 indicated, Resident 1 was a high fall risk with a score of 22.A review of the Nurse Practitioner Assessment Notes dated 12/2025 (12/2, 12/11, 12/22, 12/29), 1/2026 (1/5, 1/12, 1/15, 1/19, 1/26), 2/2026 (2/2, 2/5, 2/26), 3/2026 (3/2 and 3/3/26), included a description of .Patient remains high risk.Cont [continue] fall precautions and sitter .sitter at bedside. On 4/7/26 at 2:28 P.M., an interview and joint review of Resident 1's electronic record was conducted with Licensed Nurse (LN) 3. LN 3 stated Resident 1 had a history of falls and required assistance due to weakness, and a forward-leaning posture. LN 3 stated Resident 1 frequently attempted to get out of bed and toilet independently, particularly between 4 A.M., and 6 A.M., placing Resident 1 at high risk for falls. LN 3 stated staff reported monitoring every 30 minutes; however, record review did not identify documentation confirming consistent 30-minute safety checks were implemented. LN 3 also stated the first fall incident occurred on the 3/3/26 NOC (night) shift, when the assigned Certified Nursing Assistant (CNA) assisted Resident 1 with toileting. LN 3 stated Resident 1 became unbalanced and was assisted to the floor. LN 3 stated Resident 1 required 1:1 supervision; however, the facility had discontinued consistent 1:1 supervision (approximately 5/21/25 to 3/3/26). LN 3 stated on 3/24/26 during the morning shift it was reported to her that Resident 1 experienced an unwitnessed fall inside her room. LN 3 stated Resident 1 sustained bruises to the forehead and facial swelling and was subsequently admitted to the hospital. Furthermore, LN 3 confirmed the need for continuous 1:1 supervision to ensure staff consistently implemented individualized fall interventions; however, the facility had discontinued this intervention. LN 3 stated Resident 1 should have remained on 1:1 supervision which required staff to keep Resident 1 within direct view at all times due to high fall risk and not leave unattended. On 4/7/26 3:06 P.M., an observation, interview, and record review were conducted with Certified Nursing Assistant (CNA) 1, at the North Side nursing station. CNA 1 demonstrated use of the electronic charting (e-chart) system to review Resident 1's fall risk status and care plan interventions. CNA 1 stated Resident 1 had a history of falls, dementia (a progressive state of decline in mental abilities), and impulsive behavior, and frequently attempted to get up independently without assistance, particularly when attempting to toilet. CNA 1 stated Resident 1 had previously been on 1:1 supervision due to high fall risk; however, the 1:1 supervision was discontinued. CNA 1 stated Resident 1 was at high risk for injury due to poor safety awareness, attempts to self-transfer, and behaviors such as leaning forward and attempting to get out of bed without assistance. CNA 1 stated Resident 1 was sent to the hospital after sustaining a fall during the morning shift (approximately 7 A.M.) and acknowledged Resident 1 had multiple risk factors requiring close supervision. On 4/7/26 3:20 P.M., an interview was conducted with CNA 2, at the North side nursing station. CNA 2 stated Resident 1 had a history of falls (two falls in March 2026 on 3/3 and 3/24) and required 1:1 supervision due to impulsive behavior and a tendency to lean forward during transfers, particularly when using the bathroom. CNA 2 stated that Resident 1 did not consistently use the call light, would attempt to get up independently, and required close monitoring due to poor safety awareness and difficulty with redirection. CNA 2 stated that safety interventions were in place, including a yellow identification band for fall risk, a lowered bed, and floor mats; however, 1:1 supervision had been discontinued approximately one month prior to fall. On 4/7/26 at 4:07 P.M., an interview was conducted with CNA 4. CNA 4 stated that Resident 1 previously had 1:1 supervision due to high fall risk and impulsive behavior; however, approximately four weeks prior, staff were instructed by the nursing managers to discontinue the 1:1 sitter and provide general supervision instead. CNA 4 stated that Resident 1 was impulsive, attempted to get up independently, did not consistently use the call light, and demonstrated poor safety awareness related to her dementia. CNA 4 stated that Resident 1 frequently attempted to perform tasks, such as going to the bathroom or handling personal items without assistance, increasing her risk for falls. CNA 4 further stated that Resident 1 was safer when a sitter was present because staff could provide immediate intervention and physically remain with Resident 1 to prevent unsafe transfers. CNA 4 stated that supervision was more challenging during PM (evening) and NOC (night) shifts when there were fewer activities to keep the residents occupied. On 4/7/26 at 4:17 P.M., an interview and record review was conducted with LN 2, at the South Side nursing charting room. LN 2 stated Resident 1 had falls on 3/3/26 (assisted fall in bathroom with nursing staff) during the NOC shift and again on 3/24/26 (unwitnessed with bruising to face and arms) during shift change. LN 2 stated Resident 1 previously received 1:1 supervision due to high fall risk, which was discontinued following a change in administration. LN 2 stated that Resident 1 had dementia, poor safety awareness, and impulsive behavior, and does not consistently use the call light, resulting in attempts to stand and transfer independently. LN 2 stated that Resident 1's agitation, combativeness with staff, and impulsiveness increased the likelihood of falls without continuous supervision indicating both falls in March 2026 occurred after the 1:1 supervision was removed. LN 2 stated Resident 1 received continuous monitoring due to high fall risk and impaired safety awareness. LN 2 stated the fall on 3/24/26 could have been prevented if 1:1 supervision had remained in place, as close monitoring had previously been effective in preventing falls and reducing risk of serious injuries. On 4/8/26 at 8:53 A.M., an interview was conducted with CNA 3, assigned CNA for Resident 1 on 3/24/26. CNA 3 stated Resident 1 had a history of falls, impulsive behavior, and required assistance with toileting and transfers. CNA 3 stated Resident 1 typically woke around 6:30 A.M., required staff assistance to use the toilet, and was at high risk for attempting to stand or transfer independently without using the call light. CNA 3 stated Resident 1 previously had 1:1 supervision during the NOC (night) shift, with staff either assigned as a dedicated sitter or rotating every 30 minutes to ensure continuous monitoring. CNA 3 stated the 1:1 supervision had been discontinued prior to the fall incident. CNA 3 stated that on the morning of 3/24/26 at approximately 6:30 A.M., she assisted Resident 1 into the wheelchair for breakfast and positioned a bedside table in front of Resident 1, then left Resident 1 unsupervised to use the bathroom. However, despite requiring 1:1 supervision, Resident 1 attempted to get up independently, resulting in an unwitnessed fall. CNA 3 stated Resident 1 attempted to get up without assistance on the morning of the fall (3/24/26) and was found in her room on the floor, facing down near the left side of the bed (the side of bed that was not against the wall). CNA 3 stated Resident 1 sustained swelling to the face but remained alert. CNA 3 stated Resident 1 demonstrated poor safety awareness due to cognitive impairment, impulsiveness, and an inability to consistently follow instructions, which placed the resident at risk for repeated falls. CNA 3 stated it was important that Resident 1 received continuous 1:1 supervision because Resident 1 frequently attempted to get up independently and required ongoing cueing and redirection to prevent unsafe transfers. CNA 3 stated the fall could have been prevented if 1:1 Supervision had remained in place, as direct supervision allowed staff to promptly intervene and reduce the risk of serious injury such as head trauma. A review of Resident 1's fall care plan dated 5/20/25 indicated, .Actual fall. initiated on 5/20/25 indicated: .CNAs were also reminded not to leave the patient unattended and by herself in the room for safety d/t (due to) patient is a high fall risk. Additionally, a care plan dated 7/4/24, indicated: .Keep within supervised view as much as possible. A review of Resident 1's record, notes written by a Nurse Practitioner dated 3/3/26 14:39 (2:39 PM), indicated .Patient seen and examined. Notes reviewed and updates provided by staff. Patient being seen for follow up. She was noted with witnessed fall early this morning with head strike and hematoma to front of forehead. she was sent to ER for evaluation.small hematoma to forehead with central abrasion . Mentation at confused baseline. She continues to be a nigh[sic] fall risk due to impulsive behavior and confusion, needs sitter.last fall on 3/3/26 with head strike, sent to ER [emergency room]. A review of Resident 1's record written by LN 1 dated 3/24/2026 07:05 (7:05 A.M.). The note indicated the following: .before endorsement found by night cna on the floor resident had unwitnessed fall with noted right side of the face swollen and slightly reddened with c/o [complaint of] of 7/10 pain no open area noted resident as stated by night cna was face down on the right side in front of her wheelchair noted resident was up on her wheelchair before that as a preparation for breakfast resident with a license nurse translating resident was trying to reposition herself in her wheelchair and lost her balance going forward resident was [sic] help back by cna to her wheelchair called [Physician Name] made aware of fall with injury on residents right face swelling with pain md [Medical Doctor] ordered to transfer resident to [Hospital Name] for eval [sic]. On 4/8/28 at 12:07 P.M., an interview and record review was conducted with LN 1, in the Director of Nursing's (DON) office. LN 1 stated Resident 1 sustained an unwitnessed fall on 3/24/26 between approximately 7 A.M.-7:50 A.M. during shift change. LN 1 stated Resident 1 had a history of multiple falls, confusion, impulsivity and required close monitoring due to repeated falls. LN 1 stated Resident 1 was found with swelling to the right side of the face and arms after attempting to reposition and/or stand without assistance from the wheelchair. LN 1 stated CNA 3 was not present at the time of Resident 1's fall. LN 1 stated Resident 1 had previously received 1:1 supervision due to high fall risk, this had been discontinued prior to the fall. LN 1 stated the ambulance was called and Resident 1 was transported to the hospital for further evaluation due to facial injury and risk for potential head trauma (any injury to the scalp, skull, or brain caused by a blow, fall, or bump to the head). LN 1 stated it was important Resident 1 received continuous supervision (i.e. 1:1 supervision) and that staff consistently followed the fall care plan, including maintaining awareness of Resident 1's high fall risk and toileting needs, to prevent further injuries such as fractures, facial trauma, and head injury.Resident 1's hospital record was reviewed. Resident 1's hospital imaging notes titled, CT [computed tomography- painless imaging test that acts like a specialized X-ray (specialized camera that takes internal pictures of the body) machine hooked up to a computer] Maxillofacial [focusing on the bones and tissues of the face, jaw, mouth, and nose] Bones WO [without] IV [intravenous-soft flexible tube inserted to vein] Contrast [medical dye used for imaging] dated 3/24/26 9:49 A.M., indicated, .Right facial soft tissue [non-bone flexible, and connective parts of the body] swelling and 3 cm [centimeters] hematoma [severe bruise] right lateral [side] to the nose. Resident 1's Emergency Department notes titled [Hospital Name] ED [emergency department] Provider Note dated 3/24/26 9:50 A.M., indicated, .presenting for unwitnessed fall with facial bruising And left leg pain. Patient found at the [Skilled Nursing Facility Name] on the ground. Musculoskeletal [muscle and bone]: Paralumbar [lower back] spine tenderness. Tenderness over the left hip and femur [hip to knee bone]. This patient presents with a potentially life threatening illness of new diagnosis of syncope [fainting] versus unwitnessed fall with based on my initial evaluation and diagnostic data obtained thus far, the patient presented with symptoms and signs consistent with UTI [urinary tract infection] And [sic] facial hematoma requiring additional workup and management . On 4/8/26 at 2:00 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 1 had been evaluated by Psychiatry (a branch of medicine focused on diagnosing, treating, and preventing mental, emotional, and behavioral disorders) and was recommended for a higher level of care, such as a memory care or assisted living due to cognitive (brain/thought processes involved in gaining knowledge and understanding) impairment, impulsivity, and high fall risk. The DON stated Resident 1's family declined the transfer and requested that the resident remain at the facility with continuous supervision. The DON stated she offered the family a 1:1 sitter but explained they would have to pay for a private sitter to continue that level of supervision, which resulted in the 1:1 supervision being discontinued. The DON stated staff were expected to follow the care plan for high fall risk and should not have left Resident 1 unattended due to the resident's impaired safety awareness and inability to consistently use the call light. The DON stated leaving the resident unsupervised placed Resident 1 at risk for serious injuries, including head injury and fractures. A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing dated March 2018, indicated .The staff, with the input of the attending physician, will implement a resident -centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls .

Based on interview and record review, the facility failed to ensure licensed nurse (LN) 1 administered medications according to acceptable clinical standards of practice for two of three residents (Resident 1 and 2) when: LN 1 documented another LN's medication administration for Resident 1's Cefepime (antibiotic, medication to treat infection). LN 1 administered Resident 2's Vancomycin (antibiotic) at the wrong time (four hours after the prescribed time).This deficient practice had the potential to cause medication errors and ineffective treatment.Findings:1. A review of Resident 1's admission Record indicated the resident was admitted on [DATE] with diagnoses to include unspecified osteomyelitis (a serious infection of the bone) and chronic ulcer of the left foot.A review of Resident 1's Order Summary Report, dated 3/1/26 to 3/16/26, indicated, Pharmacy.Cefepime HCl Intravenous Solution Reconstituted (Cefepime HCl) Use 2 gram intravenously every 8 hours for infection .Order Date 03/07/26.End Date 04/18/26.A review of Resident 1's Administration Record: *PACS-IV ADMINISTRATION RECORD, dated March 2026, indicated on 3/17/26, LN 1 administered the scheduled 7 A.M. IV Cefepime dose at 10:34 A.M.A review of Resident 1's care plan for Antibiotic Therapy, revised 3/6/26, .is on Antibiotic Therapy r/t infection. osteomyelitis. Administer medication as ordered. 2. A review of Resident 2's admission Record indicated the resident was admitted on [DATE] with diagnoses to include sepsis (infection of the blood) and unspecified valve endocarditis (infection of the heart).A review of Resident 2's Order Summary Report, dated 3/1/26 to 3/16/26, indicated Vancomycin HCl Intravenous Solution (Vancomycin HCl) Use 900 mg intravenously every 12 hours for MRSA Bacteremia [sepsis] until 03/22/2026 23:59 . Start 03/10/26 2 0800.A review of Resident 2's Administration Record: *PACS-IV ADMINISTRATION RECORD, dated March 2026, indicated on 3/11/26, LN 1 administered the scheduled 8 A.M. Vancomycin IV dose at 12 P.M.A review of Resident 2's care plan for Antibiotic Therapy, revised 3/14/26, .is on Antibiotic Therapy r/t [related to] MRSA bacteremia upon admission. ***SEPSIS DUE TO METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS [MRSA]. Administer medication as ordered.On 3/18/26 at 11:40 A.M., a concurrent interview and record review was conducted with LN 1. LN 1 stated he was a registered nurse (RN, by scope of practice could administer IV medications). LN 1 stated the medication administration process included checking for the right patient, the right medication, and following the physician orders. LN 1 stated medications had to be given an hour before and an hour after the scheduled administration time. LN 1 stated the physician would have to be notified if the LN was unable to give medications on time. LN 1 reviewed Resident 1's *PACS-IV ADMINISTRATION RECORD for 3/17/26. LN 1 acknowledged his documentation on the Cefepime dose at 7 A.M. LN 1 stated he documented the 7 A.M. dose at 10:34 A.M. LN 1 stated he did not actually administer the IV antibiotic at 7 A.M. LN 1 stated he received report from the night shift RN that Resident 1's medication had been given at 7 A.M. LN 1 stated he documented the administration at 10:34 A.M. when he noticed the missing documentation from the night shift RN. LN 1 stated he should not have done what he did. LN 1 stated he did not follow the standard of practice.LN 1 then reviewed Resident 2's *PACS-IV ADMINISTRATION RECORD for 3/11/26. LN 1 acknowledged Resident 2 had a Vancomycin IV dose scheduled at 8 A.M. LN 1 stated he administered and documented the administration at 12 P.M., which was four hours later than the prescribed time. LN 1 stated Resident 2 had a doctor's appointment and was not in the facility to receive the IV medication. LN 1 reviewed Resident 2's appointment information in the appointment binder. The information indicated Resident 2 was picked up by transportation on 3/11/26 at 9 A.M. for a noon appointment. LN 1 stated Resident 2 came back to the facility from her doctor's appointment at noon. LN 1 stated he did not notify the physician regarding Resident 2's missed 8 A.M. Vancomycin dose. LN 1 stated he did not document a change of condition regarding the missed dose. LN 1 acknowledged that he should have obtained further orders from the physician to administer the resident's Vancomycin late. LN 1 further stated he could have administered Resident 2's Vancomycin prior to the resident leaving for the appointment.On 3/18/26 at 2:35 P.M., an interview was conducted with LN 2. LN 2 stated she, Never signed [documented] on other's (LN's) medication administration. That's a big no-no. LN 2 stated documenting another LN's medication administration was wrong and was not following the standard of practice. LN 2 stated she reviewed her assigned residents' appointment schedules at the start of her shift. LN 2 stated all staff had access to residents' appointment information in the appointment binder. LN 2 stated she would notify the physician if a medication administration was missed due to the resident being out for an appointment.On 3/18/26 at 3:37 P.M., an interview was conducted with the director of nursing (DON). The nurse consultant (NC) was also present. The DON stated medications should be given in a timely manner including that of residents with outside appointments. The DON stated it was her expectation for LNs to plan ahead when residents had appointments. The DON stated Resident 2's delayed IV Vancomycin dose could have been given at 7 A.M. an hour earlier than the scheduled administration time at 8 A.M. The DON stated the physician should have been notified of the four hour IV Vancomycin medication administration delay. The DON stated a change of condition documentation should have been done. The DON stated it was not acceptable for LN 1 to document another LN's medication administration. The DON stated LN 1 should have known better. The DON stated what LN 1 did was not acceptable and was not the facility's standard of practice. The NC stated she agreed with the DON. The NC stated the facility did not have a document for nursing standards of practice. The NC stated it was expected that LNs follow facility policies.A review of the facility's policy titled Administering Medications dated 2001 indicated, .4. Medications are administered in accordance with prescriber orders, including any required time frame .5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record.g. the signature and title of the person administering the drug.

