Every finding on record at Rialto Post Acute Center

Based on interview and record review, the facility failed to ensure prescribed medication was administered in accordance with the physician's orders for one of three sampled residents (Resident 1) when Resident 1 had an order to receive Lexapro (medication used for depression) and was not administered on August 6, 2026. This failure had the potential to impact Resident 1's health and safety due to missed medication. Findings: During a review of Resident 1's Face Sheet (contains medical and demographic information), the Face Sheet, indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included juvenile rheumatoid polyarthritis (inflammation in joint issues, limited movement, stiffness), asthma (lung disease causes airways to swell, making hard to breath), major depressive disorder (mood causing persistent feeling of sadness), and anxiety (emotion of fear or worry). During a review of Resident 1's Medication Administration Record (MAR-the legal log used in healthcare settings to document every drug given to a resident) dated August 2026, the MAR indicated, Lexapro Oral table 5 mg, give 1 tablet by mouth one time a day for Depression . Further review of Resident 1's MAR, the MAR indicated, the medication Lexapro was documented as not given on August 6, 2026. During a review of Resident 1's Nursing Progress Note dated August 6, 2026, at 12:52 PM, .notified resident of Lexapro medication needing refill, resident became anxious and verbalizing sadness due to not having meds. reassured resident that pharmacy will deliver meds As Soon As Possible. Director of Nursing (DON) notified for assistance with matter. requested one time administration of Ativan (medication for anxiety) to help resident with anxiety per resident request, Doctor notified and gave new one-time order for Ativan. During an interview on August 19, 2026, at 11:30 AM, with Resident 1, Resident 1 stated, .They gave me Ativan because I got anxious because they didn't have my medications available. This had happened before, and it keeps happening. During an interview on August 19, 2026, at 11:30 AM, with Licensed Vocational Nurse 1 (LVN 1), when asked if LVN 1 administered Lexapro medication to Resident 1 on August 6, 2026, LVN 1 stated, . The Lexapro she did not receive. On August 6, 2026, she did not get her medication. I called the doctor for one time Ativan with her emotional state. She was ok with that until the medication comes. We are supposed to order before, when the count gets low, we usually reorder, we call the pharmacy. If we have low count, but we were out, she did not get Lexapro medication. During an interview on August 19, 2026, at 12:11 PM, with The Director of Nurses (DON), the DON stated, The Lexapro was not available, I can agree we should have ordered both these medications before running out. During a record review of the facility's policy and procedure (P&P) titled, Medications Administration, the P&P indicated, Resident medications are administered in an accurate, safe, timely, and sanitary manner. Physician's Orders - Medications are administered in accordance with written orders of the attending physician or physician extender. If a dose is inconsistent with the resident's age and condition or a medication order is inconsistent with the resident's current diagnosis or condition, contact the physician for clarification prior to the administration of the medication. Document the interaction with the physician in the nursing progress notes and elsewhere in the medical record, as appropriate

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) for Unusual Occurrence Reporting when the facility did not notify the State Agency when they experienced a power outage on July 31, 2026. This failure has the potential to put all residents who reside at the facility at risk for their health, safety, and well-being.Findings:During a review of the facility's Tabletop Exercise: Electrical Power Outage (a discussion-based session where key personnel meet in an informal, low stress setting to talk through a simulated crisis and test their emergency response plans), dated July 31, 2026, the tabletop Exercise: Electrical Power Outage, indicated, .Purpose: To evaluate Rialto Post Acute's preparedness and response to an unexpected electrical power outage affecting resident safety clinical operations, communication, and facility services. Power outage: At approximately 7:00 on a weekday, a city-wide power outage occurs due to community wide repair. The facility lost electrical power/ affecting lighting/ air conditioning/ computers/ medication refrigeration, and phone systems. The backup generator activated, within few seconds. Power was restored at approximately 0955.Communication (15-45 Minutes) . During an interview on August 19, 2026, at 12:15 PM, with the Administrator (Admin), the Admin stated, On July 31, 2026, around 7:38 AM we had a power outage, it was a community wide outage, we did not notify CDPH. During a review of the facility's P&P titled, Unusual Occurrence Reporting dated March 2026, the P&P indicated, As required by federal or state regulations, the facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of residents, employees, and visitors. Policy Interpretation and Implementation 1. The following situations are reported to the appropriate agencies: a. emergencies or natural disasters including earthquakes, floods, gas explosions, severe fires, power outages, or other situations that damage the facility.Unusual occurrences are reported to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of an incident or as otherwise required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event will be submitted to the state agency (or other appropriate agencies) as required by federal and state regulations. During a review of California Code of Regulations Title 22, Division 5 Licensing and Certification, Chapter 3- Skilled nursing Facilities, Article 5- Administration, under S 72541 - Unusual Occurrences, it indicated Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal.

Based on interview and record review, the facility failed to ensure their wound care policy was implemented for one of three sampled residents (Resident 1) when Resident 1's back wound did not have consistent documentation pertaining to its ongoing assessment, monitoring and evaluation from May 10, 2026 through June 28, 2026. This failure potentially caused Resident 1 to be identified with a stage 4 pressure ulcer (full-thickness skin and tissue loss with directly exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone) to the mid-back with purulent drainage (a thick, opaque fluid-commonly known as pus-that oozes from a wound or sore) when Resident 1 was transferred to the acute care hospital on June 28, 2026.Findings: During a review of Resident 1's admission Record (contains demographic and medical information), indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (UTI) (an infection involving the urinary system), urinary retention (inability to completely empty the bladder, which can require use of an indwelling urinary catheter) and lack of coordination (difficulty controlling or coordinating body movements, which can increase dependence of staff for care.) During a review of Resident 1's VB-Nursing - Admit/Readmit Data Collection and Baseline -V6, dated May 10, 2026, at 2:30 PM, indicated D. Additional information indicated, Skin intact with some spot of discoloration, buttocks, sacrum (the large triangular bone at the bottom of the spine) no open wound, covered with mepilex (a protective foam dressing used to protect the skin and absorb drainage and reduce pressure/friction] for support. During a review of Resident 1's Care Plan (CP) dated May 10, 2026, the CP indicated Focus the resident has an ADL, self-care performance deficit r/t[related to].,goal, the resident's risk for decline in ADL (activities of daily living) function, will be minimize.Intervention.Mobility, resident requires assist with ambulation, bathing/showering: the resident requires assist with bating.,Skin inspection: the resident requires SKIN Inspection Observed for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. During a review of Resident 1's Physician Orders, dated May 18, 2026, at 1:56 PM, the physician's order indicated Tx [treatment] cleanse surgical site to mid spine w/ ns [with normal saline, water use to cleanse wounds], pat dry then apply zinc oxide [a topical skin protectant used to protect the skin from moisture and irritation] and leave open to air, every day shift. During a review of Resident 1's Treatment Administration Record dated from May 1, 2026, through June 30, 2026, it indicated, Tx: cleanse surgical site to mid spine w/ns, pat dry then apply zinc oxide and leave open to air. Every day. Order date: May 18, 2026; D/C (discontinue) Date: July 21, 2026. During a review of Resident 1's Licensed Nurse Skin Assessment Form dated June 10, 2026, the assessment indicated, areas of discoloration on the resident's back and dryness to the lower extremities. The body diagram did not identify any open wound to the back. During a review of Resident 1's eINTERACT Transfer Form V5, dated June 28, 2026, at 12:18 AM,. the transferred form indicated, 1. Transfer/discharge details sent to: [name of acute hospital] ., Reason (s) for other: AMS (define), fever 103.6, tachycardic, tachypnea. There was no documentation that Resident 1 had any pressure ulcers/injuries upon transfer. During a review of Resident 1's Orthopedic Surgery Consult Note from the [Name of the Acute Care Hospital] dated June 28, 2026, at 5:20 PM, the orthopedic surgery consults note indicated, Resident 1, was admitted to the hospital for sepsis. Ortho was consulted for infected hardware vs (versus) osteomyelitis. [bone infection] Patient had T10 [tenth thoracic vertebra a bone in the middle/lower part of the spine] -L4 [fourth lumbar vertebra (a bone in the lower back] laminectomies and pedicle fusion in April 2026 