Based on interview and record review, the facility failed to ensure intravenous (IV, a method of administering medications through the veins) antibiotics (medications to treat infection) were administered according to physician's orders for two of three residents (Resident 1 and 2) when:Licensed nurse (LN) 1 documented another LN's medication administration for Resident 1's Cefepime (antibiotic, medication to treat infection).2. LN 1 administered Resident 2's Vancomycin (antibiotic) four hours later than the prescribed time.This deficient practice had the potential for the residents' antibiotic therapy to have reduced efficacy and increased risk for antibiotic resistance.Findings:1. A review of Resident 1's admission Record indicated the resident was admitted on [DATE] with diagnoses to include unspecified osteomyelitis (a serious infection of the bone) and chronic ulcer of the left foot.A review of Resident 1's Order Summary Report, dated 3/1/26 to 3/16/26, indicated, Pharmacy.Cefepime HCl Intravenous Solution Reconstituted (Cefepime HCl) Use 2 gram intravenously every 8 hours for infection.Order Date 03/07/26.End Date 04/18/26.A review of Resident 1's Administration Record: *PACS-IV ADMINISTRATION RECORD, dated March 2026, indicated on 3/17/26, LN 1 administered the scheduled 7 A.M. IV Cefepime dose at 10:34 A.M. 2. A review of Resident 2's admission Record indicated the resident was admitted on [DATE] with diagnoses to include sepsis (infection of the blood) and unspecified valve endocarditis (infection of the heart).A review of Resident 2's Order Summary Report, dated 3/1/26 to 3/16/26, indicated, Vancomycin HCl Intravenous Solution (Vancomycin HCl) Use 900 mg intravenously every 12 hours for MRSA Bacteremia [sepsis] until 03/22/2026 23:59. Start 03/10/26 2 0800.A review of Resident 2's Administration Record: *PACS-IV ADMINISTRATION RECORD, dated March 2026, indicated, on 3/11/26, LN 1 administered the scheduled 8 A.M. Vancomycin IV dose at 12 P.M.On 3/18/26 at 11:40 A.M., a concurrent interview and record review was conducted with LN 1. LN 1 stated he was a registered nurse (RN, by scope of practice could administer IV medications). LN 1 stated the medication administration process included checking for the right patient, the right medication, and following the physician orders. LN 1 stated medications had to be given an hour before and an hour after the scheduled administration time. LN 1 stated the physician would have to be notified if the LN was unable to give medications on time. LN 1 reviewed Resident 1's *PACS-IV ADMINISTRATION RECORD for 3/17/26. LN 1 acknowledged his documentation on the Cefepime dose at 7 A.M. LN 1 stated he documented the 7 A.M. dose at 10:34 A.M. LN 1 stated he did not actually administer the IV antibiotic. LN 1 stated he received report from the night shift RN that Resident 1's medication had been given at 7 A.M. LN 1 stated he documented the administration at 10:34 A.M. when he noticed the missing documentation from the night shift RN. LN 1 stated he should not have done what he did.LN 1 then reviewed Resident 2's *PACS-IV ADMINISTRATION RECORD for 3/11/26. LN 1 acknowledged Resident 2 had a Vancomycin IV dose scheduled at 8 A.M. LN 1 stated he administered and documented the administration at 12 P.M., which was four hours later than the prescribed time. LN 1 stated Resident 2 had a doctor's appointment and was not in the facility to receive the IV medication. LN 1 reviewed Resident 2's appointment information in the appointment binder. The information indicated Resident 2 was picked up by transportation on 3/11/26 at 9 A.M. for a noon appointment. LN 1 stated Resident 2 came back to the facility from her doctor's appointment at noon. LN 1 stated he did not notify the physician regarding Resident 2's missed 8 A.M. Vancomycin dose. LN 1 stated he did not document a change of condition regarding the missed dose. LN 1 acknowledged that he should have obtained further orders from the physician to administer the resident's Vancomycin late. LN 1 further stated he could have administered Resident 2's Vancomycin prior to the resident leaving for the appointment.On 3/18/26 at 2:35 P.M., an interview was conducted with LN 2. LN 2 stated she, Never signed [documented] on other's (LN's) medication administration. That's a big no-no. LN 2 stated documenting another LN's medication administration was wrong and was not following the standard of practice. LN 2 stated she reviewed her assigned residents' appointment schedules at the start of her shift. LN 2 stated all staff had access to residents' appointment information in the appointment binder. LN 2 stated she would notify the physician if a medication administration was missed due to the resident being out for an appointment.On 3/18/26 at 3:37 P.M., an interview was conducted with the director of nursing (DON). The nurse consultant (NC) was also present. The DON stated medications should be given in a timely manner including that of residents with outside appointments. The DON stated it was her expectation for LNs to plan ahead when residents had appointments. The DON stated Resident 2's delayed IV Vancomycin dose could have been given at 7 A.M. an hour earlier than the scheduled administration time at 8 A.M. The DON stated the physician should have been notified of the four hour IV Vancomycin medication administration delay. The DON stated a change of condition documentation should have been done. The DON stated it was not acceptable for LN 1 to document another LN's medication administration. The DON stated LN 1 should have known better. The DON stated what LN 1 did was not acceptable and was not the facility's standard of practice. The NC stated she agreed with the DON.A review of the facility's policy titled Administering Medications dated 2001 indicated, .4. Medications are administered in accordance with prescriber orders, including any required time frame .5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record.g. the signature and title of the person administering the drug.

The facility failed to report alleged abuse of two of eleven sampled residents (Resident 11 & 2) to the State Survey Agency when it did not report when:Resident 1 allegedly kicked Resident 11 in the lower torso.Resident 4 allegedly threw a cup of water on Resident 2 while resting in bed. In addition, the facility failed to send a 5-day follow-up investigation report for both alleged abuse incidents to the State Survey Agency.This failure had the potential for alleged abuse to continue indefinitely and put alleged victims at risk of further physical and psychological harm related to the alleged abuse.Cross Reference: F610Findings:1. Record review of admission Record for Resident 1 indicated he was admitted on [DATE] for diagnoses which included: Fracture of Right Tibia (a break in the large lower leg bone ), Collision with car while on peda-cycle (pedal powered multi-person tour vehicles), Hypertension (high blood pressure), and Alcohol Dependence with Withdrawal (a chronic condition where the brain develops a physical need for alcohol to function).Record review of Minimum Data Set (MDS- federally mandated, standardized, and comprehensive assessment tool used in Medicare and Medicaid-certified nursing facilities) Section C-Cognitive (thinking processes) Patterns for Resident 1, dated 11/28/25, indicated a Brief Interview for Mental Status (BIMS) of 12, which indicated moderate cognitive impairment. Record review of MDS Section E-Behaviors for Resident 1, dated 11/28/25, indicated no potential indicator for psychosis, no behavioral symptoms, no rejection of care, and no wandering.Record review of MDS Section GG-Functional Abilities, dated 11/28/25, for Resident 1, indicated he was independent for: Self Care, Indoor Mobility, Stairs, and functional cognition. Resident 1 had impairment on one Lower Extremity (hip, knee, ankle, foot). Resident 1 also had no prior use of devices such as wheelchair or walker. Record review of admission Record for Resident 11 indicated Resident 11 was admitted on [DATE] for diagnoses which included: Epilepsy (disorder marked by sudden recurrent episodes of sensory disturbance or loss of consciousness associated with abnormal electrical activity in the brain) , Gastroenteritis (short-term swelling of the stomach and intestines, usually caused by viruses, bacteria, or parasites) , Colitis (swelling of your colon), Anxiety (feeling of fear, apprehension) and, Depression (persistent sadness, loss of interest, and changes in mood, sleep, eating, and thinking that interfere with daily functioning).Review of MDS Section C-Cognitive patterns for Resident 11, dated 11/13/25, indicated a BIMS of 15 indicating intact cognitive abilities. Review of MDS Section E-Behaviors for Resident 11, dated 11/13/25, indicated no potential indicator for psychosis, no behavioral symptoms, no rejection of care, and no wandering .Review of MDS Section GG-Functional Abilities for Resident 11, dated 11/13/25, indicated no impairment for upper and lower extremities, and resident usage of walker and wheelchair.On 1/27/26 at 12:50 P.M., a concurrent interview with the Quality Nurse (QN) and record review of the Electronic Medical Record (EMR- digital, computer-stored versions of patient's paper charts) was conducted. The QN stated that the process for resident to resident abuse was to: 1. separate the residents and make sure they are safe, 2. do head-to-toe assessment on each resident, 3. report to the Administrator (ADM), and he should initiate investigation and report to the following authorities: a. Physician (MD), b. Responsible Party (RP-is the person or entity legally and financially accountable for paying a patient's medical bills and invoices), c. Police Department (PD), d. Ombudsman (an independent, neutral advocate who helps patients), and e. California Department of Public Health (CDPH), 4. Document alleged abuse and finding in Change in Condition (CIC) note, progress note, and Care plan. The QN stated the expectation for resident-to-resident abuse was to report immediately to Abuse coordinator. The QN stated in this facility the abuse coordinator is the ADM. The QN stated that the incident between Resident 1 and Resident 11 was brought up during the interdisciplinary team (IDT- a group of professionals from different disciplines working interdependently to achieve patient focused goals through shared decision-making) meeting, but there was no follow up on the incident. The QN stated that the DON and Social Services Assistant (SSA) were arguing about the incident, and then DON stated that they (the DON & SSA) would talk about it later. The QN was unable to find any follow up about the incident in the EMR about the incident. The QN stated the importance of reporting and investigating immediately is to keep residents that were being abused safe, and to prevent it from happening again.On 1/27/26 at 1:25 P.M., a concurrent interview with the SSA and record review of SSA's notes was conducted. The SSA stated that Resident 1 came to her on 1/19/26 at 9 A.M. to vent about a situation that happened with Resident 11, his roommate, the week before. The SSA stated Resident 11 asked Resident 1 to lower the TV volume, when Resident 1 barged into his side of the room and verbalized the threat .If you don't lower the TV, I'm going to hurt you. The SSA stated, Resident 1 said he kicked Resident 11 in the lower torso to protect himself. The SSA stated the Director of Nursing (DON) and her had disagreement about her note during the IDT meeting, and they met after the IDT meeting to discuss her note. The SSA stated that DON said that she did know Resident 1 had kicked Resident 11. The SSA stated that the DON said, I doubt he (Resident 1) is telling the truth. The SSA stated at the standup meeting on 1/20/26, DON asked her to strike out the original note and write a new note. The SSA stated that the expectation for alleged abuse was to report the alleged abuse to the Abuse Coordinator immediately. The SSA stated the Abuse Coordinator was the ADM. The SSA stated that she reported to the DON and assumed that she had reported to the ADM. Further review of the EMR with SSA indicated there was no follow up, investigation, or IDT meeting done regarding the incident. The SSA stated that the importance of reporting immediately to Abuse Coordinator, investigating, and reporting to the proper authorities was to prevent further abuse. Record review of SSA's note in the EMR dated 1/19/26 at 9:42 A.M., indicated note was documented as incorrect documentation and was crossed out with a line through it. The SSA's note indicated Resident met with SS [Social Services] to discuss room incompatibility. Resident stated around 4:30 P.M.-5:30 P.M. Wednesday 01/14 he was in bed watching tv show when Resident 11 barged into his side of room and threatened to hit him if he didn't lower the tv volume. Resident [1] stated that he felt threatened, so he retaliated with kicking the resident near his lower torso. Resident stated he did not want to report it the day of because he feared getting arrested. SS notified resident we would notify administration and DON about incident. SS will follow up as needed. Strike out reason: Incorrect Documentation. Strike out date: 1/20/26 10:42 Record review of handwritten follow-up note, not in EMR, by the SSA on paper indicated: On 1/19/26, Resident [1] met with SS to discuss ongoing roommate incompatibility. Resident [1] stated there had been disagreements over the tv. Resident [1] states roommate verbally threatened him, so he felt unsafe during the interaction. Resident [1] stated that he did not report the incident sooner because he feared getting arrested. Further investigation did not warrant any change. Resident [1] was offered room change to accommodate incompatibility. Resident [1] refused any changes. SS will follow up as needed.On 1/27/26 at 2 P.M., an observation and interview with Resident 11 was conducted. Resident 11 was observed in the hallway in his wheelchair. Resident 11 was alert and oriented and agreeable to interview. Resident 11 stated that he felt safe at the facility and currently had no problems with staff or other residents. Resident 11 stated that a few weeks ago, his previous roommate, Resident 1, had kicked him with his foot and he fell back onto his wheelchair and got a bruise on his lower back from landing on the wheelchair's brake lever. Resident 11 stated he and Resident 1 did not like each other. Resident 11 stated he thinks he owns the room.he thinks he special, he's not special here. Resident 11 stated he didn't report the kick because he was afraid of Resident 1 and thought he might beat him up. Resident 11 stated he reported he fell that day to the staff. On 1/27/26 at 2:15 P.M., a concurrent interview with Charge Nurse (CRN) 2 and record review of EMR for Resident 11 was conducted. CRN 2 stated that a resident kicking another resident or a resident throwing water on another resident was resident-to-resident abuse. CRN 2 stated that the process for resident to resident abuse was: 1. separate the residents and make sure they are safe, 2. do head-to-toe assessment on each resident, 3. report to the ADM, and he should initiate investigation and report to the following authorities: a. MD, b. RP, c. PD, d. Ombudsman, and e. CDPH, 4. document alleged abuse and finding in Change in CIC note, progress note, and Care plan. CRN 2 stated she could not find any follow up notes or IDT notes about alleged abuse investigation in the EMR. CRN 2 stated after reporting to ADM, the ADM should follow, investigate, and report the alleged abuse. CRN 2 stated if not reported or investigated, victims could continue to be abused. Record review of Resident 11's EMR was conducted with CRN 2. A Nurse's note dated, 1/12/26 at 8:15 P.M., indicated Resident 11 had a fall which matched description of type of injury that Resident 11 described in his interview. Nurse's Note indicated Resident [11] .claims that he had a fall @ around 1600[ 4 P.M.] in his room and also claims that he hit his back on his wheelchair, showed his back and notice a reddish discoloration measuring about 14x6 cm(centimeters) at this time. Res[ident 11] verbalizes that he came from the bathroom and is trying to go back to his bed when he tries to squeeze himself between the bed and wheelchair, he lost his balance and landed his back on his wheelchair. Res[ident 11] claims he stood up by himself and did not inform anyone until he feels pain on his back. Res[ident 11] did not report incident earlier when evening meds were administered. Head to toe check done, no further injuries noted at this time. Neuro-check initiated, no changes in LOC. Primary MD notified with orders. On 1/27/26 at 2:30 P.M., an interview with the Assistant Director of Nursing (ADON) was conducted. The DON was currently out of state. The ADON stated that she was unaware of any recent alleged abuse cases that were being investigated at the facility, including the incident involving Resident 1 and Resident 11, and the incident involving Resident 2 and Resident 4. The ADON stated the Abuse Coordinator was the ADM. The ADON stated if an alleged abuse incident was reported to her, she would immediately report it to the ADM. The ADON stated it was important to report the alleged abuse immediately so they can conduct and investigation and do the appropriate reporting to: 1. MD, 2. RP, 3. PD, 4. Ombudsman, & 5. CDPH. The ADON stated there should be documentation of investigation and follow-up in the EMR. The ADON stated the importance of timely reporting and investigation was for patient safety, preventing emotional distress, and self-isolation of the victim. On 1/27/26 at 2:45 P.M., an interview with the ADM was conducted. The ADM stated he was the abuse coordinator. The ADM stated that the incident for Resident 1 versus Resident 11 was not reported to him. The ADM stated the expectation was if the alleged abuse was reported to him, he would have conducted an investigation and reported per policy and procedure to the appropriate authorities and send a 5-day investigation summary to the State Survey Agency. The ADM stated he did not conduct an investigation, report to the appropriate authorities, or do a 5-day summary for the alleged abuse for this incident. The ADM stated the importance of reporting immediately was to prevent further abuse from happening to the victim. On 1/28/26 at 7:43 A.M., a phone interview was conducted with the DON. The DON stated she would consider the allegation of Resident 1 kicking Resident 1, resident-to-resident abuse. The DON stated that she did not investigate the incident between Resident 1 and Resident 11 because the SSA told her it happened a couple of weeks ago, and Resident 1 who confessed the abuse allegation was already discharged . The DON stated she thought it was only words and no physical interaction occurred. The DON stated she thought a misunderstanding happened between her and the SSA, and the DON asked the SSA to strike her note from 1/19/26 .because it seemed like abuse that was not reported. The DON stated that she is new to the facility and they are changing processes to follow up, and staff are not used to the new system yet. The DON stated the QA was supposed to start the investigation and follow up with her but never did. The DON stated that the investigation was not on the follow up list, so it was not reported to the Abuse Coordinator, and an investigation was not conducted. The DON stated that the ADM is the abuse coordinator. The DON stated, I am responsible as the DON. The DON stated that alleged abuse should be reported to the appropriate authorities per policy within 2 hours of the allegation of abuse. The DON stated that by not reporting and investigating immediately after abuse was alleged, there was potential for the victim to keep being abused. On 2/13/26 at 10 A.M., a follow-up interview was conducted with the ADM. The ADM confirmed that he did not do full investigations, 5-day investigation summaries, or report to the ombudsman for either incident of alleged abuse.A record review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 2001, indicated Reporting Allegations to the Administrator and Authorities.1. If the resident abuse.is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law, 2. The Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. the state licensing/certification agency responsible for surveying/licensing the facility, b. The local/state ombudsman, c. The resident's representative, e. law enforcement officials, f. the resident's physician.3.Immediatedly is defined as: a. within two hours of an allegation involving abuse or serious bodily injury, 4. Verbal/written notices to agencies are submitted via.fax, email, or by telephone.6.Upon receiving any allegations of abuse.the administrator is responsible for determining what actions are needed for the protection of the residents.Investigating Allegations.1. All allegations are thoroughly investigated. The administrator initiates the investigations.7. The individual conducting the investigation as a minimum: a. reviews documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or resident's representative.h. interviews staff members(on all shifts) who have had contact with the resident during period of alleged incident; h. interviews resident's roommate;.l. documents the investigation completely and thoroughly. 2. Record review of admission Record for Resident 2 indicated he was admitted on [DATE] for diagnoses which included: sepsis (body's extreme, dysfunctional response to an infection), urinary tract infection (an infection occurring in any part of the urinary system), epilepsy (disorder marked by sudden recurrent episodes of sensory disturbance or loss of consciousness associated with abnormal electrical activity in the brain), and malignant neoplasm of brain(a cancerous brain tumor). Record review of Minimum Data Set (MDS- federally mandated, standardized, and comprehensive assessment tool used in Medicare and Medicaid-certified nursing facilities) section C-Cognitive (thinking processes) patterns for Resident 2 dated 12/17/25, indicated a BIMS of 11 which indicated Moderate Cognitive impairment. Record review of MDS section E-Behaviors for Resident 2, dated 12/17/25, indicated no potential indicator for psychosis, no behavioral symptoms, no rejection of care, and no wandering.Record review of MDS section GG-Functional Abilities for Resident 2, dated 12/17/25, indicated Resident 2 had no impairments for his upper and lower extremities, and usage of a wheelchair. Review of admission Record for Resident 4 indicated he was admitted on [DATE] for diagnoses which included: Myopathy (diseases that cause primary dysfunction, weakness, or degeneration of skeletal muscle fibers), Encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition ), Major Depressive Disorder (common mood disorder characterized by persistent, intense feelings of sadness, hopelessness, and a loss of interest in activities for at least two weeks), Opioid Dependence a physical and psychological state where the body relies on opioids to function normally ), and Chronic pain syndrome condition where pain persists for more than 3 to 6 months).Review of MDS Section C-Cognitive patterns for Resident 4, dated 10/31/25, indicated a BIMS of 15 indicated intact cognition. Review of MDS Section E-Behaviors for Resident 4, dated 10/31/25, indicated no potential indicator for psychosis, no behavioral symptoms, no rejection of care, and no wandering.Review of MDS Section GG-Functional Abilities for Resident 4, dated 10/31/25, indicated no impairment for his upper or lower extremities and usage of a wheelchair. On 1/27/26 at 10:15 A.M., a concurrent observation and interview was conducted with Resident 2. Resident 2 was observed in therapy in his wheelchair doing arm exercises. Resident 2 was outside enjoying some sun with his therapist. Resident 2 was alert and oriented and agreeable to interview. Resident 2 stated that about a week ago, someone threw water at him while he was resting in bed. Resident 2 stated that the alleged abuser said You snore too much. after he threw water on him. Resident 2 stated he didn't know exactly who it did, but it may have been one of his roommates. Resident 2 stated that he reported it to staff, but they didn't say anything else to him. Resident 2 stated that he felt safe in the facility at time of investigation.On 1/27/26 at 10:30 A.M., a concurrent observation and interview was conducted with Resident 3. Resident 3 was in his wheelchair outside of Resident 2' s room. Resident 3 was alert and oriented and agreeable to interview. Resident 3 stated that he felt safe in the facility and had no problems with staff and most residents. Resident 3 stated he only had problems with one resident, Resident 4, (Resident 2' roommate) who was mean to him every time they saw each other. Resident 3 stated Resident 4 called him Gay whenever he saw him in the hallway. Resident 3 seemed angry when talking about Resident 4's actions toward him and had reported to staff in the past. On 1/27/26 at 10:40 A.M., an interview with Certified Nursing Assistant 1(CNA) was conducted. CNA 1 stated that on 1/15/26 in the afternoon he went to Resident 2 to check if he needed a brief change. CNA 1 stated that when he saw Resident 2 was covered with water, and his clothes were soaked. CNA 1 stated that he had showered and changed Resident 2's clothes that morning and was dry the last time he saw him. CNA 1 stated that Resident 2 told him that the man in the wheelchair threw water on me. CNA 1 stated that throwing water on another resident was resident-to-resident abuse. CNA 1 stated the process for resident-to-resident abuse was: 1. separate the residents, 2. make sure they are safe, 3. report to the Charge Nurse (CRN), the Director of Nursing (DON), and the Administrator (ADM). CNA 1 stated that the ADM was the abuse coordinator. CNA 1 stated he immediately reported to CRN 1, the DON and the ADM. CNA 1 stated he was unsure if the ADM followed up and investigated the alleged abuse. CNA 1 stated the ADM should have investigated the abuse to prevent further abuse. On 1/27/26 at 11:50 A.M. an interview with CNA 2 was conducted. CNA 2 stated she was working with Resident 2, the day he complained about getting water thrown at him. CNA 2 stated she was working with CNA 1 on 1/15/26 and remembered that she and CNA 1 had showered Resident 2 that morning and had changed all his clothing and was dry when they left him that morning. CNA 2 stated that when CNA 1 checked on Resident 2 in the afternoon, Resident 2 was soaking wet. CNA 2 stated that Resident 2 stated the guy in the wheelchair threw water on me. CNA 2 stated she thought the person who threw the water on him was Resident 4, Resident 2's roommate. CNA 2 stated Resident 4 had a history of being aggressive with other residents. CNA 2 stated the process for resident-to-resident abuse was: 1. separate the residents, 2. make sure they are safe, 3. report to the CRN, the DON, and the ADM. CNA 2 stated that the ADM was the abuse coordinator. CNA 2 stated that throwing water on another resident or kicking another resident was resident-to-resident abuse and it should be reported and investigated to prevent further abuse.On 1/27/26 at 12:25 P.M, an observation and interview with Resident 4 was conducted. Resident 4 observed in his bed resting. Resident 4 was alert and oriented, but agitated during attempt to interview, and was not agreeable to interview. Resident 4 stated I don't want to talk with you.On 1/27/26 at 12: 35 P.M., a concurrent interview with CRN 1, observation of her mobile phone texts, and record review of electronic medical record (EMR- digital, computer-stored versions of patient's paper charts) was conducted. CRN 1stated that she was the charge nurse the day that Resident 2 had water thrown on him. CRN 1 stated that the incident was reported to her at 11 A.M. CRN 1 stated that she considered the incident to be resident to resident abuse case and it should be reported to abuse coordinator. CRN 1 stated the abuse coordinator in the facility was the ADM. CRN 1 stated that she wrote a note that Resident 2 had water thrown on him by another resident, and that it was reported to the DON and the ADM. CRN 1 presented a copy of the text she made to the interdisciplinary team( IDT- a group of professionals from different disciplines working interdependently to achieve patient focused goals through shared decision-making), which included the ADM, DON, Social Services Director (SSD), and Quality (QN) Nurse, notifying them that Resident 2 had water thrown on him by another resident. EMR was reviewed with CRN 1, CRN 1 stated that she did not see any IDT report on the alleged abuse or any follow-up by Social Services (SS) or ADM. CRN 1 stated that after reporting the alleged abuse to the abuse coordinator, she would expect him to report to proper authorities and conduct an investigation. CRN 1 stated she would expect they would separate the residents involved. CRN 1 stated a possible outcome of not reporting or investigating the alleged abuse it that the abuse can keep happening to the victim.Record review of Nurse's Note for Resident 4, dated 1/13/26 at 2:26 P.M., indicated Res(ident 4) was verbally aggressive and displayed threatening behavior to CNA who informed him he is not allowed to have coffee in stainless mug due to potential risk of burns from hot beverages. Staff observed stainless mugs were full of hot coffee. Educated on risks of keeping hot beverages and conduct with staff.Record review of nursing note for Resident 2, dated 1/15/26 at 3:22 P.M., indicated Resident [2] claims that someone threw water on him but cannot recall the face upon assessment resident gown is wet.Record review of Nurse's Note for Resident 4, dated 1/26/26 at 2 P.M., indicated CNA reported that [Resident 4] may become upset if roommate is assisted back to bed at this time. CNA was informed that writer would speak with resident to provide explanation.Writer was also informed by staff that Resident 4 had previously expressed agitation related to noise and there is concern he may throw water or potentially harm his roommate if the roommate becomes noisy.Staff were advised to continue monitoring interaction closely and to report any escalation in behavior immediately. DON.,and Administrator.were informed.On 1/27/26 at 12:50 P.M., an interview with the Quality Nurse (QN) and review of EMR for Resident 2 was conducted. The QN stated that she found out about Resident 2 getting water thrown on him, during the IDT team meeting. The QN stated she spoke to the DON who stated she was going to talk to Social Services about investigating the alleged abuse on 1/26/26. The QN stated the ADM was the abuse coordinator. The QN stated that typical process for resident-to-resident abuse was to:1. separate the residents and make sure they are safe, 2. do head-to-toe assessment on each resident, 3. report to the ADM, and he should initiate investigation and report to the following authorities: a. Physician (MD), b. Responsible Party (RP- is the person or entity legally and financially accountable for paying a patient's medical bills and invoices), c. Police Department (PD), d. Ombudsman (an independent, neutral advocate who helps patients), and e. California Department of Public Health (CDPH), 4. Document alleged abuse and findings in Change in Condition (CIC) note, progress note, and Care plan. The QN stated alleged abuse should be reported to the ADM, and he should report to the appropriate authorities and investigate the incident. The QN stated the importance of reporting immediately is for patient safety and preventing further abuse. The QN stated that she could not find any notes regarding the investigation or followup of the alleged abuse in the EMR. On 1/27/26 at 2:30 P.M., an interview with the Assistant Director of Nursing (ADON) was conducted. The DON was currently out of state. The ADON stated that she was unaware of any recent alleged abuse cases that were being investigated at the facility, including the incident involving Resident 1 and Resident 11, and the incident involving Resident 2 and Resident 4. The ADON stated the Abuse Coordinator was the ADM. The ADON stated if an alleged abuse incident was reported to her, she would immediately report it to the ADM. The ADON stated it was important to report the alleged abuse immediately so they can conduct and investigation and do the appropriate reporting to: 1. MD, 2. RP, 3. PD, 4. Ombudsman, & 5. CDPH. The ADON stated there should be documentation of investigation and follow-up in the EMR. The ADON stated the importance of timely reporting and investigation was for patient safety, preventing emotional distress, and self-isolation of the victim.On 1/27/26 at 2:45 P.M., an interview with the ADM was conducted. The ADM stated he was the abuse coordinator. The ADM stated he investigated the alleged abuse for Resident 2 versus Resident 4 but didn't report it because Resident 2 did not complain about water being thrown on him when he interviewed him. The ADM stated that Resident 2 and Resident 4 were offered room changes but both refused so they did not pursue the incident as alleged abuse and did not further investigate. The ADM stated that the investigation was not documented in the EMR and he was unsure why. The ADM stated he was not sure if the abuse had occurred and was unsure if he should have reported it. The ADM stated that not reporting the abuse immediately and properly investigating the alleged abuse could have .the abuse repeated, escalated, and put the victims at further risk.On 1/28/26 at 7:43 A.M., a phone interview was conducted with the DON. The DON stated that Resident 2 getting a cup of water thrown on him by another resident was resident-to-resident abuse. The DON stated that the ADM conducted an investigation of this incident. The DON stated that QA nurse was supposed to be the one starting the investigation, and she (the DON) would follow up. The DON stated that she could not follow up on the investigation. The DON stated that the ADM did talk to both residents involved and both refused room change. The DON stated for alleged abuse, they should report to the appropriate authorities per policy and procedure within 2 hours of the allegation of abuse. The DON stated the facility did not report this alleged abuse to the appropriate authorities because She believed that the incident did not happen. The DON stated that not reporting and investigating alleged abuse in a timely manner could put the residents at risk for more abuse. On 2/13/26 at 8:39 A.M., an attempt to contact ombudsman for interview was made. A message was left with the ombudsman service as ombudsman was on vacation until 2/17/26. On 2/13/26 at 10 A.M., a follow-up interview was conducted with the ADM. The ADM confirmed that he did not do full investigations, 5-day investigation summaries, or report to the ombudsman for either incident of alleged abuse.A record review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 2001, indicated Reporting Allegations to the Administrator and Authorities.1. If the resident abuse.is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law, 2. The Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. the state licensing/certification agency responsible for surveying/licensing the facility, b. The local/state ombudsman, c. The resident's representative, e. law enforcement officials, f. the resident's physician.3.Immediatedly is defined as: a. within two hours of an allegation involving abuse or serious bodily injury, 4. Verbal/written notices to agencies are submitted via.fax, email, or by telephone.6.Upon receiving any allegations of abuse.the administrator is responsible for determining what actions are needed for the protection of the residents.Investigating Allegations.1. All allegations are thoroughly investigated. The administrator initiates the investigations.7. The individual conducting the investigation as a minimum: a. reviews documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or resident's representative.h. interviews staff members(on all shifts) who have had contact with the resident during period of alleged incident; h. interviews resident's roommate;.l. documents the investigation completely and thoroughly.