and had healed wounds prior discharge., Per IM, [internal medicine] current wound may be result of pressure ulcers. Per son, patient has right-sided weakness s/p [status post] CVA [cerebrovascular accident, stroke] and has been able to walk with a walker., Son was only made aware of pressure ulcers on June 28, 2026, when patient was admitted to the hospital.Objective, Derm (dermal means related to the skin): grade 4 pressure ulcer mid back with purulent drainage., A review of Resident 1's clinical records was conducted on August 14, 2026, at 2:36 PM. There was no documentation of weekly wound assessments, wound measurements, wound progress notes, change of condition documentation or other records describing the appearance, progression or response to the treatment of Resident 1's back wound from (date) until the date Resident 1 was transferred to the hospital on June 28, 2026. During a concurrent interview and record review on August 14, 2026, at 2:48 PM, with the Director of Nursing (DON), the DON reviewed Resident 1's clinical records, and stated Resident 1 had undergone back surgery in April 2026, and was admitted to the facility on [DATE], with a surgical area to the back. The DON stated the area was not opened upon admission. The DON stated a treatment order was initiated on May 18, 2026, to cleanse the surgical area with normal saline and apply treatment as ordered. The DON further stated residents receiving skin treatments were expected to be monitored and evaluated, with changes in skin condition reported to the physician and documented. However, the DON was unable to provide weekly wound assessments, wound measurements, progress notes, change of condition documentation or other records describing the appearance, progression or response to the treatment of Resident 1's back area prior to the June 28, 2026, hospital transfer. During an interview on August 14, 2026, at 3:12 PM, the License Vocational Nurse /Treatment Nurse LVN/TX nurse, stated residents with identified wounds were placed on a wound - treatment list and followed during weekly wound rounds. The LVN/TX nurse stated that residents followed by an outside healthcare provider were evaluated during weekly rounds with the outside wound provider, who documented wound assessments and recommendations on a separate wound assessment form. The LVN/TX nurse further stated changes in wound condition were reported to the physician and treatment orders obtained and updated as indicated. During a subsequent interview on August 14, 2026, at 3:28 PM with the DON, the DON stated that when a resident developed a new skin concern or required skin treatment, nursing staff were expected to assess and monitor the area, notify the physician of changes, obtain and implement treatment orders, update the care plan as indicated, and document the resident's response to treatment. The DON stated resident receiving wound treatment were expected to have ongoing wound monitoring documentation. The DON was unable to provide documentation showing that Resident 1's back wound was consistently assessed, measured, or evaluated for progression or response to the treatment prior to June 28, 2026, hospital transfer. During a review of the facility's policy and procedure (P&P) titled Wound Care, undated, the P&P indicated, the purpose of this procedure is to provide guidance for the care of wound to promote healing., documentation the following should be recorded in the resident's medical record: 1. Type of wound care given, 2. The date and time the wound care was given, 3. The position in which the resident was placed, 4. The name and titled of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessments data (i.e. wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data., Reporting, 1. Notify the supervisor if the resident refuses the wound care. 2. Report other information in accordance with facility policy and professional standards of practice.