Based on observations, interviews, and record review the facility failed to thoroughly investigate alleged abuse of two of eleven sampled residents (Resident 11 & 2) when it did not adequately investigate the following incidents:1. Resident 1 allegedly kicked Resident 11 in the lower torso.2. Resident 4 allegedly threw a cup of water on Resident 2. This failure had the potential for alleged abuse to continue indefinitely and put alleged victims at risk of further abuse, bodily, and mental harm related to the alleged abuse.Cross Reference: F609Findings:1. Record review of admission Record for Resident 1 indicated he was admitted on [DATE] for diagnoses which included: Fracture of Right Tibia (a break in the large lower leg bone ), Collision with car while on peda-cycle (pedal powered multi-person tour vehicles), Hypertension (high blood pressure), and Alcohol Dependence with Withdrawal (a chronic condition where the brain develops a physical need for alcohol to function).Record review of Minimum Data Set (MDS- federally mandated, standardized, and comprehensive assessment tool used in Medicare and Medicaid-certified nursing facilities) Section C-Cognitive (thinking processes) Patterns for Resident 1, dated 11/28/25, indicated a Brief Interview for Mental Status (BIMS) of 12, which indicated moderate cognitive impairment. Record review of MDS Section E-Behaviors for Resident 1, dated 11/28/25, indicated no potential indicator for psychosis, no behavioral symptoms, no rejection of care, and no wandering.Record review of MDS Section GG-Functional Abilities, dated 11/28/25, for Resident 1, indicated he was independent for: Self Care, Indoor Mobility, Stairs, and functional cognition. Resident 1 had impairment on one Lower Extremity (hip, knee, ankle, foot). Resident 1 also had no prior use of devices such as wheelchair or walker. Record review of admission Record for Resident 11 indicated Resident 11 was admitted on [DATE] for diagnoses which included: Epilepsy (disorder marked by sudden recurrent episodes of sensory disturbance or loss of consciousness associated with abnormal electrical activity in the brain) , Gastroenteritis (short-term swelling of the stomach and intestines, usually caused by viruses, bacteria, or parasites) , Colitis (swelling of your colon), Anxiety (feeling of fear, apprehension) and, Depression (persistent sadness, loss of interest, and changes in mood, sleep, eating, and thinking that interfere with daily functioning).Review of MDS Section C-Cognitive patterns for Resident 11, dated 11/13/25, indicated a BIMS of 15 indicating intact cognitive abilities. Review of MDS Section E-Behaviors for Resident 11, dated 11/13/25, indicated no potential indicator for psychosis, no behavioral symptoms, no rejection of care, and no wandering .Review of MDS Section GG-Functional Abilities for Resident 11, dated 11/13/25, indicated no impairment for upper and lower extremities, and resident usage of walker and wheelchair.On 1/27/26 at 12:50 P.M., a concurrent interview with the Quality Nurse (QN) and record review of the Electronic Medical Record (EMR- digital, computer-stored versions of patient's paper charts) was conducted. The QN stated that the process for resident to resident abuse was to: 1. separate the residents and make sure they are safe, 2. do head-to-toe assessment on each resident, 3. report to the Administrator (ADM), and he should initiate investigation and report to the following authorities: a. Physician (MD), b. Responsible Party (RP-is the person or entity legally and financially accountable for paying a patient's medical bills and invoices), c. Police Department (PD), d. Ombudsman (an independent, neutral advocate who helps patients), and e. California Department of Public Health (CDPH), 4. Document alleged abuse and finding in Change in Condition (CIC) note, progress note, and Care plan. The QN stated the expectation for resident-to-resident abuse was to report immediately to Abuse coordinator. The QN stated in this facility the abuse coordinator is the ADM. The QN stated that the incident between Resident 1 and Resident 11 was brought up during the interdisciplinary team (IDT- a group of professionals from different disciplines working interdependently to achieve patient focused goals through shared decision-making) meeting, but there was no follow up on the incident. The QN stated that the DON and Social Services Assistant (SSA) were arguing about the incident, and then DON stated that they (the DON & SSA) would talk about it later. The QN was unable to find any follow up about the incident in the EMR about the incident. The QN stated the importance of reporting and investigating immediately is to keep residents that were being abused safe, and to prevent it from happening again.On 1/27/26 at 1:25 P.M., a concurrent interview with the SSA and record review of SSA's notes was conducted. The SSA stated that Resident 1 came to her on 1/19/26 at 9 A.M. to vent about a situation that happened with Resident 11, his roommate, the week before. The SSA stated Resident 11 asked Resident 1 to lower the TV volume, when Resident 1 barged into his side of the room and verbalized the threat .If you don't lower the TV, I'm going to hurt you. The SSA stated, Resident 1 said he kicked Resident 11 in the lower torso to protect himself. The SSA stated the Director of Nursing (DON) and her had disagreement about her note during the IDT meeting, and they met after the IDT meeting to discuss her note. The SSA stated that DON said that she did know Resident 1 had kicked Resident 11. The SSA stated that the DON said, I doubt he (Resident 1) is telling the truth. The SSA stated at the standup meeting on 1/20/26, DON asked her to strike out the original note and write a new note. The SSA stated that the expectation for alleged abuse was to report the alleged abuse to the Abuse Coordinator immediately. The SSA stated the Abuse Coordinator was the ADM. The SSA stated that she reported to the DON and assumed that she had reported to the ADM. Further review of the EMR with SSA indicated there was no follow up, investigation, or IDT meeting done regarding the incident. The SSA stated that the importance of reporting immediately to Abuse Coordinator, investigating, and reporting to the proper authorities was to prevent further abuse. Record review of SSA's note in the EMR dated 1/19/26 at 9:42 A.M., indicated note was documented as incorrect documentation and was crossed out with a line through it. The SSA's note indicated Resident met with SS [Social Services] to discuss room incompatibility. Resident stated around 4:30 P.M.-5:30 P.M. Wednesday 01/14 he was in bed watching tv show when Resident 11 barged into his side of room and threatened to hit him if he didn't lower the tv volume. Resident [1] stated that he felt threatened, so he retaliated with kicking the resident near his lower torso. Resident stated he did not want to report it the day of because he feared getting arrested. SS notified resident we would notify administration and DON about incident. SS will follow up as needed. Strike out reason: Incorrect Documentation. Strike out date: 1/20/26 10:42 Record review of handwritten follow-up note, not in EMR, by the SSA on paper indicated: On 1/19/26, Resident [1] met with SS to discuss ongoing roommate incompatibility. Resident [1] stated there had been disagreements over the tv. Resident [1] states roommate verbally threatened him, so he felt unsafe during the interaction. Resident [1] stated that he did not report the incident sooner because he feared getting arrested. Further investigation did not warrant any change. Resident [1] was offered room change to accommodate incompatibility. Resident [1] refused any changes. SS will follow up as needed.On 1/27/26 at 2 P.M., an observation and interview with Resident 11 was conducted. Resident 11 was observed in the hallway in his wheelchair. Resident 11 was alert and oriented and agreeable to interview. Resident 11 stated that he felt safe at the facility and currently had no problems with staff or other residents. Resident 11 stated that a few weeks ago, his previous roommate, Resident 1, had kicked him with his foot and he fell back onto his wheelchair and got a bruise on his lower back from landing on the wheelchair's brake lever. Resident 11 stated he and Resident 1 did not like each other. Resident 11 stated he thinks he owns the room.he thinks he special, he's not special here. Resident 11 stated he didn't report the kick because he was afraid of Resident 1 and thought he might beat him up. Resident 11 stated he reported he fell that day to the staff. On 1/27/26 at 2:15 P.M., a concurrent interview with Charge Nurse (CRN) 2 and record review of EMR for Resident 11 was conducted. CRN 2 stated that a resident kicking another resident or a resident throwing water on another resident was resident-to-resident abuse. CRN 2 stated that the process for resident to resident abuse was: 1. separate the residents and make sure they are safe, 2. do head-to-toe assessment on each resident, 3. report to the ADM, and he should initiate investigation and report to the following authorities: a. MD, b. RP, c. PD, d. Ombudsman, and e. CDPH, 4. document alleged abuse and finding in Change in CIC note, progress note, and Care plan. CRN 2 stated she could not find any follow up notes or IDT notes about alleged abuse investigation in the EMR. CRN 2 stated after reporting to ADM, the ADM should follow, investigate, and report the alleged abuse. CRN 2 stated if not reported or investigated, victims could continue to be abused. Record review of Resident 11's EMR was conducted with CRN 2. A Nurse's note dated, 1/12/26 at 8:15 P.M., indicated Resident 11 had a fall which matched description of type of injury that Resident 11 described in his interview. Nurse's Note indicated Resident [11] .claims that he had a fall @ around 1600[ 4 P.M.] in his room and also claims that he hit his back on his wheelchair, showed his back and notice a reddish discoloration measuring about 14x6 cm(centimeters) at this time. Res[ident 11] verbalizes that he came from the bathroom and is trying to go back to his bed when he tries to squeeze himself between the bed and wheelchair, he lost his balance and landed his back on his wheelchair. Res[ident 11] claims he stood up by himself and did not inform anyone until he feels pain on his back. Res[ident 11] did not report incident earlier when evening meds were administered. Head to toe check done, no further injuries noted at this time. Neuro-check initiated, no changes in LOC. Primary MD notified with orders. On 1/27/26 at 2:30 P.M., an interview with the Assistant Director of Nursing (ADON) was conducted. The DON was currently out of state. The ADON stated that she was unaware of any recent alleged abuse cases that were being investigated at the facility, including the incident involving Resident 1 and Resident 11, and the incident involving Resident 2 and Resident 4. The ADON stated the Abuse Coordinator was the ADM. The ADON stated if an alleged abuse incident was reported to her, she would immediately report it to the ADM. The ADON stated it was important to report the alleged abuse immediately so they can conduct and investigation and do the appropriate reporting to: 1. MD, 2. RP, 3. PD, 4. Ombudsman, & 5. CDPH. The ADON stated there should be documentation of investigation and follow-up in the EMR. The ADON stated the importance of timely reporting and investigation was for patient safety, preventing emotional distress, and self-isolation of the victim. On 1/27/26 at 2:45 P.M., an interview with the ADM was conducted. The ADM stated he was the abuse coordinator. The ADM stated that the incident for Resident 1 versus Resident 11 was not reported to him. The ADM stated the expectation was if the alleged abuse was reported to him, he would have conducted an investigation and reported per policy and procedure to the appropriate authorities and send a 5-day investigation summary to the State Survey Agency. The ADM stated he did not conduct an investigation, report to the appropriate authorities, or do a 5-day summary for the alleged abuse for this incident. The ADM stated the importance of reporting immediately was to prevent further abuse from happening to the victim. On 1/28/26 at 7:43 A.M., a phone interview was conducted with the DON. The DON stated she would consider the allegation of Resident 1 kicking Resident 1, resident-to-resident abuse. The DON stated that she did not investigate the incident between Resident 1 and Resident 11 because the SSA told her it happened a couple of weeks ago, and Resident 1 who confessed the abuse allegation was already discharged . The DON stated she thought it was only words and no physical interaction occurred. The DON stated she thought a misunderstanding happened between her and the SSA, and the DON asked the SSA to strike her note from 1/19/26 .because it seemed like abuse that was not reported. The DON stated that she is new to the facility and they are changing processes to follow up, and staff are not used to the new system yet. The DON stated the QA was supposed to start the investigation and follow up with her but never did. The DON stated that the investigation was not on the follow up list, so it was not reported to the Abuse Coordinator, and an investigation was not conducted. The DON stated that the ADM is the abuse coordinator. The DON stated, I am responsible as the DON. The DON stated that alleged abuse should be reported to the appropriate authorities per policy within 2 hours of the allegation of abuse. The DON stated that by not reporting and investigating immediately after abuse was alleged, there was potential for the victim to keep being abused. On 2/13/26 at 10 A.M., a follow-up interview was conducted with the ADM. The ADM confirmed that he did not do full investigations, 5-day investigation summaries, or report to the ombudsman for either incident of alleged abuse.A record review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 2001, indicated Reporting Allegations to the Administrator and Authorities.1. If the resident abuse.is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law, 2. The Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. the state licensing/certification agency responsible for surveying/licensing the facility, b. The local/state ombudsman, c. The resident's representative, e. law enforcement officials, f. the resident's physician.3.Immediatedly is defined as: a. within two hours of an allegation involving abuse or serious bodily injury, 4. Verbal/written notices to agencies are submitted via.fax, email, or by telephone.6.Upon receiving any allegations of abuse.the administrator is responsible for determining what actions are needed for the protection of the residents.Investigating Allegations.1. All allegations are thoroughly investigated. The administrator initiates the investigations.7. The individual conducting the investigation as a minimum: a. reviews documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or resident's representative.h. interviews staff members(on all shifts) who have had contact with the resident during period of alleged incident; h. interviews resident's roommate;.l. documents the investigation completely and thoroughly. 2. Record review of admission Record for Resident 2 indicated he was admitted on [DATE] for diagnoses which included: sepsis (body's extreme, dysfunctional response to an infection), urinary tract infection (an infection occurring in any part of the urinary system), epilepsy (disorder marked by sudden recurrent episodes of sensory disturbance or loss of consciousness associated with abnormal electrical activity in the brain), and malignant neoplasm of brain(a cancerous brain tumor). Record review of Minimum Data Set (MDS- federally mandated, standardized, and comprehensive assessment tool used in Medicare and Medicaid-certified nursing facilities) section C-Cognitive (thinking processes) patterns for Resident 2 dated 12/17/25, indicated a BIMS of 11 which indicated Moderate Cognitive impairment. Record review of MDS section E-Behaviors for Resident 2, dated 12/17/25, indicated no potential indicator for psychosis, no behavioral symptoms, no rejection of care, and no wandering.Record review of MDS section GG-Functional Abilities for Resident 2, dated 12/17/25, indicated Resident 2 had no impairments for his upper and lower extremities, and usage of a wheelchair. Review of admission Record for Resident 4 indicated he was admitted on [DATE] for diagnoses which included: Myopathy (diseases that cause primary dysfunction, weakness, or degeneration of skeletal muscle fibers), Encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition ), Major Depressive Disorder (common mood disorder characterized by persistent, intense feelings of sadness, hopelessness, and a loss of interest in activities for at least two weeks), Opioid Dependence a physical and psychological state where the body relies on opioids to function normally ), and Chronic pain syndrome condition where pain persists for more than 3 to 6 months).Review of MDS Section C-Cognitive patterns for Resident 4, dated 10/31/25, indicated a BIMS of 15 indicated intact cognition. Review of MDS Section E-Behaviors for Resident 4, dated 10/31/25, indicated no potential indicator for psychosis, no behavioral symptoms, no rejection of care, and no wandering.Review of MDS Section GG-Functional Abilities for Resident 4, dated 10/31/25, indicated no impairment for his upper or lower extremities and usage of a wheelchair. On 1/27/26 at 10:15 A.M., a concurrent observation and interview was conducted with Resident 2. Resident 2 was observed in therapy in his wheelchair doing arm exercises. Resident 2 was outside enjoying some sun with his therapist. Resident 2 was alert and oriented and agreeable to interview. Resident 2 stated that about a week ago, someone threw water at him while he was resting in bed. Resident 2 stated that the alleged abuser said You snore too much. after he threw water on him. Resident 2 stated he didn't know exactly who it did, but it may have been one of his roommates. Resident 2 stated that he reported it to staff, but they didn't say anything else to him. Resident 2 stated that he felt safe in the facility at time of investigation.On 1/27/26 at 10:30 A.M., a concurrent observation and interview was conducted with Resident 3. Resident 3 was in his wheelchair outside of Resident 2' s room. Resident 3 was alert and oriented and agreeable to interview. Resident 3 stated that he felt safe in the facility and had no problems with staff and most residents. Resident 3 stated he only had problems with one resident, Resident 4, (Resident 2' roommate) who was mean to him every time they saw each other. Resident 3 stated Resident 4 called him Gay whenever he saw him in the hallway. Resident 3 seemed angry when talking about Resident 4's actions toward him and had reported to staff in the past. On 1/27/26 at 10:40 A.M., an interview with Certified Nursing Assistant 1(CNA) was conducted. CNA 1 stated that on 1/15/26 in the afternoon he went to Resident 2 to check if he needed a brief change. CNA 1 stated that when he saw Resident 2 was covered with water, and his clothes were soaked. CNA 1 stated that he had showered and changed Resident 2's clothes that morning and was dry the last time he saw him. CNA 1 stated that Resident 2 told him that the man in the wheelchair threw water on me. CNA 1 stated that throwing water on another resident was resident-to-resident abuse. CNA 1 stated the process for resident-to-resident abuse was: 1. separate the residents, 2. make sure they are safe, 3. report to the Charge Nurse (CRN), the Director of Nursing (DON), and the Administrator (ADM). CNA 1 stated that the ADM was the abuse coordinator. CNA 1 stated he immediately reported to CRN 1, the DON and the ADM. CNA 1 stated he was unsure if the ADM followed up and investigated the alleged abuse. CNA 1 stated the ADM should have investigated the abuse to prevent further abuse. On 1/27/26 at 11:50 A.M. an interview with CNA 2 was conducted. CNA 2 stated she was working with Resident 2, the day he complained about getting water thrown at him. CNA 2 stated she was working with CNA 1 on 1/15/26 and remembered that she and CNA 1 had showered Resident 2 that morning and had changed all his clothing and was dry when they left him that morning. CNA 2 stated that when CNA 1 checked on Resident 2 in the afternoon, Resident 2 was soaking wet. CNA 2 stated that Resident 2 stated the guy in the wheelchair threw water on me. CNA 2 stated she thought the person who threw the water on him was Resident 4, Resident 2's roommate. CNA 2 stated Resident 4 had a history of being aggressive with other residents. CNA 2 stated the process for resident-to-resident abuse was: 1. separate the residents, 2. make sure they are safe, 3. report to the CRN, the DON, and the ADM. CNA 2 stated that the ADM was the abuse coordinator. CNA 2 stated that throwing water on another resident or kicking another resident was resident-to-resident abuse and it should be reported and investigated to prevent further abuse.On 1/27/26 at 12:25 P.M, an observation and interview with Resident 4 was conducted. Resident 4 observed in his bed resting. Resident 4 was alert and oriented, but agitated during attempt to interview, and was not agreeable to interview. Resident 4 stated I don't want to talk with you.On 1/27/26 at 12: 35 P.M., a concurrent interview with CRN 1, observation of her mobile phone texts, and record review of electronic medical record (EMR- digital, computer-stored versions of patient's paper charts) was conducted. CRN 1stated that she was the charge nurse the day that Resident 2 had water thrown on him. CRN 1 stated that the incident was reported to her at 11 A.M. CRN 1 stated that she considered the incident to be resident to resident abuse case and it should be reported to abuse coordinator. CRN 1 stated the abuse coordinator in the facility was the ADM. CRN 1 stated that she wrote a note that Resident 2 had water thrown on him by another resident, and that it was reported to the DON and the ADM. CRN 1 presented a copy of the text she made to the interdisciplinary team( IDT- a group of professionals from different disciplines working interdependently to achieve patient focused goals through shared decision-making), which included the ADM, DON, Social Services Director (SSD), and Quality (QN) Nurse, notifying them that Resident 2 had water thrown on him by another resident. EMR was reviewed with CRN 1, CRN 1 stated that she did not see any IDT report on the alleged abuse or any follow-up by Social Services (SS) or ADM. CRN 1 stated that after reporting the alleged abuse to the abuse coordinator, she would expect him to report to proper authorities and conduct an investigation. CRN 1 stated she would expect they would separate the residents involved. CRN 1 stated a possible outcome of not reporting or investigating the alleged abuse it that the abuse can keep happening to the victim.Record review of Nurse's Note for Resident 4, dated 1/13/26 at 2:26 P.M., indicated Res(ident 4) was verbally aggressive and displayed threatening behavior to CNA who informed him he is not allowed to have coffee in stainless mug due to potential risk of burns from hot beverages. Staff observed stainless mugs were full of hot coffee. Educated on risks of keeping hot beverages and conduct with staff.Record review of nursing note for Resident 2, dated 1/15/26 at 3:22 P.M., indicated Resident [2] claims that someone threw water on him but cannot recall the face upon assessment resident gown is wet.Record review of Nurse's Note for Resident 4, dated 1/26/26 at 2 P.M., indicated CNA reported that [Resident 4] may become upset if roommate is assisted back to bed at this time. CNA was informed that writer would speak with resident to provide explanation.Writer was also informed by staff that Resident 4 had previously expressed agitation related to noise and there is concern he may throw water or potentially harm his roommate if the roommate becomes noisy.Staff were advised to continue monitoring interaction closely and to report any escalation in behavior immediately. DON.,and Administrator.were informed.On 1/27/26 at 12:50 P.M., an interview with the Quality Nurse (QN) and review of EMR for Resident 2 was conducted. The QN stated that she found out about Resident 2 getting water thrown on him, during the IDT team meeting. The QN stated she spoke to the DON who stated she was going to talk to Social Services about investigating the alleged abuse on 1/26/26. The QN stated the ADM was the abuse coordinator. The QN stated that typical process for resident-to-resident abuse was to:1. separate the residents and make sure they are safe, 2. do head-to-toe assessment on each resident, 3. report to the ADM, and he should initiate investigation and report to the following authorities: a. Physician (MD), b. Responsible Party (RP- is the person or entity legally and financially accountable for paying a patient's medical bills and invoices), c. Police Department (PD), d. Ombudsman (an independent, neutral advocate who helps patients), and e. California Department of Public Health (CDPH), 4. Document alleged abuse and findings in Change in Condition (CIC) note, progress note, and Care plan. The QN stated alleged abuse should be reported to the ADM, and he should report to the appropriate authorities and investigate the incident. The QN stated the importance of reporting immediately is for patient safety and preventing further abuse. The QN stated that she could not find any notes regarding the investigation or followup of the alleged abuse in the EMR. On 1/27/26 at 2:30 P.M., an interview with the Assistant Director of Nursing (ADON) was conducted. The DON was currently out of state. The ADON stated that she was unaware of any recent alleged abuse cases that were being investigated at the facility, including the incident involving Resident 1 and Resident 11, and the incident involving Resident 2 and Resident 4. The ADON stated the Abuse Coordinator was the ADM. The ADON stated if an alleged abuse incident was reported to her, she would immediately report it to the ADM. The ADON stated it was important to report the alleged abuse immediately so they can conduct and investigation and do the appropriate reporting to: 1. MD, 2. RP, 3. PD, 4. Ombudsman, & 5. CDPH. The ADON stated there should be documentation of investigation and follow-up in the EMR. The ADON stated the importance of timely reporting and investigation was for patient safety, preventing emotional distress, and self-isolation of the victim.On 1/27/26 at 2:45 P.M., an interview with the ADM was conducted. The ADM stated he was the abuse coordinator. The ADM stated he investigated the alleged abuse for Resident 2 versus Resident 4 but didn't report it because Resident 2 did not complain about water being thrown on him when he interviewed him. The ADM stated that Resident 2 and Resident 4 were offered room changes but both refused so they did not pursue the incident as alleged abuse and did not further investigate. The ADM stated that the investigation was not documented in the EMR and he was unsure why. The ADM stated he was not sure if the abuse had occurred and was unsure if he should have reported it. The ADM stated that not reporting the abuse immediately and properly investigating the alleged abuse could have .the abuse repeated, escalated, and put the victims at further risk.On 1/28/26 at 7:43 A.M., a phone interview was conducted with the DON. The DON stated that Resident 2 getting a cup of water thrown on him by another resident was resident-to-resident abuse. The DON stated that the ADM conducted an investigation of this incident. The DON stated that QA nurse was supposed to be the one starting the investigation, and she (the DON) would follow up. The DON stated that she could not follow up on the investigation. The DON stated that the ADM did talk to both residents involved and both refused room change. The DON stated for alleged abuse, they should report to the appropriate authorities per policy and procedure within 2 hours of the allegation of abuse. The DON stated the facility did not report this alleged abuse to the appropriate authorities because She believed that the incident did not happen. The DON stated that not reporting and investigating alleged abuse in a timely manner could put the residents at risk for more abuse. On 2/13/26 at 8:39 A.M., an attempt to contact ombudsman for interview was made. A message was left with the ombudsman service as ombudsman was on vacation until 2/17/26. On 2/13/26 at 10 A.M., a follow-up interview was conducted with the ADM. The ADM confirmed that he did not do full investigations, 5-day investigation summaries, or report to the ombudsman for either incident of alleged abuse.A record review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 2001, indicated Reporting Allegations to the Administrator and Authorities.1. If the resident abuse.is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law, 2. The Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. the state licensing/certification agency responsible for surveying/licensing the facility, b. The local/state ombudsman, c. The resident's representative, e. law enforcement officials, f. the resident's physician.3.Immediatedly is defined as: a. within two hours of an allegation involving abuse or serious bodily injury, 4. Verbal/written notices to agencies are submitted via.fax, email, or by telephone.6.Upon receiving any allegations of abuse.the administrator is responsible for determining what actions are needed for the protection of the residents.Investigating Allegations.1. All allegations are thoroughly investigated. The administrator initiates the investigations.7. The individual conducting the investigation as a minimum: a. reviews documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or resident's representative.h. interviews staff members(on all shifts) who have had contact with the resident during period of alleged incident; h. interviews resident's roommate;.l. documents the investigation completely and thoroughly.

Based on observation, interview and record review the facility failed to provide services according to standards of clinical practice when it did not report and document a change of condition in a timely manner for one of eight sampled residents.This failure had the potential to delay interventions and treatments which could have affected Resident 1's health outcomes.Findings:Review of admission Record indicated Resident 1 was admitted on [DATE] with diagnoses which included: Acute Embolism and Thrombosis of femoral vein bilateral (thrombosis is the formation of a clot in a vessel, and an embolism occurs when part of that clot breaks off and travels to block another vessel), Acute Kidney Failure (the sudden loss of kidney function), Obstructive and Reflux Uropathy (a blockage in the urinary tract that stops or slows urine flow, causing urine to back up and potentially damage the kidneys, leading to symptoms like pain, swelling, frequent urination, and difficulty urinating), Hydronephrosis (the swelling of one or both kidneys due to urine backing up), Retention of urine (the inability to completely empty the bladder).Review of History and Physical examination dated 9/22/25 indicated .The patient is A&OX3[alert and oriented to person, place, time] .Patient has capacity .Review of Physical Therapy Progress note date 11/19/2025 at 12:30 P.M, indicated Pt received in supine in bed, both dtrs [daughters] present. Pt noted with increase pallor(paleness), lethargy, and clammy skin. Pt declines therapy d/t [due to] reports of severe abdominal pain 8/10. RLQ [right lower quadrant of abdomen] noted to be stiff and possibly distended.Med nurse and charge nurse made aware.On 12/9/25 at 2:35 P.M., a concurrent interview with Licensed Nurse 1(LN 1) and record review of Resident 1's Electronic Medical Record ( EMR) was conducted. Review of Resident 1's EMR indicated that Physical Therapy Note was written at 11/19/2025 at 12:30 P.M. indicating Resident 1's change of condition. LN 1 stated that the PT note indicated that Med nurse and charge nurse made aware. so they should have put a change in condition (CIC) note as well at that time. LN 1 stated the first nursing note about Resident 1's change of condition was at 3:12 P.M. LN 1 stated the expectation for a resident's change of condition is to notify the resident's attending physician (MD) or nurse practitioner (NP), notify Responsible Party(RP), get orders from the MD or NP, and document in a timely manner with a CIC note. LN 1 stated that the resident's nurse should have written a CIC note to communicate what the change was and what was done to intervene.On 12/9/25 at 2:50 P.M., a concurrent interview with LN 2, the charge nurse on unit on 11/19/25, and record review of Resident 1's EMR was conducted. LN 2 stated because the facility was in an Covid outbreak, the protocol for any symptoms was first to test for COVID. LN 2 stated at the time of incident, Resident 1 tested negative for COVID, and had stable vital signs (VS), but was complaining of abdominal pain and confusion, as written in her nurse's note. LN 2 stated she texted the NP initially when she first saw Resident 1 about 12:30 P.M. LN 2 stated that she did not chart when she initially texted NP. LN 2 stated that she texted the NP, two more times (times not remembered or documented) and after she did not respond, and then she called NP directly. LN 2 stated the expectation was to document that she notified NP each time, and that NP did not respond. LN 2 stated the importance of timely notification, response, and documentation was to provide the right intervention for Resident 1 in timely manner. LN 2 stated she asked the medication nurse (LN 3) to check on Resident 1 throughout the incident. LN 2 stated that she was not sure why there was no progress note from LN 3 about Resident 1's CIC in the EMR . Review of Infection Preventionist's (IP) CIC note written on 11/19/25 at 3:12 P.M., indicated, Resident's daughter reported that patient has increased confusion. Rehab staff also reported that patient was c/o [complained of] RLQ abdominal pain during therapy. Upon assessment, patient was alert but confused. RLQ noted with mild tenderness when palpated (touched). No guarding [of the abdomen] observed. Abdomen also slightly distended. BP 127/81. Pulse of 107.Date and time of clinician notification 11/19/25 at 15:00(3 P.M.).Date and time of family/resident representative notification 15:00.On 12/10/25 at 8:09 A.M., a phone interview was conducted with LN 3. LN 3 stated that she initially saw Resident 1 when she gave him his medication in the morning around 8:30 A.M. LN 3 stated that at 12 P.M. on 11/19/25, Resident 1 was complaining of RLQ abdominal pain. LN 3 stated that she only spoke to the daughter when the therapist came to talk to her about Resident 1's change of condition. LN 3 stated that resident's daughter was dealing mainly with the nurse, LN 2. LN 3 stated that she assessed resident, did vital signs, assessed resident's abdomen, assessed the resident's urinary catheter, and mental status. LN 3 stated that Resident 1 was confused and had dark yellow urine in foley catheter. LN 3 stated that he had no fever, but they were suspecting a possible UTI. LN 3 stated that she texted the NP at about 12:35 P.M. without response. LN 3 stated that NP did not return her text the first time and after they texted a second time with no response (time not remembered), and her charge. LN 2 called the NP directly at 3 P.M. LN 3 stated that she should have documented Resident 1's condition after assessing resident and again after talking with the NP after contacted about CIC. LN 3 stated she should have charted when she texted NP, and that NP did not respond. LN 3 stated that she did not chart that day because she had been busy that day, and that her charge nurse charted a COC (change of condition) at 3 PM. LN 3 stated the importance of timely documentation was because if it was not documented it was not done. LN 3 stated when the change of condition occurred, she should have contacted the MD or NP within the first 30 minutes to an hour, so they can make timely interventions for the Resident. LN 3 stated that 3 hours was too long.Review of facility document titled eINTERACT Change in Condition Evaluation V5.1 dated 11/19/2025 at 19:35 [7:35 P.M.] indicated The change in condition.Abdominal firm to palpitation and catheter.started 11/19/25 in afternoon.Family notified Charge nurse of persistent abdominal pain from morning. Assessment done and found firmness of abdomen upon palpation. Bowel sounds normal on auscultation. Catheter found with no urine 100CC removed in the morning and 300 CC on bladder scan. Family requested to send to the ED(Emergency Department) for further evaluatIon d/t increased concern.Review of facility document titled eInteract Transfer Form V5 dated 11/19/25 at 7:55 P.M. indicated Resident 1 was transferred to the hospital on [DATE] at 8 P.M. for Family request d/t [due to} increased abd [abdominal] pain and transfer was unplanned.On 12/18/25 at 11:02 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated that notification and documentation of change of condition should be accurate and done in a timely manner. The DON stated that if you didn't document it, you can't prove that you did it.Review of facility policy titled Change in a Resident's Condition or Status dated 2001 indicated The nurse notify the resident's attending physician on call when there has been a(an). d. significant change in the resident's physical/emotional/mental conditions.2. A significant change of condition is a major decline or improvement in resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting) ).d. ultimately based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument.Review of facility policy and procedure titled Charting and Documentation dated 2001, indicated, All services provided to the resident.or any changes in the resident's medical, physical, psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.2. The following information is to be documented in the resident medical record.d. Changed in the resident's condition.7. Documentation of procedures and treatments will include care-specific details including: .c. the assessment data and/or any unusual findings obtained during procedure/treatment.f. notification of family, physician, or other staff.