Based on interview and record review, the facility failed to ensure laboratory results were followed up in a timely manner for one of three sampled residents (Resident 1) when Resident 1, who had an indwelling foley catheter (a tube place into the bladder that stays in place to drain urine into a bag), developed hematuria (blood in the urine), confusion, and altered mental status. The facility failed to notify the physician when the result of urinalysis and urine culture and sensitivity (UA/CNS, test used identify a urinary infection and determine appropriate antibiotic treatment) was reported as contaminated, obtain additional physician orders, or repeat the urine test. This failure resulted in a delay in the further evaluation and treatment of Resident 1's urinary infection. Resident 1 subsequently required emergency hospitalization and was diagnosed with a catheter - associated urinary tract infection (UTI), requiring intravenous (IV-intravenous, a small tube placed into a vein to give fluids or medications directly into the bloodstream) antibiotics (medicine used to treat infections caused by bacteria) and intensive care unit (ICU) treatment.Findings:During a review of Resident 1's admission Record (contains demographic and medical information), it indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (UTI) ( an infection involving the urinary system), urinary retention (inability to completely empty the bladder, which can require use on an indwelling urinary catheter) and lack of coordination (difficulty controlling or coordinating body movements, which can increase dependence of staff for care.)During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment used to identify a resident's clinical condition and care needs), under Section GG - Functional Abilities, dated May 17, 2026, the MDS, indicated Resident 1 was coded 01 for toileting hygiene. (A score of 01 means dependent helper does All of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity).During a review of Resident 1's Care Plan (CP), dated May 10, 2026, the CP indicated, focus the resident has (indwelling suprapubic) catheter, Goal, the resident's risk for s/s (signs and symptoms) of urinary infection will be minimized thought the review date., interventions., monitor/record/report to MD (medical doctor) for s/sx (signs and symptoms) UTI.blood.,)During a review of Resident 1's Nursing Progress Note dated June 25, 2026, at 9:58 PM, the nursing progress note, indicated, noted blood on resident's catheter, v/s (vital signs obtained. MD and family notified. MD ordered to replace catheter and UA/CNS. Catheter replaced by Tx (treatment) nurse.During a review of Resident 1's Nursing Progress Note dated June 26, 2026, at 3:46 AM, the nursing progress note indicated, Hematuria (blood in the urine), -Received resident resting in bed., skin is warm and dry to touch, afebrile, continue on monitoring for blood in urine, resident noted with urine output of 300 ml (three hundred, milliliters, unit of liquid) in the f/c [foley catheter bag], a bag connected to the foley catheter that collects urine as it drains from the bladder] collection blood with blood in it.urine sample was collected and is ready for pick up. Called in [Name of the lab] lab tech [Name of lab tech] regarding urine collection continue with plans of care.During a review of Resident 1's Physician Orders dated June 26, 2026, the physician orders indicated, UA with C&S /t (due to) hematuria one time only for 1 day. Start Date June 26, 2026.During a review of Resident 1's Urinalysis result, collected on June 26, 2026, at 6:09 AM, the urinalysis result indicated blood 3+ (a large amount of blood detected in the urine), Nit (nitrites, may indicate bacteria in the urine) .During a review of Resident 1's Nursing Progress Note dated June 26, 2026, at 3:01 PM, the nursing progress note indicated .with episodes of confusion and forgetfulness continue monitoring for hematuria., waiting for UA results. During a review of Resident 1's Nursing Progress Note dated June 27, 2026, at 6:28 AM, the nursing progress note indicated, resident on monitoring for hematuria.During a review of Resident 1's Urine Culture (a laboratory test used to identify bacteria that may cause a urinary infection) result, collected on June 26, 2026, at 6:09 AM, and resulted on June 27, 2026, at 12:40 PM, the final result indicated, Multiple organisms present, probable contaminant. During a review of Resident 1's Nursing Progress Note dated June 28, 2026, at 12:31 AM, the nursing progress note, indicated, Resident skin hot to touch T. (temperature) 103.6 (a unit used to measure temperature), (high fever; normal adult temperature is 97.7 - 99.1 ) appears in respiratory distress with RR (respiratory rate) of 28 (number of breaths per minute, normal rate is 12-20), HR (heart rate of) 116 (number of heart beats per minute, normal range 60-100) , with of Blood pressure of 80/50 (the force of blood moving through the arteries; normal range is 90/60 - 120 /80). We initiated cooling measures and administered Tylenol 650 mg. o2 (oxygen) sat 80% at RA (room air), (initiated supplemental o2 tank via n/c (nasal cannula- a small tube placed in the nostrils to provide oxygen) at 