Based on observation, interview, and record review, the facility failed to ensure a resident who required assistance with incontinent (loss of bowel and bladder control ) care, was provided care in a timely manner for one of four sampled residents (Resident 4) reviewed for ADL (activities of daily living- bathing or showering, dressing, getting in and out of bed or a chair, walking, toileting and eating) care. This failure resulted in not meeting Resident 4 ' s need for comfort and had the potential for further complications such as skin breakdown and infection. Findings: Resident 4 was admitted to the facility on [DATE] with diagnoses including left fibula (the smaller of the two bones in the lower leg) fracture and type 2 diabetes with hyperglycemia (abnormal high blood sugar) according to the facility ' s Admission Record. On 5/6/25 at 8:45 A.M. an unannounced onsite visit to the facility was conducted related to a complaint regarding lack of staff assistance with a resident ' s incontinent care. During an interview on 5/6/25 at 9:33 A.M. with CNA 1, CNA 1 stated call lights should be answered within 5 minutes because if a resident was wet, the resident can develop a skin breakdown. CNA 1 further stated if a resident was constantly wet, the resident can get an infection such as a urinary tract infection. During an interview on 5/6/25 at 9:42 A.M. with Resident 4, Resident 4 stated during the first week of her admission she waited one hour before her brief was changed. Resident 4 stated it was very uncomfortable because she had a bowel movement. Resident 4 stated this morning (5/6/25) when her breakfast tray was served, she requested the Certified Nurse Assistant (CNA) to change her brief because it was, Soaking wet. Resident 4 stated the CNA told her that breakfast trays were still being passed and Resident 4 ' s brief will be changed after passing of trays. Resident 4 stated she waited an hour for the CNA to return to change her brief. Resident 4 stated she felt, Uncomfortable because she was wet. A review of Resident 4 ' s bowel and bladder assessment dated [DATE] was conducted. The assessment indicated that Resident 4 had bladder and bowel incontinence with a usual voiding pattern of upon rising and after meals. During a review of Resident 4 ' s care plans, the care plan dated 4/29/25 indicated, .Resident is incontinent of [x] bladder ]x] bowel and is not a candidate for retraining due to long history of incontinence .Provide check and change incontinence management .Provide clean and dry clothes after incontinent episodes . An interview was conducted on 5/6/25 at 11:12 A.M. with Resident 4 ' s assigned CNA (CNA 3). CNA 3 stated she delivered Resident 4 ' s breakfast tray and Resident 4 told her she (Resident 4) needed to be changed because she was soaking wet. CNA 3 stated she explained to Resident 4 that breakfast trays were still being passed and would return after trays were passed. CNA 3 stated she changed Resident 4 ' s brief after breakfast. CNA 3 stated if she was wearing a wet brief, she would feel uncomfortable. An interview on 5/6/25 at 11:19 A.M. was conducted with the Director of Staff Development (DSD- a licensed nurse certified for staff training). The DSD stated she in-serviced the CNAs to check the residents if they needed to be changed prior to meals, especially those residents who were incontinent of their bowel and bladder. The DSD stated she expected the CNAs to change residents' briefs right away if residents were wet or soiled. The DSD stated if a resident sat on feces or urine, the resident would be uncomfortable and may develop a skin breakdown. The DSD stated she would feel uncomfortable if she was left soaking wet. The DSD further stated it was unacceptable for a resident to have to wait and sit on a wet brief. During an interview on 5/9/25 at 12:05 P.M. with the Director of Nursing (DON), the DON stated it was a priority to change the resident ' s brief instead of passing meal trays for the resident ' s comfort and dignity. The DON stated she would not want to eat knowing her brief was wet. During a review of the facility ' s policy and procedure (P&P) titled, Resident Rights, dated February 2021, the P&P indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: a. a dignified existence; b. be treated with respect, kindness, and dignity . A review of the facility ' s P&P titled, Answering the Call Light, dated September 2022 was conducted. The P&P indicated, .Answer the resident call system immediately .If you are uncertain as to whether or not a request can be fulfilled, or if you cannot fulfill the resident ' s request, ask the nurse supervisor for assistance .

Based on interview and record review, the facility failed to obtain a physician ' s order for a blood sugar fingerstick (a method of measuring blood sugar levels in the blood) in accordance with the facility's policy and procedure and care plan for one of four sampled residents (Resident 4) reviewed. This failure had the potential to affect the delivery of care provided to Resident 4. Findings: On 4/30/25 at 8:45 A.M, an unannounced onsite visit at the facility was conducted related to the care of a resident with diabetes (too much sugar circulating in the blood). Resident 4 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus with hyperglycemia (high blood sugar) according to the facility ' s Admission Record. An interview was conducted with Resident 4 on 4/30/25 at 10:06 a.m. Resident 4 stated she had a diagnosis of diabetes and was checking her blood sugar twice a day when she was at home. Resident 4 stated her blood sugar was also checked when she was at the hospital. Resident 4 stated she got upset with staff because the staff did not know she had diabetes and was not checking her blood sugar. Resident 4 stated the staff started checking her blood sugar before meals after she told them she had diabetes. Resident 4 stated the first time her blood sugar was checked, the result was over 300 (an abnormal high value). A review of Resident 4 ' s physician ' s orders was conducted. The physician ' s orders dated 4/27/25 indicated, .Insulin Lispro [a fast-acting medication that helps regulate blood sugar levels] .inject as per sliding scale .before meals for DM-2 [diabetes mellitus type 2- a long-term condition in which the body has trouble controlling blood sugar] . There was no physician ' s order for checking Resident 4 ' s blood sugar. During a review of Resident 4 ' s care plan dated 4/28/25, the care plan indicated, .Diabetes: Resident has a diagnosis of diabetes and is at risk for complications .Interventions/Tasks .Blood glucose checks as ordered. Report to physician if blood glucose is outside set parameters . A joint record review and interview on 4/30/25 at 12:03 P.M. was conducted with Licensed Nurse (LN) 1. LN 1 reviewed Resident 4 ' s physician ' s orders in the electronic medical record (EMR) and stated Resident 4 was receiving insulin. LN 1 stated there was no order to check Resident 4 ' s blood sugar prior to administering the insulin. LN 1 stated even without a physician ' s order; the medication nurses still checked Resident 4 ' s blood sugar because Resident 4 was on insulin. LN1 further stated, a physician ' s order was needed for resident safety and to provide a reason for the use of the insulin. During an interview on 4/30/35 with a Nurse Practitioner (NP) at the facility, the NP stated it was expected for nursing staff to write a separate order for a blood sugar fingerstick. The NP further stated the EMR should show a separate blood sugar check order. An interview was conducted on 5/1/25 at 2:18 P.M. with LN 2. LN 2 stated if a resident was admitted to the facility with insulin orders but without an order for blood sugar fingerstick, the nursing staff will call the physician to obtain an order. LN 2 stated an order was needed to monitor the resident ' s blood sugar levels. LN 2 stated that a physician ' s order was needed to obtain a resident ' s blood sugar fingerstick. During an interview on 5/1/24 at 3:13 P.M. with the Director of Nursing (DON), the DON stated a blood sugar fingerstick was an invasive procedure and it required a physician ' s order. A review of the facility ' s policy and procedure (P&P) titled, Obtaining a Fingerstick Glucose Level, dated October 2011 was conducted. The P&P indicated, .The purpose of this procedure is to obtain a blood sample to determine the resident ' s blood glucose level .Preparation 1. Verify that there is a physician ' s order for this procedure .

Based on record review and interview, the facility did not maintain a complete Physician Orders for Life Sustaining Treatment (POLST- a medical form used to communicate a resident's wishes during a life-threatening emergency) for eight of 32 residents reviewed for complete and accurate medical records. (Residents 2,15, 45, 57, 58, 59, 245, 111) This failure did not provide an accurate representation of the care provided and had the potential to cause confusion amongst care providers. Findings: 1. Resident 2 was readmitted to the facility on [DATE] with diagnoses including hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction ((disrupted blood flow to the brain) according to the facility's Admission Record. 2. Resident 15 was admitted to the facility on [DATE] with diagnoses including fracture of shaft left femur (long, central part of thigh bone) according to the facility's Admission Records. 3. Resident 45 was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation (an irregular, rapid heartbeat causing poor blood flow) according to the facility's Admission Records. 4. Resident 57 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction according to the facility's Admission Record. 5. Resident 58 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease (heart problems that develop due to long term high blood pressure) with heart failure according to the facility's Admission Record. A concurrent record review and interview was conducted on [DATE] at 8:12 A.M. with Licensed Nurse (LN) 11. LN 11 reviewed POLST forms in the electronic medical records (EMR) for Resident 2, 15, 45, 57 and 58 at the nurse's station. LN 11 stated POLST forms for Residents 2, 15, 45, 57 and 58 were all incomplete in section D of the form pertaining to information regarding advance directives (a legal document with a person's wishes for medical care when unable to communicate them). The Social Service Director (SSD) was at the nurse's station and stated nurses were responsible for completing the POLST form including section D regarding advance directives. LN 11 stated the admission nurse completed the form during admission of a resident. LN 11 stated she had worked as an admission nurse and have not completed or followed up with section D of the POLST. LN 11 stated it was important to complete section D the advance directive part of the POLST to help determine if a resident can make decisions regarding care. An interview was conducted with the Director of Nursing (DON) on [DATE] at 1:45 P.M. The DON stated POLST for residents should be complete for continuity of care and for staff to be well informed. A review of the facility's policies and procedures (P&P) titled, Charting and Documentation, dated [DATE] indicated, .The medical record should facilitate communication between the interdisciplinary team [IDT- team members with various areas of expertise who work together toward the goals of their residents] regarding the resident's condition and response to care .Documentation in the medical record will be objective .complete, and accurate . 47466 Findings. 6. A review of Resident 59's undated Admission Record indicated Resident 59 was admitted to the facility on [DATE] with diagnoses that include cancer of the left ear and chronic obstructive pulmonary disease (a chronic lung disease that caused difficulty in breathing). A review of Resident 59's Physician Orders for Life Sustaining Treatment (POLST-a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can and cannot be done at the end of life) dated [DATE] indicated Resident 51 was A. attempt Resuscitation CPR), B. selective treatment C. trial period of artificial means nutrition, including feeding tubes and D. was left blank regarding Advanced Directives, as signed by Resident 59. A review of Resident 59's minimum data set (MDS- a federally mandated assessment tool) dated ,d+[DATE] indicated Resident 59's brief interview for mental status (BIMS) score was 15, which meant Resident 59's cognition (thought process) was intact. 7. A review of Resident 245's undated Admission Record indicated Resident 245 was admitted to the facility on [DATE] with diagnoses that include Hypertension (elevated blood pressure ) and Dementia (a progressive state of decline in mental abilities). A review of Resident 245's POLST dated [DATE] indicated Resident 245 was A. attempt CPR, selective treatment C. Trial period of artificial means of nutrition, including feeding tubes D. was left blank regarding Advanced Directives , as signed by Resident 245's family member (FM), Resident 245's daughter. A review of Resident 245's minimum data set (MDS) dated [DATE] , indicated Resident 245's BIMS score was 09 which meant Resident 245's cognition (thought process) was moderately impaired. A review of Resident 245's MDS dated [DATE] indicated Resident BIMS score was 09 which meant Resident 245's cognition ( thought process ) moderately impaired. A review of the facility's policies and procedures (P&P) titled, Charting and Documentation, dated [DATE] indicated, .The medical record should facilitate communication between the interdisciplinary team [IDT- team members with various areas of expertise who work together toward the goals of their residents] regarding the resident's condition and response to care .Documentation in the medical record will be objective .complete, and accurate . 50175 8. Resident 111 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a problem in the brain caused by an illness in the body) and age-related cognitive decline (difficulty thinking and remembering) according to the Admission Record. A concurrent interview and record review was conducted with the Director of Nursing (DON) on [DATE] at 10:16 A.M. The DON stated Resident 111's POLST Section D was blank. The DON stated a blank Section D indicated that there was no documentation that someone asked Resident 111 or the responsible party if Resident 111 had an Advance Directive. A review of the facility's policies and procedures (P&P) titled, Charting and Documentation, dated [DATE] indicated, .The medical record should facilitate communication between the interdisciplinary team [IDT- team members with various areas of expertise who work together toward the goals of their residents] regarding the resident's condition and response to care .Documentation in the medical record will be objective .complete, and accurate .

Based on interview and record review, the facility failed to prevent a stage four (bedsore extended to muscle, tendon or bone) pressure injury from developing after admission for one of three residents (Resident 15) reviewed for pressure injuries. This failure had the potential to affect Resident 15's quality of life. Findings: Resident 15 was admitted to the facility on [DATE] with diagnoses including fracture of shaft left femur (long, central part of thigh bone) according to the facility's Admission Records. During an observation on 4/14/25 at 9:09 A.M. Resident 15 was in bed with an air mattress and overbed trapeze. Resident 15 stated he was on air mattress due to a bedsore on his buttock. Resident 15 was pointing towards his buttocks area. A review of admission records for Resident 15 titled, 01. NURSING-ADMISSION/READMISSION EVALUATION/ASSESSMENT, dated 11/20/24 was conducted. The admission record indicated no pressure injuries. During an interview on 4/15/25 at 7:45 A.M. with Resident 15, Resident 15 stated he was admitted to the facility due to a left leg surgery, but he laid in one position and developed a pressure sore on his buttock. A review of Resident 15's BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK, dated 11/20/24 indicated a score of 15 .AT RISK . A review of the skin care plan dated 11/20/24 for Resident 15 was conducted. The skin care plan indicated, .at risk for skin breakdown .assist to turn and reposition as indicated . An interview was conducted on 4/16/25 at 8:58 A.M. with Certified Nurse Assistant (CNA) 12. CNA 12 stated Resident 15 had a bedsore on his buttock due to being up on the wheelchair too long. CNA 12 stated Resident 15 required assistance with repositioning. CNA 12 stated to prevent bedsores, residents should be changed frequently, reposition every two hours and as needed. During an interview on 4/16/25 at 9:11 A.M. with CNA 13, CNA 13 stated residents needed to be repositioned every two hours and checked frequently to prevent developing pressure ulcers. A concurrent record review and interview on 4/16/25 at 10:03 A.M. was conducted with the Treatment Nurse (TN). The TN stated Resident 15 had a stage four pressure ulcer on the sacrum (the triangular shaped bone at the base of the back). The TN showed photos of Resident 15's pressure ulcer. The photo dated 12/10/24 indicated 2.28cm (centimeter) by 1.95 cm, with 80% eschar (black dead tissue) and unstageable (a type of bed sore where the base is covered by dead or yellowish tissue) on the right iliac crest (top of the hip bone). Care plans for Resident 15 were reviewed with the TN. The TN stated the care plans for Resident 15 indicated Resident 15 developed a popped blister on 12/6/24, re-classified as Deep Tissue Injury (DTI-a purple or maroon area of intact skin or blood-filled blister due to damage of soft tissue from pressure or shear) on 12/10/24, re-classified by the wound physician as unstageable (a full thickness tissue loss where the depth of the wound is hidden by a layer of eschar or slough in the wound) on 12/11/24, then re-classified as a stage four on 1/17/25 as the pressure ulcer progressed. The TN stated shearing might have caused Resident 15's pressure ulcer. The TN further stated Resident 15 had developed a blood blister on the coccyx (tailbone) and another DTI on the right buttock as of 4/15/25. During a review of the physician's progress note for Resident 15 dated 12/11/24, the progress note indicated, .Consulted for managing wounds .Patient was > [greater than] 5 hrs [hours] in the wheelchair. advised [sic] to keep sitting in the wheelchair within 1-2 hrs max . An interview on 4/17/25 at 2:34 P.M. was conducted with the Director of Nursing (DON). The DON stated she expected staff to identify residents' comorbidities and be proactive in preventing skin issues. A review was conducted of the facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries, dated April 2020. The P&P indicated, .Reposition all residents with or at risk of pressure injuries on an individualized schedule .Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines .

Based on observation, interview, and record review, the facility failed to ensure a medication was given as ordered by a physician for one of three residents (Resident 107) observed for medication administration. This failure had the potential for Resident 107's medical needs to be unmet. Findings: Resident 107 was admitted to the facility on [DATE] with diagnoses including diabetes (high blood sugar), according to the Admission Record. Licensed Nurse (LN) 31 was observed preparing and administering medications to Resident 107 on Wednesday, 4/16/25, at 7:55 A.M. Resident 107 was given the following medications: benazepril (a blood pressure medication), empagliflozin (a diabetes medication), apixaban (a blood thinner), gabapentin (a medication to treat nerve pain), arginine (a supplement), ascorbic acid (a vitamin), aspirin (a blood thinner), ferrous sulfate (an iron supplement), multivitamin, and insulin glargine (a diabetes medication). A review of Resident 107's medical record was conducted on 4/16/25. A review of Resident 107's physician's orders included dulaglutide injection (a diabetes medication) every Wednesday. Resident 107 did not receive dulaglutide during the medication administration observation. An interview was conducted with LN 31 on 4/16/25 at 10:10 A.M. LN 31 stated she did not notice that dulaglutide was due because it was on the last part of the medication administration record (a record including a resident's medication orders). LN 31 stated she had not given the medication yet. LN 31 stated dulaglutide was due at 9:00 A.M. A follow-up interview was conducted with LN 31 on 4/16/25 at 10:44 A.M. LN 31 stated dulaglutide was not available when it was due, and the medication needed to be ordered from the pharmacy. An interview with the Director of Nursing (DON) was conducted on 4/17/25 at 10:11 A.M. DON stated medications needed to be available when it was due. DON stated medication nurses were responsible for making sure the medication was available, especially if it was due only once a week. DON stated it was important to give medications on time and to follow physician's orders. A review of the facility's policy titled Administering Medications, revised April 2019, indicated .Medications are administered in accordance with prescriber orders, including any required time frame .Medications are administered within one (1) hour of their prescribed time .

Based on interview and record review the facility failed to ensure one of 8 residents (41) reviewed for psychotropics (drugs that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) had the proper indication for the use of an anti-anxiety medication (a drug used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness and muscle tightness that may occur as a reaction to stress). This failure resulted in Resident 41's continued use of an antipsychotic medication without proper indication and possible exposure to the medication's side effects. Findings: A review of Resident 41's undated Admission Record indicated that Resident 41 was admitted to the facility on [DATE] with diagnoses that included Anxiety Disorder (feelings of worry, nervousness and fear) and Major Depressive Disorder (persistent feelings of sadness and loss of interest in activities). An interview on 4/16/25 at 8:52 A.M., with Resident 41 was conducted. Resident 41 was seen lying in bed, watching TV in her room. Resident 41 stated she had been taking xanax (medication to treat anxiety) for years for her anxiety. Resident 41 stated she gets panic attacks and would feel her heart beating fast and somehow, she felt like she had to be somewhere but does not know where. Resident 41 stated the facility was giving the medication as needed before, but she had requested it to be administered on a routine basis. Resident 41 stated it usually takes two hours for the medication to work on her before she calmed down or else she is trouble. A review of Resident 41's minimum data set (MDS- a federally mandated assessment tool) dated 3/17/25 indicated Resident 41 had a brief interview for mental status (BIMS) of 15 which meant Resident 41's cognition (thought process) was intact. An interview on 4/16/25 at 8:50 A.M., with certified nursing assistant (CNA) 24 was conducted. CNA 24 stated when Resident 41 started talking about her family issues, Resident 41 gets anxious, and Resident 41 would tell CNA 24 she felt her heart beating fast. An interview on 4/16/25 at 9:10 A.M., with Licensed Nurse (LN) 21 was conducted. LN 21 stated Resident 41 would exhibit anxiety manifested by Resident 41's refusal of care. An interview on 4/17/25 at 8:05 A.M., with LN 22 was conducted. LN 22 stated Resident 41 did not have any episodes of feeling of impending danger, she was alert and oriented enough to let staff know. LN 22 stated the behavior monitoring was not accurate for the use of xanax. LN 22 stated feeling of impending danger was not the same as panic attacks. LN 22 stated it was important to get the right behavior monitoring for the efficacy of the medication and to provide Resident 41's physician adequate information regarding Resident 41's progress. A record review of Resident 41's Physician's orders dated 3/2/25 indicated Alprazolam tablet 0.5 mg, give 1 tablet by mouth every 8 hours for anxiety, as exhibited by: feeling of impending danger. A review of Resident 41's care plan dated 3/18/22 indicated Requires use of xanax for anxiety as evidenced by (AEB): feeling of impending danger. An interview on 4/17/25 at 10:00 A.M., with the Director of Nursing (DON) was conducted. The DON stated it was important to identify the exact behavior to give the proper intervention, and the facility does the gradual dose reduction (GDR) to ensure the medication worked. A review of the facility's policy on Psychotropic Medication Use dated February 2025, indicated Policy Interpretation and Implementation .#3 .c. adequate monitoring for efficacy and adverse consequences. Adequate Indications for Psychotropic Medication Use .#1.Adequate indication for use refers to the identified , documented clinical rationale for administering medication that is based on .a. an assessment of the resident's condition .