5 l /min, (liters per minute) then (difficulty of breathing) went up to 88% (the percentage of oxygen carried in the blood; normal is 95% -100%). Continued displaying unstable VS (vital signs- measuring of body basic function including blood pressure, heart rate, respiration) and off baseline of mentation. On call MD.and order the resident transfer to acute hospital.During a review of Resident 1's Emergency Department Physician Note date June 28, 2026, at 12:36 AM, Resident 1 presented to the ED with respiratory distress, and AMS [altered mental status] prior to arrival., was found by EMS [emergency medical services] to be hypoxic to the 80s on RA [room air] with associated hypotension and tachycardia., Patient ill-appearing, toxic, [looking very sick or seriously ill] cachectic, [very thin and weak]in acute respiratory distress [difficulty breathing] with tachypnea [breathing faster than normal]., Foley catheter with dark sedimented urine [urine that is dark in color and contains visible particles].Further review of Resident 1's Emergency Department Physician Note from [Name of the Acute Care Hospital] indicated, DDx (differential diagnosis, a list of possible conditions that may be causing a person's symptoms] includes septic shock (a life - threatening condition cased by a severe infection that leads to dangerously low blood pressure and can cause the body's organs to stop working] with source likely urinary (catheter-associated UTI) vs [versus] pulmonary (pneumonia)., UA grossly positive (the urine testes showed clear signs of a urinary tract infection, (UTI)] During a review or Resident 1's Inpatient Discharge Summary from [Name of Acute Care Hospital], dated June 29, 2026, at 4:30 PM, the discharge summary indicated, Per chart review, patient presents from [facility name] for UTI symptoms. En route with EMS, patient was hypoxic and altered. Oxygen saturation improved with NRB [non-rebreather mask, a face mask that delivers a high amount of oxygen]. In the ED, patient was initially alert and oriented, and responded appropriately to questions. Patient stated his main concerns with difficulty breathing and back pain. However, while patient was still in the ED, he subsequently became hypoxic, bradycardic (slow heart rate), with altered mental status, therefore decision was made to intubate (inserts a tube) patient for airway protection. The discharge summary further indicated, Patient was intubated for airway protection, started on levophed (norepinephrine, a medication used to raise dangerously low blood pressure]. IVF [Intravenous fluids, given directly into a vein] given. No stable for transfer to [Acute hospital where patient was seen prior] therefore admitted to MICU (Medical Intensive Care Unit, a hospital unit that provides close monitoring and specialized treatment for seriously ill patients) for shock [a life-threatening condition in which the body's organs do not receive enough blood and oxygen. A review of Resident 1's clinical records was conducted on August 14, 2026, at 1:48 PM. There was no documented evidence to indicate that the physician was notified of the contaminated urine culture result, that additional physician orders were obtained, or that the urine specimen was repeated before Resident 1 was transferred to the hospital on June 28, 2026.During a concurrent interview and record review on August 14, 2026, at 1:56 PM, with the Director of Nursing (DON), the DON reviewed Resident 1's Nursing Progress Notes dated from June 25, 2026, through June 28, 2026. The DON confirmed there was no documentation showing the physician was notified after the urine culture result was reported as contaminated. The DON stated the nurse who received the laboratory result was expected to notify the physician, obtain any necessary follow - up orders and document the physician notification and interventions in the nursing progress notes. The DON further stated that when a urine culture is contaminated, the physician should be notified for further direction which may include repeating the urine test. During a telephone interview on August 14, 2026, at 2:04 PM, with the Registered Nurse / Supervisor (RN 1), the RN 1 stated that when a urine culture result is reported as contaminated, the nurse is expected to notify the physician, obtained an order to repeat the specimen as indicated, and document the physician notification and follow-up in the nursing progress notes., The RN 1, further stated that if the notification and intervention were not documented, there was no evidence that they were completed.During a review of the facility's policy and procedure (P&P) titled Lab and Diagnostic Test Results-Clinical Protocol, undated, the P&P indicated, 1. When test results are reported to the facility, a nurse will first review the results. a. if staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure., 5. Upon assessment and review of laboratory results, the nurse will coordinate with the doctor regarding the possibility of a repeat lab order due to potential contamination. A physician can be notified by phone, fax, voicemail, email, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff). a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results.

Based on interview and record review, the facility failed to ensure their Resident Rights policy and procedure was implemented for one of three sampled residents (Resident 1) when Resident 1's son who has Power of Attorney POA ( legal document that lets you name a trusted person (called an agent) to make financial, legal, or health care decisions for you) and was a contact on facesheet was not informed of Resident 1's transfer to the hospital.This failure had the potential to compromise Resident 1's safety and to place Resident 1 and Resident 1's son in emotional distress.Findings:During a review of Resident 1's admission Record (general demographics information), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included left hip dislocation (joint injury, ends connected bones are forced out of position), diabetes mellitus type 2 (disorder characterized by high/low blood sugar), hypertension (high blood pressure), urinary tract infection (bacterial infection in urinary system). Further review indicated Resident 1's son was on the contact list. During a review of Resident 1's California General Durable Power of Attorney, dated July 21, 2026, it indicated Resident 1's son was Resident 1's DPOA. During a review of Resident 1's Nursing Progress Note, dated July 24, 2026, at 10:38 PM, it indicated, At around 2000 (8:00 PM), this LVN (Licensed Vocational Nurse) entered resident's room with CNA (Certified Nursing Assistant) to check blood glucose and administer evening medications. Director of Nursing (DON) entered room and also witnessed resident stating, my son will sue this facility if you invite [Name of Resident 1's Roommate] friend in here again. [Resident 1's Roommate] reported that Resident 1 was having hallucinations. Doctor made aware of resident deviation from baseline and recommended transfer to hospital for reevaluation during AM shift. At 2052 (8:52 PM), AMR arrived to pick up resident for transfer to acute Hospital. Resident stated, my son will be mad at me, and appeared fearful. [Name of Ambulance Company] assisted in safe transfer of resident to Hospital.During a review of Resident 1's clinical records, there was no documented evidence to indicate Resident 1's son was notified of Resident 1's transfer to the hospital on July 24, 2026.During a telephone interview with Resident 1's son, on August 5, 2026, at 9 AM, Resident 1's son stated, They [facility] did not call me when they sent my mom [Resident 1] out twice.During a concurrent interview and record review, on August 5, 2026, at 1:45 PM, with the Director of Nursing (DON), the DON reviewed Resident 1's clinical records and could not see any no documented evidence to indicate Resident 1's son was notified of Resident 1's transfer to the hospital on July 24, 2026. The DON stated, I don't see it documented in resident medical record.During a review of the facility's policy and procedure (P&P) titled, Resident Rights revised January 2026, the P&P indicated, Rialto Post Acute is committed to protecting and promoting the rights of all residents in accordance with CMS regulations (42 CFR S483.10) and California Title 22. Residents are treated with dignity, respect, and individuality and are supported in exercising their rights while residing at the facility. Procedure: 2. Right to Be Informed & Participate in Care a. Residents have the right to be fully informed of their medical condition, treatment options, and changes in care. b. Residents may participate in care planning and treatment decisions and may refuse treatment.

Based on interview and record review, the facility failed to report an allegation of sexual abuse to the California Department of Public Heath (CDPH) for one of three sampled residents (Resident 1), when Resident 1 claimed she was sexually abused by a treatment nurse (TN).This failure had the potential to place Resident 1 at risk for further abuse and physical or psychological harm.During a review of Resident 1's admission Record (form with health information), the admission Record indicated an admission date of June 4, 2026, with diagnoses which included history of falling, left artificial hip joint (a man made part that replaces the natural hip when it is damaged), and type 2 diabetes mellitus (when the body cannot process sugar appropriately and results in too much sugar in the bloodstream).During a review of Resident 1's Care Plan (a written guide specific to the resident's needed care and goals), initiation date of July 22, 2026, the Care Plan indicated, .7/22/26 (July 22, 2026) around 4pm. during police officer interview with the resident [Resident 1], resident reported to a police officer that she was sexually abused by a treatment nurse.During a concurrent interview and record review on July 29, 2026, at 11:51 AM with the Director of Nursing (DON), Resident 1's Change of Condition Evaluation (CIC) dated July 22, 2026, was reviewed. The CIC indicated, . Resident [Resident 1] reported to a police officer that she was sexually abused by a treatment nurse. The DON stated she did not report the alleged sexual abuse to CDPH. The DON further stated she should have reported the allegation to CDPH, .as soon as possible or within two hours.During an interview on July 29, 2026, at 12:30 PM, with the Administrator, the Administrator confirmed she did not report Resident 1's allegation of sexual abuse by a TN to CDPH. The Administrator stated that she did not think to report the incident because the police officer was laughing and even remarked that it did not happen after the resident reported being sexually abused.During a concurrent interview and record review on July 29, 2026, at 12:57 PM, with the Administrator and the DON, the facility's Policy and Procedure (P&P) titled, Staff-to-Resident Abuse Prevention, Reporting, and Response, dated January 26, 2026, was reviewed. The P&P indicated, . All allegations. involving staff-to-resident abuse shall be immediately reported. and the Administrator or designee will notify. California Department of Public Health (CDPH) in accordance with state requirements. The Administrator and the DON, both, stated the P&P was not followed.