Based on observation, interview, and record review, the facility failed to ensure current infection control practices were followed when a facility employee touched the spout of beverage cartons upon opening the cartons during mealtime. This failure had the potential for cross contamination (spread of germs and bacteria) and infection. Findings: A dining room observation was conducted on 4/14/25 at 11:34 A.M. at the facility's south dining room. The dining room was observed with four round tables with numbers 1, 2, 3 and 4. The Restorative Nursing Assistants (RNA-a Certified Nurse Assistant who worked alongside rehab staff to provide exercises for residents with limited mobility) were at tables 1, 2 and 3. Table 4 had two residents who were waiting for their trays to be served. On 4/14/25 at 12:05 P.M. meal trays for the residents in table 4 were served by Licensed Nurse (LN) 11. LN 11 opened three small cartons of beverages using her bare forefinger to open the spout on the cartons. LN 11 then proceeded to feed one of the residents in table 4. An observation and interview was conducted on 4/16/25 at 12:15 P.M. with RNA 2. RNA 2 demonstrated how to open a beverage carton. RNA 2 stated after pulling the carton's opening to the sides, the corner of the carton must be squeezed, and the spout will open. RNA 2 stated if the spout will not open, pull the other end of the carton to the sides and the carton will fully open. RNA 2 stated touching the spout was an infection control issue. An observation and interview on 4/16/25 at 12:27 P.M. was conducted with LN 11. LN 11 demonstrated how to open a beverage carton. LN 11 stated after pulling the edges of the carton, the carton should be squeezed at the ends and the spout will open. LN 11 stated she did not follow this procedure and placed her finger on the spout to open it. LN 11 stated using her finger was an infection control issue. During an interview on 4/17/25 at 2:35 P.M. with the Director of Nursing (DON), the DON stated staff should not open beverage cartons by touching the spout because of infection control and spreading of germs. A review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated April 2025 was conducted. The P&P indicated, .Prevention of Infection .educating staff and ensuring that they adhere to proper techniques and procedures .communicating the importance of standard precautions . The policy did not define standard precautions to prevent the spread of infection and explain the precautions during resident care activities. During a review of the Centers for Disease Control and Prevention (CDC- the national public health agency that protects the public's health in the United States https://www.cdc.gov/infection-control/hcp/isolation-precautions/summary-recommendations.html) Summary of Recommendations, dated November 27, 2023, the recommendations indicated .Assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting .

Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status by not providing a nutritional supplement for one of four residents (Resident 2) reviewed for nutrition and with a significant weight loss. This failure had the potential to result in Resident 2's unplanned weight loss which could lead to further decline in weight and overall health condition. Findings: Resident 2 was readmitted to the facility on [DATE] with diagnoses including dysphagia (difficulty in swallowing) following cerebral infarction (disrupted blood flow to the brain) according to the facility's Admission Record). On 4/14/25 9:52 A.M. Resident 2 was observed in her bed watching TV. During interview Resident 2 did not respond verbally but nodded that she was okay. Resident 2 did not respond to further questions. During a review of Resident 2's physician's orders in the electronic medical record (EMR), the physician's orders indicated, .RNA dining program daily at lunch .Boost VHC [Very high calorie nutritional supplement] with meal for supplement . During the dining observation on 4/14/25 at 11:42 A.M. Resident 2 was observed being assisted with her meal by the Restorative Nurse Assistant (RNA- a CNA who work alongside rehab staff to provide exercises for residents with limited mobility) 1. The meal tray included a small glass of thickened milk, small glass of thickened water, a small glass of thickened juice, three small cups of puree food, a plate of puree food and a bowl of soup. RNA 1 stated Resident 2 requires encouragement to eat and has had weight loss. There was no Boost on resident's tray. On 4/15/25 at 8:41 A.M. Licensed Nurse (LN) 12 was observed encouraging Resident 2 to eat breakfast in Resident 2's room. A concurrent observation of Resident 2's meal tray was conducted. The meal tray included thickened milk, thickened water and thickened juice. There was no Boost with Resident 2's meal. On 4/15/25 at 11:50 A.M. Resident 2 was observed in the dining room. RNA 1 named the beverages served for Resident 2's. RNA 1 stated the beverages were: thickened milk, thickened juice and thickened water. There was no Boost served with Resident 2's meal. During an observation on 4/16/25 at 7:53 A.M. Resident 2 was in her room for breakfast. Certified Nurse Assistant (CNA) 13 was assisting Resident 2 to eat. CNA 13 stated Resident 2 had three beverages on the meal tray. CNA 13 stated a thickened juice, water and milk were served with Resident 2's meal. There was no Boost served with the meal. A concurrent record review and interview on 4/16/25 at 2:07 P.M. was conducted with Licensed Nurse (LN) 13. LN 13 reviewed the physician's orders for Resident 2. LN 13 stated there was an order for Boost VHC with meals for supplement. LN 13 stated the CNAs was responsible for getting the Boost from the LNs which was kept in the medication cart and Resident 2 did not receive the Boost. LN 3 reviewed Resident 2's weight record. LN 3 stated Resident 2's weight on 3/7/25 was 103 lb. (pounds) and 91 lb. on 4/9/25. LN 3 stated Resident 2 had significant weight loss. LN 13 further stated it was important for Resident 2 to receive the Boost to help with her nutrition. A review of the Registered Dietician's (RD) progress note for Resident 2 dated 4/10/25 was conducted. The progress notes indicated, .- [minus]12# [pounds] x 1 mo [month] 11.6% .underweight status .wt [weight] below goal . A review of Resident 2's weight record in the EMR indicated: 1/4/25 110 lb. 2/3/25 106 lb. 3/1/25 100 lb. 3/7/25 103 lb. 3/17/25 98 lb. 4/3/25 97 lb. 4/9/25 91 lb. During an interview on 4/16/25 at 2:45 P.M. with the Registered Dietician (RD), the RD stated she expected staff to provide Boost to Resident 2. The RD stated she was not aware that Resident 2 was not receiving the Boost. The RD stated Boost was an intervention to address Resident 2's weight loss and it was specific to be given with meals in case Resident 2 did not eat the food that was served. An interview with the Director of Nursing (DON) on 4/17/25 at 2:34 P.M. was conducted. The DON stated staff should follow physician's order to provide resident's needs. The DON further stated if Boost was ordered due to weight loss, staff should provide it to the resident. During a review of the facility's policy and procedure (P&P) titled, Nutritional Assessment, dated October 2017, the P&P indicated, .The nutritional assessment will be conducted .and shall identify at least .an estimate of calorie, protein, nutrient and fluid needs .The multidisciplinary team [team members with various areas of expertise working together towards the goals of the residents] shall identify .Inadequate availability of food or fluids-lack of access to the amount of food or fluids that the resident requires to maintain sufficient nutrition and hydration . During a review of the facility's policy and procedure (P&P) titled, Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, dated September 2012, the P&P indicated, .The nursing staff will monitor and document .dietary intake of residents .Treatment decisions should consider all pertinent evidence and relevant issues .The physician will authorize appropriate interventions .

Based on observation , interview and record review, the facility failed to ensure one of ten residents (19) observed during lunch in the dining room had a meal tray at the same time as the other residents. This failure had the potential to not provide and preserve Resident 19's dignity and respect. Findings. A review of Resident 19's undated Admission Record indicated that Resident 19 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (abnormal blood sugar) with Diabetic Neuropathy (a type of nerve damage that occurs with diabetes). During a dining room lunch observation on 4/14/25 at 11:42 A.M., residents were seated in their assigned areas in the dining room. There were three tables assigned for restorative feeding program (aims to help individuals regain or maintain their ability to eat independently). The fourth table was observed with two residents seated. Licensed Nurse 11 checked the meal ticket with the trays and then handed it to the restorative aides and certified nursing assistants to give to the residents. The three tables where residents seated for RNA feeding started eating and were assisted by staff. An observation on 4/14/25 at 12:09 P.M. was conducted. Resident 19 was observed looking around in the dining room while other residents were eating their lunch. Resident 19 stated, I am hungry, but it happens at times when I would have to wait to get served my tray. Everyone had their tray and I don't, I guess it's okay, but I am hungry. Resident 19 was observed to receive her lunch tray 30 minutes after all the other residents' trays were served. An interview on 4/14/25 at 12:15 P.M., with the restorative nursing assistant (RNA) was conducted. The RNA stated every resident in the dining room should have their tray at the same time, to provide and preserve their dignity and ensure respect. An interview on 4/14/25 at 12:25 P.M., in the dining room with Licensed Nurse 13 was conducted. LN 13 stated it was inappropriate for Resident 19 to have waited for her tray while other residents have eaten or started eating. LN 13 stated I would be upset if everyone had their trays, and I didn't. LN 13 stated it was important for all the residents in the dining room to have their trays served at the same time to ensure the facility provided them the dignity and respect. An interview on 4/17/25 at 10:00 A.M., with the Director of Nursing (DON) was conducted. The DON stated it was a dignity issue and that every resident in the dining room should be served their trays at the same time. The DON stated I would feel left out too if I did not get a tray. A review of the facility's policy on Resident Rights dated February 2021 , indicated, Policy statement .Employees shall treat all residents with kindness , respect and dignity. Policy Interpretation and Implementation #1. Federal and state laws guarantee certain basic rights to all residents in the facility. These rights include a. a dignified existence .

Based on observation, interview and record review, the facility failed to monitor and reassess a change in condition (significant worsening of a resident's physical or mental health) for one sampled resident (303). This failure had the potential for complications related to Resident 303's health. Findings: Per the facility admission record, Resident 303 was admitted on [DATE] with diagnoses that included chronic kidney disease stage 3 (condition where the kidneys gradually lose their ability to filter waste products from the blood, leading to a buildup of toxins and other substances in the body). Per the facility progress notes, on 4/12/25 at 3:36 P.M., a potassium level of 5.6 (normal levels 3.5 and 5.5) was reported to the physician. The physician ordered to insert a peripheral intravenous (IV) catheter (a small, thin, flexible tube inserted into a vein to deliver fluids, medications, or blood products directly into the bloodstream). The IV was inserted into Resident 303's back of left hand. Per the facility progress notes, on 4/13/25 at 9:14 P.M., Resident 303's IV infiltrated (when the tip of the catheter slips out of the vein and some of the fluid leaks out into the tissues under the skin) which caused swelling and pain. On 4/14/25, at 8:35 A.M., an observation and interview were conducted with Resident 303 in her room. Resident 303 stated she had an IV in her left hand, but it made her left hand and arm swollen with pain last night. When Resident 303 held up both of her hands and arms together, the left hand and arm were visibly swollen compared to her right hand and arm. Resident 303 stated that the nurses have not helped her with the swelling. On 4/15/25 at 10:09 A.M., a concurrent interview and record review was conducted with a licensed nurse (LN 1). LN 1 reviewed Resident 303's medical record and stated there were no documentation for monitoring or reassessing Resident 303's swollen left hand and arm. LN 1 stated it is their process to monitor and reassess the resident's change in conditions every shift for 72 hours. LN 1 stated that the importance of monitoring and reassessing a change in condition is to ensure the resident's health is improving and that there are no complications related to the change. On 4/17/25 at 10:51 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated that for all change in conditions, it is her expectation that nursing are to monitor, reassess and document the identified change in condition every shift. A review of the facility policy titled Change in a Resident's Condition or Status, dated February 2021. indicated that .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical .condition or status.

Based on observation, interview, and record review, the facility failed to ensure services to meet professional standards for two of 32 sampled residents when: 1. Resident 123's midline catheter (tube inserted in the upper arm with the tip located just below the armpit to allow access to the bloodstream for medications, fluids, blood draws, and other treatments) dressing was not changed and monitored. 2. The facility failed to provide a nutritional supplement in accordance with the resident's physician's orders. (Resident 2) This failure had the potential for complications related to intravenous (IV - method of delivering fluids, medications, or nutrients directly into the bloodstream through a vein) therapy and the potential for not meeting Resident 2's nutritional needs. Findings: 1. Per the facility's admission record, Resident 123 was admitted on [DATE] with diagnoses that included pneumonia (lung infection). A review of Resident 123's physician's orders indicated, on 4/13/25 an order was made for IV-dressing change .upon admission and to change midline dressing every night shift every seven days. On 4/14/25 at 10:45 A.M., an observation and interview were conducted with Resident 123 in his room. Resident 123 had an IV line on the right upper arm. Resident 123 stated a nurse changed the dressing yesterday and could not recall if the nurse measured his arm or the IV catheter. On 4/15/25 at 10:09 A.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 1. A review of the IV line dressing change documentation dated 4/13/25 in the IV Medication Administration Record (MAR) for Resident 123, measurements of arm circumference and catheter length were not done. LN 1 stated the importance of measuring arm circumference and the catheter length for a midline catheter was to ensure proper placement and prevent complications. On 4/17/25 at 10:51 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated that measuring arm circumference and the catheter length for a midline catheter during the dressing change was a standard of practice and should have been done. DON stated the importance of the measuring is to make sure it is functional. A review of the facility's policy titled Peripheral and Midline IV Dressing Changes, dated March 2022, indicated .8. For midline catheters, measure arm circumference . 46235 2. Resident 2 was readmitted to the facility on [DATE] with diagnoses including dysphagia (difficulty in swallowing) following cerebral infarction (disrupted blood flow to the brain) according to the facility's Admission Record. On 4/14/25 9:52 A.M. Resident 2 was observed in her bed watching TV. During interview Resident 2 did not respond verbally but nodded that she was okay. Resident 2 did not respond to further questions. During a review of Resident 2's physician's orders in the electronic medical record (EMR), the physician's orders indicated, .RNA dining program daily at lunch .Boost VHC [Very high calorie nutritional supplement] with meal for supplement . During the dining observation on 4/14/25 at 11:42 A.M. Resident 2 was observed being assisted with her meal by the Restorative Nurse Assistant (RNA- a CNA who work alongside rehab staff to provide exercises for residents with limited mobility) 1. The meal tray included a small glass of thickened milk, small glass of thickened water, a small glass of thickened juice, three small cups of puree food, a plate of puree food and a bowl of soup. RNA 1 stated Resident 2 required encouragement to eat and has had weight loss. There was no Boost on resident's tray. On 4/15/25 at 8:41 A.M. Licensed Nurse (LN) 12 was observed encouraging Resident 2 to eat breakfast in Resident 2's room. A concurrent observation of Resident 2's meal tray was conducted. The meal tray included thickened milk, thickened water and thickened juice. There was no Boost with Resident 2's meal. On 4/15/25 at 11:50 A.M. Resident 2 was observed in the dining room. RNA 1 named the beverages served for Resident 2. RNA 1 stated the beverages were: thickened milk, thickened juice and thickened water. There was no Boost served with Resident 2's meal. During an observation on 4/16/25 at 7:53 A.M. Resident 2 was in her room for breakfast. Certified Nurse Assistant (CNA) 13 was assisting Resident 2 to eat. CNA 13 stated Resident 2 had three beverages on the meal tray. CNA 13 stated a thickened juice, water and milk were served with Resident 2's meal. There was no Boost served with the meal. An interview on 4/16/25 at 2:07 P.M. was conducted with Licensed Nurse (LN) 13. LN 13 reviewed the physician's orders for Resident 2. LN 13 stated there was an order for Boost VHC with meals for supplement. LN 13 stated the CNAs were responsible for getting the Boost from the LNs which was kept in the medication cart. LN 13 further stated it was important for Resident 2 to receive the Boost to help with her nutrition. During an interview on 4/16/25 at 2:45 P.M. with the Registered Dietician (RD), the RD stated she expected staff to provide Boost to Resident 2. The RD stated she was not aware that Resident 2 was not receiving the Boost. The RD stated Boost was an intervention to address Resident 2's weight loss and it was specific to be given with meals in case Resident 2 did not eat the food that was served. An interview with the Director of Nursing (DON) on 4/17/25 at 2:34 P.M. was conducted. The DON stated staff should follow physician's order to provide resident's needs. During a review of the facility's policy and procedure (P&P) titled, Physician's Orders, dated June 2013, the P&P indicated, .Physician's orders must be given, managed and carried out in accordance with applicable laws and regulations .

Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS- a nursing assessment tool) for one of seven sampled residents (Resident 134) reviewed for MDS accuracy. This deficient practice resulted in providing inaccurate information to the Federal database (information maintained by the federal government). Findings: Resident 134 was admitted to the facility with diagnoses including cystitis (inflammation of the bladder) according to the facility's Admission Record. During a review of Resident 134's MDS dated [DATE], the MDS, section O0100J1 indicated an x for dialysis (procedure done by a trained professional to remove wastes and excess fluids from the body). A review of Resident 134's physician's orders in the electronic medical record (EMR) indicated no orders for dialysis treatments. An interview and observation was conducted with Resident 134 on 4/15/25 at 8:52 A.M. Resident 134 was in bed and stated she had irritation with frequent urination. Resident 134 stated she was starting an antibiotic today (4/15/25). Resident 134 did not have a dialysis graft (a synthetic tube placed in the arm, used to connect an artery or vein used as pathway during dialysis treatments). Resident 134 stated she did not have dialysis treatments. An interview on 4/16/25 at 2:29 P.M. was conducted with licensed nurse (LN) 13. LN 13 stated she was the assigned medication nurse for Resident 134. LN 13 stated Resident 134 did not have dialysis. A concurrent record review and interview was conducted with the MDS nurse (MDSN). The MDSN reviewed Resident 134's diagnoses and MDS in the EMR. The MDSN stated the MDS was marked with an x which meant Resident 134 was on dialysis. The MDSN stated the MDS assessment dated [DATE] was coded inaccurately because Resident 134 was not on dialysis. The MDSN further stated that it was important for the MDS to be accurate because it determined the resident's plan of care and reimbursement for the facility. During an interview on 4/17/25 at 2:34 P.M. with the Director of Nursing (DON), the DON stated the MDS assessment should be accurate because it captured the resident's condition to formulate a care plan. A review of the facility's policy and procedure (P&P) titled, Accuracy of the Resident Assessment, dated December 2023 was conducted. The P&P indicated, .Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment . A review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023 was conducted. Chapter 1.2 page seven of the User's Manual indicated the Resident Assessment Instrument (RAI) consisted of the MDS. The User's Manual chapter 1.2, page eight indicated, .The RAI process has multiple regulatory requirement .Federal regulations .require that (1) the assessment accurately reflects the resident's status . Furthermore chapter 5.5, page 668 of the User's Manual indicated, .the MDS must be accurate as of the ARD [Assessment Reference Date] .