Based on observation, interview and record review, the facility failed to respect the rights and dignity of one of three sampled residents (Resident 3) when Resident 1 was left sitting on the bedside commode (BSC- a portable toilet placed near the resident's bed) with the privacy curtain open, leaving her buttocks visible to public view. This failure had the potential to compromise Resident 3's privacy and dignity which may cause embarrassment or humiliation while receiving toileting care.During a review of Resident 3's admission Record (contains demographic and medical information), it indicated Resident 3 was admitted to the facility on [DATE], with diagnoses that included lack of coordination (difficulty controlling coordinating body movements), overactive bladder (a condition that causes a sudden and frequent urge to urinate) and dependence on wheelchair. During a review of Resident 3's MDS (minimum data set, a clinical assessment of all residents in nursing homes) 3.0 Section GG (functional Abilities and Goals, dated July 24, 2026, indicated, Resident 3 was coded 01 Dependent for toilet transfers (helper does ALL of the effort. Resident does none of the effort to complete the activity.) During a review of Resident 3's care plan titled ADL (Activities of Daily Living) - self-care performance deficit r/t [related to] asthma (difficulty of breathing. dated July 20, 2026, it indicated, goal, the resident's risk for decline in ADL function will be minimize., Interventions, toilet use: the resident requires assistance for toileting. During a concurrent observation and interview on July 24, 2026, at 5:40 PM, with the Assistant Director of Nursing (ADON), in Resident 3's room, Resident 3 was sitting on a bedside commode (BSC- a portable toilet placed near the resident's bed) with the privacy curtain open. Resident 3's back was uncovered and her buttocks was visible from the open doorway and in public view. Anyone passing by the resident's room was able to see Resident 3, sitting on the BSC while toileting. The ADON stated, For privacy, the curtain should be closed. During a concurrent telephone interview and record review on September 1, 2026, at 4:27 PM, with the Director of Nursing (DON), the DON reviewed the facility's undated policy and procedure (P&P) titled, Resident Rights, which indicated under Section 4, Right to Privacy & Confidentiality, b. Privacy is provided during medical treatment, personal care, visits and communications. The DON stated staff were expected to provide residents with privacy and dignity when using a bedside commode, including closing the privacy curtain. The DON acknowledged the policy was not followed. The DON stated she did not know why the CNA did not close the privacy curtain and stated the CNA may have forgotten to close it.

Based on observation, interview, and record review, the facility failed to ensure an allegation of suspected abuse was immediately reported to the State Survey Agency (The State agency responsible for overseeing nursing homes and investigating compliance concerns) in accordance with state and federal regulations for one of three sampled residents (Resident 1). This failure had the potential to delay the investigation and implementation of protective measures necessary to ensure Resident 1 was protected from potential abuse or further injury. Findings: During a review of Resident 1's admission Record (contains demographic and clinical information) it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included vascular dementia (a condition in which reduces blood flow or damage to blood vessels in the brain causes problems with memory, thinking, judgment and behavior), traumatic subdural hemorrhage with loss of consciousness(bleeding that occurred between the brain and its outer covering after an injury to the head) and lack of coordination (difficulty coordinating body movements.) During a review of Resident 1's Shower Day Skin Inspection, dated July 6, 2026, it indicated Resident 1 was noted with discoloration on his neck and bilateral lower extremities (legs). During a review of Resident 1's Change in Condition Evaluation, dated July 9, 2026, at 12:28 PM, it indicated Resident 1's B6. Skin Status Evaluation, 5. Discoloration.6b.Document location and details: Site other, description, left mandible.,4. Summarize your observations, evaluation and recommendations: Per daughter, while feeding the resident she accidentally bumped this food tray, causing it to move close to the resident's face., B. Provider Notification and Feedback, 1. Were the change in condition and notifications reported to primary care clinician? 