Based on observation, interview, and record review the facility failed to notify the attending physician and resident representative on four of five residents (Resident 2, 3, 5 and 7) reviewed for changes in condition when: 1. Resident 2 ' s representative was not notified of a wound deterioration. 2. Resident 3 ' s attending physician was not notified of a significant weight loss. 3. Resident 5 ' s attending physician was not notified of a significant weight loss. 4. Resident 7 ' s representative was not notified of a wound deterioration. These failures had the potential for a delay in care in treatment. In addition, the residents ' representatives were not aware of the change in condition. 1. Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (an impairment of brain function, such as memory loss and judgment) and muscle weakness according to the facility ' s Admission Record. During an interview on 9/9/24 at 8:48 A.M. with Resident 2 ' s granddaughter, the granddaughter stated Resident 2 was admitted to the facility with a bruise on the tailbone which worsened to a stage four wound (bedsore extended to muscle, tendon, or bone) and the family was not notified. During a review of Resident 2 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 7/9/24, section GG0170 A through E indicated Resident 2 was dependent with rolling in bed, sit to lying, lying to sitting on side of bed, sit to stand and transfers. During observation on 9/9/24 at 9:41 A.M., Resident 2 was in bed with an air mattress and oxygen via nasal cannula (a small plastic tube, which fits into the person ' s nostrils for providing supplemental oxygen). Resident spoke only Spanish. A review of Resident 2 ' s care plans was conducted. Resident 2 ' s skin care plan initiated on 7/2/24 indicated, .at risk for skin breakdown related to activity intolerance, Braden Risk (a measurement of a resident ' s risk of developing pressure ulcers, or sores) score, Cardiovascular disease .impaired ADL (activities of daily living) ability .Assist to turn and reposition as indicated/tolerated, check skin during daily care provisions . On 9/9/24 at 9:35 A.M. the treatment nurse (TN) was observed entering Resident 2 ' s room. The TN stated she will be providing treatment to Resident 2 ' s pressure ulcer (bedsore) on the sacro-coccyx (the triangular shaped bone at the base of the back area and tailbone) area. The TN was observed during treatment of Resident 2 ' s pressure ulcer. Resident 2 ' s sacro-coccyx area was observed with a large (size of a golf ball), deep pressure ulcer with medium amount of tan/yellow drainage inside the pressure ulcer, yellow tissue and with foul odor. Resident 2 stated, Oww, as the treatment nurse cleaned the pressure ulcer. An interview and joint record review on 9/9/24 at 10:17 A.M. was conducted with the treatment nurse. The TN was not able to find Resident 2 ' s initial skin assessment in the resident ' s electronic medical record (EMR). The TN reviewed Resident 2 ' s progress notes (PN) dated 7/16/24 and stated Resident 2 developed stage two (some of the outer surface or the deeper layer of the skin is damaged) pressure ulcers on Resident 2 ' s medial (middle) buttocks. The TN stated the family was not notified. During a follow up unannounced visit at the facility on 9/23/24 licensed nurse (LN) 1 was interviewed at 10:30 A.M. LN 1 stated resident change in condition was documented in the e-INTERACT (Interventions to Reduce Acute Care Transfers- an electronic communication form about changes in resident status) change in condition form. LN 1 stated the resident ' s physician and family should be notified of any resident change in condition. On 9/23/24 at 12:24 P.M., the assistant director of nursing (ADON) was interviewed. A concurrent record review of Resident 2 ' s progress notes was conducted with the ADON. The progress notes dated 8/15/24 at 3:44 P.M. indicated, .Sacro coccyx stage 4 pressure injury, deteriorating. Measuring 3 cm [centimeter] x 2 cm x 2.5 cm, undermining [a pocket on wound ' s edges] 9-4 o'clock @ 3.5 cm, 70% granulation [process of wound healing] and 30% slough [dead tissue] with large amount of serosanguinous [bloody] drainage). The ADON stated the son was Resident 2 ' s responsible party and was not notified of the wound deterioration. The ADON stated it was important to notify the responsible party to be aware of Resident 2 ' s regression or progress. During an interview on 10/2/24 at 10:49 A.M. with the Director of Nurses (DON), the DON stated it was her expectation for licensed nurses to update the family and the physician for any resident change in condition. DON stated the family and the physician needed to be aware of the change and to discuss the plan of care. 2. Resident 3 was admitted to the facility on [DATE] with diagnoses including protein-calorie malnutrition (reduced nutrients in the body) according to the facility ' s Admission Record. During an observation on 9/9/24 at 10:15 A.M., Resident 3 was in bed watching TV. Resident 3 stated she was told she had lost weight. Resident 3 stated her weight loss was due to stomach pain when eating and had decreased meal intake. An interview on 9/23/24 at 10:30 A.M. was conducted with licensed nurse (LN) 1. LN 1 stated for residents with weight loss, the attending physician and dietician will be notified, and the e-INTERACT (Interventions to Reduce Acute Care Transfers- an electronic communication form about changes in resident status) change in condition and progress notes will be completed. LN 1 stated the resident ' s physician should be notified of any resident change in condition. During an interview and concurrent record review on 9/23/24 at 12:06 P.M. with the ADON, the ADON reviewed Resident 3 ' s weight record. The ADON stated Resident 3 ' s weighed 205 lbs.(pounds) on 8/1/24 and 187 lbs. on 9/3/24. The ADON stated the attending physician was notified of significant weight changes. The ADON reviewed the nutrition care plan dated 9/5/24 for Resident 3 which indicated a weight loss of 18 lbs. in one month. The ADON then reviewed progress notes for Resident 3 and stated there was no physician notification regarding the weight loss. During an interview on 10/2/24 at 10:49 A.M. with the Director of Nurses (DON), the DON stated it was her expectation for licensed nurses to update the family and the physician for any resident change in condition. DON stated the family and the physician needed to be aware of the change and discuss the plan of care. 3. Resident 5 was admitted to the facility on [DATE] with diagnoses including encounter for attention to gastrostomy (feeding tube) and quadriplegia (loss of ability to move both arms and legs) according to the facility ' s Admission Record. During an observation on 9/23/24 at 9:16 A.M., Resident 5 was in bed with his eyes closed. A tube feeding pump was observed on a pole next to Resident 5 ' s bed and it was turned off. An interview on 9/23/24 at 10:30 A.M. was conducted with licensed nurse (LN) 1. LN 1 stated for residents with weight loss, the attending physician and dietician will be notified, and the e-INTERACT (Interventions to Reduce Acute Care Transfers- an electronic communication form about changes in resident status) change in condition and progress notes will be completed. LN 1 stated the resident ' s physician should be notified of any resident change in condition. During an interview and concurrent record review on 9/23/24 at 12:18 P.M. with the ADON, the ADON reviewed Resident 5 ' s weight record. The ADON stated Resident 5 ' s weights indicated: 139 lbs. on 8/5/24, 133 lbs. on 8/12/24, 136 lbs. on 8/19/24, 135 lbs. on 8/30/24 and 129 lbs. on 9/4/24. The ADON further reviewed progress notes for Resident 5 and stated the attending physician was not informed of the ten-pound weight loss in one month. An interview on 10/2/24 at 10:54 A.M. with the Registered Dietician (RD) was conducted. The RD stated a list of residents who triggered for undesirable weight change was provided to the nursing staff during the skin and weight meetings on Thursdays. The RD stated nursing staff would complete the e-INTERACT change in condition and notify the attending physician for weight changes. 4. Resident 7 was admitted to the facility on [DATE] with diagnoses including unspecified protein-calorie malnutrition (reduced nutrients in the body) and left femur (thigh bone) fracture according to the facility ' s Admission Record. The Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 8/824 for Resident 7 indicated a cognitive (thinking, reasoning, or remembering) score of 12, indicating moderate cognitive impairment. During an observation on 9/23/24 at 9:46 A.M., Resident 7 was in bed lying on her left side with her eyes closed. Resident 7 was observed with an air mattress in bed. An interview on 9/23/24 at 9:31 A.M. with certified nurse assistant (CNA) 1 was conducted. CNA 1 stated to prevent pressure ulcers, residents were kept clean and dry, repositioned in bed every two hours, and offered to be out of bed to attend activities. During an interview on 9/23/24 at 10:46 A.M. with licensed nurse (LN) 2, LN 2 stated the change in condition form will be completed if a resident had a new skin issue or if a wound deteriorated. LN 2 further stated the physician and family should be notified to be aware of the resident ' s condition and for the physician to provide orders. A review of Resident 7 ' s care plans was conducted. The skin care plan initiated on 6/28/24 for Resident 7 indicated, .Resident is at risk for skin breakdown related to activity intolerance .impaired ADL ability .Assist to turn and reposition as indicated . An interview and concurrent record review on 9/23/24 at 1:13 P.M. with the assistant director of nurses (ADON) was conducted. The ADON stated Resident 7 ' s admission skin assessment indicated a left hip surgical incision (after surgery wound). The ADON reviewed progress notes for Resident 7. The ADON stated resident developed a stage two (some of the outer surface or the deeper layer of the skin is damaged) on Resident 7 ' s coccyx (tailbone) on 7/8/24. The ADON Resident 7 ' s wound was debrided (surgical procedure to remove dead tissue) by the wound physician and the wound became a stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). The ADON stated Resident 7 ' s family was not notified of Resident 7 ' s wound condition. The ADON stated it was important to notify the resident ' s family to be aware of the resident ' s regression or progress. During an interview on 10/2/24 at 10:49 A.M. with the Director of Nurses (DON), the DON stated it was her expectation for licensed nurses to update the family and the physician for any resident change in condition. DON stated the family and the physician needed to be aware of the change and discuss the plan of care. During a review of the facility ' s policy and procedure (P&P) titled, Change in a Resident ' s Condition or Status, dated February 2021, the P&P indicated, .Our facility promptly notifies the resident, his or her attending physician, and the resident representative of the changes in the resident ' s medical/mental condition and /or status .

Based on observation, interview, and record review, the facility did not ensure one of three residents (Resident 2) reviewed for pressure ulcers (bedsore) received the necessary care and services to prevent worsening of the resident ' s pressure ulcer. This failure had the potential for infection and affect the resident ' s overall well-being. Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (an impairment of brain function, such as memory loss and judgment) and muscle weakness according to the facility ' s Admission Record. During a review of Resident 2 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 7/9/24, section GG0170 A through E indicated Resident 2 was dependent on staff with rolling in bed, sit to lying, lying to sitting on side of bed, sit to stand and transfers. A review of Resident 2 ' s care plans was conducted. Resident 2 ' s skin care plan initiated on 7/2/24 indicated, .at risk for skin breakdown related to activity intolerance, Braden Risk score [a measurement of a resident ' s risk of developing pressure ulcers, or sores], Cardiovascular disease .impaired ADL [(activities of daily living] ability .Assist to turn and reposition as indicated/tolerated, check skin during daily care provisions . During observation on 9/9/24 at 9:41 A.M., Resident 2 was in bed with an air mattress (mattress designed to distribute the resident ' s body weight and help prevent skin breakdown) and oxygen via nasal cannula (a small plastic tube, which fits into the person ' s nostrils for providing supplemental oxygen). Resident spoke only Spanish. On 9/9/24 at 9:35 A.M. the treatment nurse (TN) was observed entering Resident 2 ' s room. The TN stated she will be providing treatment to Resident 2 ' s stage four (bedsore extended to muscle, tendon or bone) pressure ulcer on Resident 2 ' s sacro-coccyx (the triangular shaped bone at the base of the back area and tailbone) area. The TN was observed during treatment of Resident 2 ' s pressure ulcer. Resident 2 ' s sacro-coccyx area was observed with a large (size of a golf ball), deep pressure ulcer with medium amount of tan/yellow drainage inside the pressure ulcer, yellow tissue and with foul odor. Resident 2 stated, Oww, as the treatment nurse cleaned the pressure ulcer. An interview and joint record review on 9/9/24 at 10:17 A.M. was conducted with the TN. The TN reviewed Resident 2 ' s progress notes (PN) dated 7/15/24 and stated Resident 2 developed stage two (some of the outer surface or the deeper layer of the skin is damaged) pressure ulcers on Resident 2 ' s medial (middle) buttock, then on 7/16/24 Resident 2 had stage two pressure ulcers on the left and right medial buttocks. The TN stated she did not know Resident 2 ' s skin condition upon admission and was not able to find Resident 2 ' s initial skin assessment in the Resident 2 ' s electronic medical record (EMR). During a follow up visit at the facility on 9/23/24 at 9:31 A.M., certified nurse assistant (CNA) 1 was interviewed. CNA 1 stated it was the facility ' s policy to prevent pressure ulcers from developing. CNA 1 stated interventions to prevent pressure ulcers were to keep residents ' skin clean, dry, reposition residents every two hours while in bed, offer residents to get up from bed and take them to activities. During an interview on 9/23/24 at 10:30 A.M. with licensed nurse (LN) 1, LN 1 stated to prevent pressure ulcers, residents should be repositioned every two hours and every one hour if a resident already had a pressure ulcer. A telephone interview was conducted on 9/27/24 at 9:39 A.M. with the Quality Assurance nurse (QA-a nurse who monitors and improves nursing practices and patient care). The QA nurse stated she reviewed the progress notes in e-INTERACT (Interventions to Reduce Acute Care Transfers- an electronic quality improvement program designed to improve identification, evaluation, and communication about changes in resident status) change in condition and the wound physician ' s progress notes for Resident 2. The QA nurse stated Resident 2 ' s records indicated: The Admission/Readmission Assessment, dated 6/4/24 Resident 2 ' s initial skin assessment on admission indicated Resident 2 had a maceration (a softening and breaking down of skin resulting from prolonged exposure to moisture) on the buttocks. The e-INTERACT Change in Condition Evaluation, dated 7/8/24 indicated Resident 2 had a stage two on the right medial buttock with light drainage. The PN for Resident 2 dated 7/9/24 indicated Resident 2 was sent out to the hospital for low oxygen level. The Admission/Readmission Assessment, dated 7/15/24 indicated Resident 2 had a stage two on the right medial buttock. The Skin/Wound note, dated 7/16/24 indicated Resident 2 had a stage two on the left and right medial buttock. The e-INTERACT Change in Condition Evaluation, dated 7/21/24 indicated an unstageable pressure (a full thickness tissue loss where the depth of the wound is hidden by a layer of eschar [scab like dead tissue] or slough [yellow/white material in wound bed, dead tissue] in the wound) ulcer on Resident 2 ' coccyx (tailbone) and with 100% necrotic (scab like dead tissue) tissue. The Skin/Wound note, dated 7/24/24 indicated Resident 2 had a deep tissue injury (DTI-a purple or maroon-colored area of intact skin or blood-filled blister due to damage of soft tissue from pressure or shear) on the Sacro coccyx (the triangular shaped bone at the base of the back extending to the tailbone). The Skin/Wound note, dated 7/31/24 indicated Resident 2 ' s pressure ulcer on the Sacro coccyx was reclassified by the physician as stage three (full thickness skin loss that extends into the subcutaneous [deepest layer of skin] tissue but does not expose muscle, tendon, or bone). The physician ' s Visit Report dated 7/31/24 indicated Resident 2 ' s Sacro coccyx area had a stage four (bedsore extended to muscle, tendon, or bone) pressure ulcer. The facility ' s Skin/Wound Note dated 8/15/24 indicated Resident 2 ' s stage four pressure ulcer was deteriorating, with undermining (a pocket on wound ' s edges), slough (yellow/white material in wound bed, dead tissue) and serosanguinous (bloody) drainage. The facility ' s Skin/Wound Note, 8/28/24 indicated Resident 2 was seen by the wound physician and ordered negative- pressure wound therapy (NWPT-treatment using a device that pulls fluid and bacteria from a wound) for Resident 2 ' pressure ulcer. During an interview on 9/27/24 at 9:49 A.M. the QA nurse acknowledged that Resident 2 ' s skin condition had deteriorated while Resident 2 was in the facility. An interview was conducted on 10/2/24 at 10:49 A.M. with the Director of Nursing (DON). The DON acknowledged that Resident 2 developed a pressure ulcer at the facility and the pressure ulcer had deteriorated. A review of the facility ' s undated policy and procedure(P&P) titled, Pressure Injuries/Skin Breakdown-Clinical Protocol was conducted. The P&P did not provide guidance to staff regarding pressure ulcer prevention and maintenance.

Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1), who was frail and had cognitive impairment, was free from an avoidable fall with injury when: 1. Certified nursing assistant (CNA) 2 placed Resident 1 in a wheelchair, who was agitated and was left alone unattended, in the hallway around 2 A.M. 2. Resident 1's written care plan was not followed related to locomotion (how the resident moves between locations including self-sufficiency in a wheelchair) that was required to be provided by at least one staff. As a result, Resident 1 fell out of the wheelchair and hit her head on the floor. Resident 1 sustained a laceration (open wound) to her left forehead that required evaluation at the hospital and sutures (stitches holding the edges of a wound together) to close the laceration. Findings: On 9/26/23 at 8:40 A.M., an onsite investigation was conducted for a complaint that alleged Resident 1 had fallen while unsupervised and sustained a head injury. A review Resident 1's facility Admission Record dated 9/26/23, indicated the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses to include Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Resident 1's facility nursing progress notes indicated the resident had a history of multiple falls: 3/8/22, Resident 1 was found lying on their right side in the southeast hallway. 8/29/22, Resident 1 had an unwitnessed fall around 3:10 P.M. in the dining hallway. Resident 1 was found sitting on the floor by maintenance staff and a restorative nursing assistant (provides rehabilitative care to individuals recovering from illnesses or injuries). 8/29/22, Resident 1 had a witnessed fall around 5:15 P.M. in the hallway in front of the resident's room. Resident 1 hit the left side of their head. 9/21/22, Resident 1 fell while in the shower room.Resident unable to give full description of incident d/t [due to] current mentation .[Resident 1 was] being physically aggressive toward staff, yelling out and scratching staff . resident kept pushing herself backwards . and slid off shower chair . landed on her buttocks A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment) dated 6/3/23, indicated the resident scored 02 on the brief interview of mental status (a score of 02 meant the resident had severe cognitive impairment). The same MDS assessment indicated the resident required extensive assistance (staff had to provide weight bearing support) and one-person physical assistance for locomotion in the wheelchair. A review of Resident 1's activity of daily living (ADL, self-care activities like locomotion and getting dressed) care plan dated 1/11/21 and revised 6/8/23, indicated the resident required extensive assistance provided by one staff while the resident did locomotion in her wheelchair. A review of Resident 1's change of condition progress note dated 8/17/23 and documented at 4:33 A.M., indicated, . [Resident 1] found on the floor by staff after unwitnessed fall from wheelchair to floor, with approx [approximate] 2 cm [centimeter] laceration to L [left] eyebrow area. Wound presents with profuse [excessive] bleeding. [Resident 1] currently agitated/confused, and combative [aggressive]with staff . [Resident 1] sent out via ambulance for stitches and follow up A review of Resident 1's nursing progress note dated 8/17/23 and documented at 12:12 P.M., indicated the resident returned to the facility after being treated at the emergency room . Resident 1 was observed to have sutures on the left eyebrow area. A review of Resident 1's physician progress note dated 8/17/23 and documented at 3:19 P.M., indicated the resident was evaluated by the physician due to a fall that occurred at 2 A.M.Patient sustained laceration to left forehead which was sutured in the ER [emergency room ] . Per son at bedside, nursing and roommate patient has been experiencing difficulties with sleeping, at most able to sleep two hours at a time, she has uncontrollable impulsive [tendency to act without thinking] behavior attempting to get OOB [out of bed] unassisted The physician's note further indicated Resident 1 had bruising to the eye area and left side of the head, and that the resident was, .confused, frail, [foreign language] speaking, and had generalized weakness. On 9/26/23 at 9:03 A.M., an interview was conducted with Resident 2 (roommate of Resident 1) inside the resident's room. Resident 2 stated Resident 1 was her friend. Resident 2 stated Resident 1 had dementia (cognitive impairment and memory loss) and needed a lot of supervision. Resident 2 stated Resident 1 would go around in her wheelchair, touching everything and put objects into Resident 1's mouth. Resident 2 stated while inside of their shared room a few months ago, Resident 1 got a hold of some paper and started eating it. Resident 2 stated Resident 1 had become physically weaker lately. Resident 2 stated on the night Resident 1 fell , Resident 1 had been restless and was trying to get out of bed which had woken Resident 2 up. Resident 2 stated she used her call light to summon help for Resident 1. Resident 2 stated a CNA (did not identify their name) came and put Resident 1 into her wheelchair and brought the resident into the hallway. Resident 2 stated sometime later, staff brought Resident 1 back into the room and Resident 1 was bleeding from the head. On 9/26/23 at 11:06 A.M., an interview was conducted with the director of staff development (DSD). The DSD stated she had investigated Resident 1's fall incident that occurred on 8/17/23. The DSD stated CNA 2 had placed Resident 1 into their wheelchair when they were in a state of agitation and left the resident unsupervised in the hallway. The DSD stated CNA 2 had been familiar with Resident 1 and knew better. The DSD stated Resident 1 was confused and should not have been left alone in their wheelchair in the middle of the night. The DSD stated CNA 2 had been disciplined with a write up and then CNA 2 quit and no longer worked at the facility. A review of Resident 1's progress note dated 8/17/23 and authored by the DSD indicated, Met and spoke with the resident's son regarding the incident last night . Writer reeducated the CNA about how to handle residents with special needs and how to communicate properly with the licensed nurse and other CNAs On 9/26/23 at 2:25 P.M., an interview was conducted with CNA 3. CNA 3 stated Resident 1 was, Very confused even when speaking [foreign language]. CNA 3 stated Resident 1 required frequent checks because the resident would eat things like paper. CNA 3 stated Resident 1 would become agitated and sometimes scratch staff during care because Resident 1 was confused. CNA 3 stated she would not put Resident 1 into the wheelchair and let the resident do locomotion by themselves even in the daytime. CNA 3 stated when unattended, Resident 1 would try and go out different doors and pulled objects off surfaces. CNA 3 stated Resident 1 leans dangerously forward in the wheelchair and required staff to pull the resident up often while sitting in the wheelchair. CNA 3 stated there was a good chance Resident 1 would fall forward when sitting in the wheelchair. CNA 3 stated Resident 1 required more supervision when agitated and should not be left alone. CNA 3 stated, It's common sense. On 9/27/23 at 7:05 A.M., a telephone interview was conducted with CNA 4. CNA 4 stated she was working on 8/17/23 with CNA 2, but it was CNA 2 who was assigned to provide care to Resident 1. CNA 4 stated Resident 1 was always confused and required extensive supervision due to the resident's wandering into other rooms and putting things into the resident's mouth. CNA 4 stated that night had been busy and she had been providing care to another resident when CNA 2 came and told her they were going to put Resident 1 into their wheelchair. CNA 4 stated, I told [CNA 2] not to do that because I couldn't watch [Resident 1]. CNA 4 stated Resident 1 often put her legs over the bed but was too weak to get out of bed on her own. CNA 4 stated, [Resident 1] was safer in bed until someone could watch her. CNA 4 stated, The next thing I know [CNA 2] tells me, 'Oh hey, I got [Resident 1] up and I'm going on my lunch break.' CNA 4 stated she was still with her resident providing care and again told CNA 2 not to do that. CNA 4 stated when CNA 2 came back, she then went on her own lunch break. CNA 4 stated she got a text message when she was on break that Resident 1 had fallen. CNA 4 stated she came back inside the building and saw Resident 1 on the floor over by Room A on the north side of the building. CNA 4 stated Resident 1 had self-propelled in the wheelchair, Pretty far from her room. CNA 4 stated they were a skeleton crew at night and did not have as many staff present and in the hallways, as during the daytime. CNA 4 stated putting Resident 1 into the wheelchair while agitated and leaving the resident unsupervised was, The worst idea [CNA 2] could have had. On 10/3/23 at 1:01 P.M., a telephone interview was conducted with CNA 2. CNA 2 stated she no longer worked for the facility. CNA 2 stated she had been assigned to provide care to Resident 1 on 8/17/23. CNA 2 stated CNA 4 had been her partner during that time and that CNA 4 had agreed to watch Resident 1 while she went on a lunch break. CNA 2 stated Resident 1 had fallen while she on her lunch break and under the care of CNA 4. CNA 2 stated Resident 1 was confused and would carry around stuffed toys that the resident thought were babies. CNA 2 stated Resident 1 had been agitated and was trying to get out of bed that night. CNA 2 was asked if she had reported Resident 1's agitation to the licensed nurse (LN). CNA 2 stated she, Told [LN 5] who just said 'okay' and didn't really listen. CNA 2 stated she decided to place Resident 1 into her wheelchair and leave the resident unattended in the hallway because she had seen other staff do that on previous occasions. CNA 2 stated, I trusted [CNA 4] to watch [Resident 1] when I went to lunch. CNA 2 then stated when she returned from lunch, she saw Resident 1 sitting in the wheelchair in the hallway. CNA 2 further stated she went into another resident's room to provide care and heard a loud boom, and saw that Resident 1 had fallen in the hallway. CNA 2 was informed this statement was inconsistent with her previous statement. CNA 2 was asked to clarify if Resident 1 fell during her lunch break or while providing care to another resident. CNA 2 did not provide an answer and the interview was ended. On 10/4/23 at 8:58 A.M., a telephone interview was conducted with LN 5. LN 5 stated she was familiar with Resident 1 and that the resident was not confused but was alert and oriented. LN 5 was informed her statement did not match the resident's medical records that indicated Resident 1 had cognitive impairment. LN 5 was asked to clarify. LN 5 then stated Resident 1 was very confused and not very alert. LN 5 was asked about Resident 1's fall incident that occurred on 8/17/23. LN 5 stated they did not recall Resident 1 having any fall during her shift and that she did not think that Resident 1 had been her assigned resident. LN 5 was informed she was on the sign-in sheet and assigned to Resident 1 on 8/17/23. LN 5 stated, Well that's in August and I can't remember that far back. LN 5 was informed that according to Resident 1's medical record the resident had profuse bleeding from the head after the fall and first aid had been rendered. LN 5 then stated she remembered the fall incident and that Resident 1, Wasn't really bleeding. LN 5 stated she had, Performed an operation on [Resident 1's] eye and put stitches. LN 5 was asked to clarify that statement. LN 5 stated, Okay, that was at the hospital. LN 5 then made some incoherent statements. LN 5 was asked if she was able to continue with the interview. LN 5 stated, Yes. LN 5 stated CNA 2 had informed her that Resident 1 was agitated and trying to get out of bed. LN 5 was asked how she responded to CNA 2's concern. LN 5 then stated CNA 2 did not tell her anything that night. LN 5 was asked if she had provided any medications to Resident 1 that night for agitation or sleep. LN 5 stated, I didn't give [Resident 1] anything that night not even Tylenol. LN 5 again stated she could not remember if she had worked that night. On 10/4/23 at 9:12 A.M., an interview was conducted with the director of nursing (DON) related to the telephone interview that was conducted with LN 5. The DON was informed that LN 5 made contradictory and incoherent statements during the interview and the LN was unsure if she had worked the night of 8/17/23. The DON stated LN 5 was the LN responsible for Resident 1 on 8/17/23 and had been present during the resident's fall incident. The DON stated she spoke to LN 5 about Resident 1's fall and, [LN 5] knows about the fall. On 10/4/23 at 9:45 A.M., a continuous observation was conducted beginning in the hallway outside of Resident 1's assigned room (Resident 1 was not currently in the facility). Resident 1's room was located on the south end of the building. Room A (where CNA 4 stated the resident's fall occurred) was observed on the opposite end of the building on the north side (same hallway). In between Resident 1's assigned room to where the fall was reported to have occurred (Room A), there was the kitchen, laundry, dining hall, staff lounge, and other resident rooms. On 10/4/23 at 10:05 A.M., a joint interview and record review was conducted with LN 6. LN 6 stated Resident 1 was confused, frail, and had become weaker over the last several months. LN 6 stated Resident 1 tended to lean forward while in the wheelchair and required supervision when seated in the wheelchair. LN 6 reviewed Resident 1's medication administration record for 8/16/23 at 9 P.M. and stated the resident had received trazodone (medication that can make a person sleepy) and melatonin (a sleep aid). LN 6 stated those medications could have made Resident 1 drowsy and unable to safely sit in her wheelchair. LN 6 reviewed Resident 1's ADL care plan revised 6/8/23 and MDS assessment dated [DATE], and stated the resident required one staff to assist when the resident was in her wheelchair performing locomotion. LN 6 stated Resident 1's MDS assessment and ADL care plan should have been followed. LN 6 further stated Resident 1 should not have been placed in her wheelchair and left unsupervised at night. LN 6 stated Resident 1 should not have been permitted to perform locomotion in her wheelchair alone. On 10/4/23 at 11 A.M., a joint interview and record review was conducted with the minimum data set assessment nurse (MDSN). The MDSN stated Resident 1 had a multiple fall history. The MDSN reviewed Resident 1's MDS assessment dated [DATE], and stated extensive one person assistance for locomotion meant a staff member had to be present and holding the wheelchair handles while guiding the resident in their wheelchair. The MDSN stated the required assistance that was assessed in Resident 1's MDS assessment dated [DATE] and ADL care plan revised after the completion of the MDS on 6/8/23, should have been provided to the resident. The MDSN stated, [Resident 1] shouldn't have been going around [the facility] alone. On 10/4/23 at 12:32 P.M., an interview was conducted with the DON. The DON stated it was her expectation for Resident 1's MDS assessment and ADL care plan to have been followed and fully implemented. The DON stated Resident 1 should not have been placed into her wheelchair and left unsupervised while agitated. The DON stated staff should have been present when Resident 1 was performing locomotion in the wheelchair as this could have prevented the resident from falling. The DON stated Resident 1 was not able to provide feedback related to the fall incident due to the resident's impaired cognition. The DON stated a reasonable and cognitively intact person would consider a fall with an injury that required suturing at the hospital to be painful. On 10/4/23 at 3:50 P.M., an interview was conducted with the administrator (ADM) and quality assurance nurse (QAN). The ADM asked how Resident 1's fall had occurred. The QAN stated CNA 2 had been interviewed and stated that Resident 1 fell out of her wheelchair when CNA 2 had gone to the nurses' station to inform the LN the resident had been placed in her wheelchair. The ADM and QAN were informed CNA 2 had inconsistent statements related to Resident 1's fall incident during a telephone interview conducted on 10/3/23. The ADM stated that they wished the unfortunate incident had not occurred. A review of the facility's policy titled Safety and Supervision of Residents revised July 2017, indicated, .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Individualized, Resident-Centered Approach to Safety .3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: .d. Ensuring that interventions are implemented A review of the facility's policy titled Dementia- Clinical Protocol revised November 2018, .4. Direct care staff will support the resident in initiating and completing activities and tasks of daily living. a. Bathing, dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported throughout the day as needed

Based on observation, interview, and record review, the facility failed to ensure three of three residents (Resident 1, 2, and 3) were transferred (how a resident moved from one surface to another) in a safe manner using the mechanical lift, when: 1. Resident 1 and Resident 2 were transferred from the bed with only one certified nursing assistant (CNA) present to operate the mechanical lift. 2. CNAs transferred Resident 3 from the bed manually without using a mechanical lift. In addition, the facility failed to develop and implement a process that ensured slings (devices a resident sits in that attach to the mechanical lift) were verified to support resident ' s weight and maintained in a safe working order. As a result, Resident 1 fell from the mechanical lift when the sling broke while being transferred out of bed by CNA 1. Resident 1 sustained a fracture of her left pinky finger and bruised her left ribs after the fall from the mechanical lift. Resident 1 experienced pain from her injuries and was fearful of being placed in the mechanical lift again. Resident 2 and Resident 3 were at risk for falls and injuries. Findings: A review of Resident 1 ' s Admission Record, dated 4/21/23, indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following a stroke and morbid obesity (a disorder involving excessive body fat that increases the risk of health problems). A review of Resident 1 ' s Minimum Data Set Assessment (MDS, an assessment tool), dated 1/13/23, indicated the resident had a score of 14 on the brief interview of mental status (a score of 13-15 meant the resident was cognitively intact). The same MDS assessment further indicated, Resident 1 required extensive assistance (staff to provide weight-bearing support) and two or more staff to assist during transfers. A review of Resident 2 ' s Admission Record, dated 4/21/23, indicated the resident was admitted to the facility on [DATE] with diagnoses to include spinal stenosis (narrowing of the spinal canal) and morbid obesity. A review of Resident 2 ' s MDS assessment, dated 3/24/23, indicated the resident had a score of 13 on the brief interview of mental status. The same MDS assessment further indicated Resident 2 required extensive assistance and two or more staff to assist during transfers. A review of Resident 3 ' s Admission Record dated, 4/21/23, indicated the resident was admitted to the facility on [DATE] with diagnoses to include muscle weakness and an acquired absence of the left leg below the knee. Resident 3 ' s Admission Record further indicated the resident was self-responsible (able to understand and make decisions). A review of Resident 3 ' s MDS assessment, dated 3/29/23, indicated the resident required extensive assistance and two or more staff to assist during transfers. On 4/20/23 at 12 P.M., an observation and interview were conducted with Resident 1 inside the resident ' s room. Resident 1 was in bed with her left hand wrapped with a bandage. Resident 1 ' s left hand had dark, blue bruising visible around the bandaged area. Resident 1 stated she could only get out of bed with a mechanical lift. Resident 1 stated she was on her way to get a shower (on 4/13/23) and certified nursing assistant (CNA) 1 had been assisting her. Resident 1 stated she had purchased her own sling from the facility approximately five years ago so she would have one of her own that fit her size. Resident 1 stated she usually watched the staff to make sure the sling was connected to the lift correctly. Resident 1 stated CNA 1 seemed to be in a hurry, and she did not get a chance to verify the placement of the sling. Resident 1 stated CNA 1 had transferred her alone using the mechanical lift. Resident 1 stated her transfers from bed were usually done with one CNA as, It ' s too hard to get two CNAs. Resident 1 stated while she was in the mechanical lift and hoisted above the floor, she felt her left leg fall from the sling while the rest of her body was still inside the sling. Resident 1 stated CNA 1 tried to lower the lift, but she slid out of the sling and hit the floor before the lift lowered completely. Resident 1 stated she had been naked at the time of the fall and, I was in such terrible pain and my sides are bruised. Resident 1 was asked if she currently had any pain related to the fall from the mechanical lift. Resident 1 stated, Of course I have pain. It ' s in my hand, my finger ' s broken. Resident 1 stated she had a brief look at her sling after the incident and saw the plastic buckle that secured her left leg was cracked. Resident 1 stated it was her shower day today, but she was going to ask for a bed bath because she was afraid to get in the mechanical lift again. Resident 1 stated, I don ' t feel safe. Like I can ' t get out of bed now. Two slings were observed hanging up beside Resident 1 ' s bed, one for a standing mechanical lift, and another for a full body mechanical lift. The sling with the green border had a maximum weight limit on the label of 440 pounds (lbs.). The sling with the orange border had a maximum weight limit of 600 lbs. A review of Resident 1 ' s progress notes titled Incident Note, dated 4/13/23, indicated, CNA alerted writer that pt [patient] is on the floor. Came to check on the pt. Seen pt lying on her left side, screaming for help saying, ' .it hurts, it hurts pls [please] don ' t move me. ' CNA, during transfer for a shower while pt still on [brand name] lift, the sling gave up The Incident Note further indicated the CNA had used the resident ' s personal sling which had been used for approximately seven years. A review of Resident 1 ' s hospital documentation titled Emergency Documentation dated 4/13/23, indicated, .assumed care of patient, here after a fall from a [brand name] lift at SNF [skilled nursing facility]. Pt has a fracture to left pinky and will be getting a finger splint to that finger. Pt had bruising to the left ribs and pain upon palpitation to that area . On 4/20/23 at 12:30 P.M., an interview was conducted with CNA 2. CNA 2 stated she was familiar with Resident 1 and had provided care to the resident many times. CNA 2 stated Resident 1 was very alert and would frequently go around the facility in her wheelchair. CNA 2 stated two staff were required when operating a mechanical lift for the safety of the resident and the staff. CNA 2 stated one staff would operate the lift, while the other staff held the resident and guided the placement of the resident. CNA 2 stated since Resident 1 ' s incident in the lift, the resident seemed more nervous. CNA 2 stated, She doesn ' t want to get up out of bed anymore because she ' s scared to go in the lift. CNA 2 stated she saw some bruising on Resident 1 ' s ribs and the resident was complaining of pain more than usual. On 4/20/23 at 2:20 P.M., an interview was conducted with CNA 1. CNA 1 stated she had assisted Resident 1 on 4/13/23 using the mechanical lift. CNA 1 stated another CNA had been present the entire time to help during the mechanical lift transfer. CNA 1 stated the resident preferred to use her own sling. CNA 1 stated the sling had looked okay but that she did not know, and had not verified, how much weight it could hold. On 4/20/23 at 2:55 P.M., an interview was conducted with CNA 1 with the director of staff development (DSD) present. CNA 1 stated that she had been mistaken in the previous interview conducted at 2:20 P.M. and wanted to clarify. CNA 1 stated she had been alone when she transferred Resident 1 using the mechanical lift. CNA 1 stated she had received training prior to the incident and knew two staff were required to operate the lift while transferring a resident. CNA 1 stated she had assumed everyone was too busy to help, and that she had not asked for staff assistance when transferring Resident 1 on 4/13/23. On 4/20/23 at 3:07 P.M., a joint interview and record review was conducted with the DSD and director of nursing (DON). The in-service training sign-in sheet titled Transfer and Lifting, dated 3/27/23, indicated CNA 1 had attended the in-service. The DON stated the sling involved in the incident had belonged to Resident 1 and had been thrown away. The DON stated Resident 1 ' s sling ' s label had been too faded to verify the weight limit. The DON and DSD both stated the facility did not have a system in place for checking the integrity of the slings or verifying the weight limits with the residents ' current weight. The DON and DSD further stated their expectation was for two staff to participate in all resident transfers using a lift. A review of Resident 1 ' s monthly weights were as followed: 1/4/23 449 lbs. (pounds) 2/4/23 466 lbs. 3/24/23 446 lbs. 4/4/23 442 lbs. 5/1/23 448 lbs. On 4/20/23 at 3:20 P.M., a joint observation and interview was conducted with the DSD. The DSD stated verifying the resident ' s weight was below the maximum weight limit on the sling ' s label was important for resident safety. The DSD stated weight over the limit could cause the equipment to break or fail. The DSD observed Resident 1 ' s sling with the green border hanging up in the resident ' s room and brought the sling out into the hallway for review. Resident 1 ' s name was written on the sling and the label indicated the maximum weight limit was 440 lbs. The DSD stated, This isn ' t the right sling, and that it was not safe for Resident 1 ' s current weight. The DSD stated there needed to be a facility process to check the resident ' s weight after being weighed, since weight could fluctuate, and to then evaluate the weight limit of the sling that was used. On 4/20/23 at 4:55 P.M., an interview was conducted with the physical therapist (PT) 1. PT 1 stated two staff were required when transferring a resident using a lift. PT 1 stated this was for both resident and staff safety. PT 1 stated the purpose of having two staff was for: one of the staff focus on the safe operation of the mechanical lift, while the other staff held onto the resident ' s legs, guiding the positioning of the resident, and monitoring the resident during the transfer. PT 1 stated if the second staff had been present when transferring Resident 1 on 4/13/23, they could have noticed the sling failure and able to hold onto the resident ' s leg and helped ease the resident ' s descent to the floor. On 4/20/23 at 5:10 P.M., an interview was conducted with the quality assurance nurse (QAN). The QAN stated two staff were required during resident transfers using any lift. The QAN stated she had investigated Resident 1 ' s incident on 4/13/23 and determined that there should have been two staff transferring the resident with the lift and that personal slings should not be used. The QAN stated when the facility chose to utilize Resident 1 ' s personal sling, the facility was responsible for ensuring the safety and maintaining the quality of it. The QAN further stated there had been no system or process in place for routinely checking the quality and functionality of the slings or verifying the resident ' s weight with the sling being used after the resident was weighed. A review of the facility provided list titled Resident Response List, dated 4/20/23, indicated thirteen residents required the mechanical lift for transfers. Resident 2 and Resident 3 were identified on the Resident Response List. On 4/20/23 at 5:33 P.M., an interview was conducted with Resident 2 inside the resident ' s room. Resident 2 stated she was transferred by only one staff using the mechanical lift. Resident 2 asked, Are two staff supposed to do it? On 4/20/23 at 5:40 P.M., an interview was conducted with Resident 3 inside the resident ' s room. Resident 3 stated staff did not transfer her with a mechanical lift. Resident 3 stated, CNAs just lift me under my armpits and move me. If there ' s a lift, I want to be using one. On 4/20/23 at 5:43 P.M., an interview was conducted with licensed nurse (LN) 1. LN 1 stated staff should transfer Resident 3 with the mechanical lift. On 4/20/23 at 6:10 P.M., an interview was conducted with the director of nursing (DON). The DON stated two staff were always required while a resident was transferred in a lift because one staff manned the machine while the other staff managed the resident. The DON stated this was done to ensure resident and staff safety while the lift was in use. The DON stated she had responded to Resident 1 ' s room on 4/13/23 and had assessed the resident after the incident. The DON stated she had observed Resident 1 seated on the floor on top of the metal legs of the mechanical lift. The DON stated Resident 1 ' s left hand was underneath the resident ' s buttocks. The DON stated Resident 1 had been upset and in pain. The DON stated Resident 1 had expressed being afraid to use the lift again. A review of the lesson plan titled Transfer and Lifting- Safely moving Residents, dated 3/27/23, indicated, .Use teamwork (2 person assist) by asking your teammates for help and talking with them about what you do as you plan and while doing it A review of the manufacturer ' s guidance for slings used by the facility titled Passive Clip Slings [brand name], revised 4/2022, indicated, .Safe Working Load (SWL) Always follow the lowest SWL of the total system E.g. [brand name] lift spreader bar has a SWL of 160 kg [kilograms] (352 lbs.) and the [brand name] sling has a SWL of 272 kg (600lbs.). This means that the lift spreader bar has the lowest SWL. The patient is not allowed to weigh more than the lowest SWL . The caregiver shall inspect the sling before and after every use. The sling should be checked for all deviations listed below. If any of these deviations are visible, replace the sling immediately . unreadable or damaged label . Service life -Recommended period of use sling models [brand names] 1.5 years . all other slings 2 years A review of the facility ' s policy titled Safe Lifting and Movement of Residents, revised July 2017, indicated, .2. Manual lifting of residents shall be eliminated when feasible . 5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary A review of the facility ' s policy titled Assistive Devices and Equipment, revised January 2020, indicated, .Our facility maintains and supervises the use of assistive devices and equipment for residents .6. The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment . b. Personal fit- the equipment or device is used only according to its intended purpose and is measured to fit the resident ' s size and weight. c. Device condition- devices and equipment are maintained on schedule and according to manufacturer ' s instructions. Defective or worn devices are discarded or repaired