1.Yes. 2. Date and time of clinician notification 7/9/2026 (July 9, 2026) at 3:00 PM. During a review of Resident 1's clinical records, there was no documented evidence to indicate the facility reported an allegation of suspected abuse to the State Survey Agency. During a concurrent observation and interview with Resident 1, on July 16, 2026, at 12:11 PM, in the presence of Certified Nurse Assistant (CNA 1), inside Resident 1's room, Resident 1 was observed with a large yellowish discoloration to the left side of Resident 1's jawline and neck. Resident 1 was unable to provide a clear explanation as to how he sustained the discoloration. During a subsequent interview with CNA 1, CNA 1 stated the discoloration had been previously observed during Resident 1's personal care. CNA 1 stated she asked the charge nurse what had happened and was informed that Resident 1's daughter had been feeding him and had accidentally dropped a plate on him. During an interview on July 16, 2026, at 12:54 PM, with the Director of Nursing (DON), the DON stated she was aware of the discoloration at Resident 1's left jawline/ or neck. The DON stated the facility investigated the injury and was informed that Resident 1 moved his head while his daughter was feeding him and came into contact with the meal tray/plate. The DON further stated that on July 13, 2026, staff subsequently expressed concerns regarding how Resident 1's daughter interacted with Resident 1. Staff reported observing the daughter tapping Resident 1 on the face/check and shoulder while obtaining his attention. The DON stated that the incident was not reported to California Department of Public Health (CDPH- State Agency responsible for overseeing nursing home and investigating compliance concerns) because the facility determined the incident was accidental and did not consider suspected abuse. The DON stated the facility staff are mandated reporters and acknowledged that allegations of suspected abuse must be reported immediately. During a review of the facility's policy and procedure titled Abuse Prevention, Prohibition, Reporting, and Staff Training Policy undated, indicated, Purpose to protect patients/residents from abuse, neglect, exploitation and mistreatment and to ensure timely reporting and staff training. Policy, abuse, neglect, exploitation, and mistreatment are strictly prohibited. All staff are required to prevent, recognize, report and respond to any suspected or actual abuse immediately.,Prevention, staff must follow care plans and safety protocols.,Reporting Requirements, all staff are mandatory reporters, Any suspected, witnessed, or alleged abuse must be reported immediately to a supervisor.

Based on interview and record review, the facility failed to identify signs of developing pressure ulcer (a tissue damage that results in full thickness loss of skin) in a timely manner for one of three sampled residents (Resident 1). This failure had the potential for Resident 1's pressure ulcer to worsen due to not receiving the proper treatment that it needs.Findings: During a review of Resident 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included, quadriplegia paralysis of the limbs), multiple sclerosis (a condition where the body's healthy cells are mistakenly attacked by the body's cells and organs), acute respiratory failure (a condition where the lungs cannot get enough oxygen into the blood) and lymphocytosis (a condition indicating the body's cells and organs are fighting an infection). A review of Resident 1's Medical Record, titled Change in Condition Evaluation, dated March 3, 2026, documented by the Wound Treatment Nurse (WTN), indicated, CNA (certified nursing assistant) approached me and reported a pressure injury on patient right hip upon observation notice that resident denied any pain at that time on right hip wound stage 3 3.7x3 x 0.3 90% (percent) granulation and 10% slough noted called MD (medical director) and explained resident skin condition and received new orders for xeroform (sterile, non-adhering, petrolatum-based gauze dressing designed to keep wounds moist, protected, and promote healing). During an interview on March 16, 2026, at 10:45 AM, with Certified Nursing Assistant (CNA 1), CNA 1 stated, We do daily skin checks when we give care and report any change of skin problem we see to our charge nurses. CNA 1 further stated, To prevent skin, break down and pressure ulcers, residents are repositioned every two hours. During an interview with the WTN, on March 16, 2026, at 10:55 AM, the WTN stated, he identified a new pressure injury on Resident 1's hip which was stage three (a tissue damage that results in full thickness loss of skin) after a CNA had reported it to him March 3, 2026. The WTN further stated, [Name of Resident 1]'s right hip area was clear and did not have any skin break before. During an interview on March 3, 2026, at 11:05 AM, with the Director of Nursing (DON), the DON stated, he was made aware of a new pressure injury, stage three, on the right hip of Resident 1, on March 3, 2026. DON further stated, Staff are supposed to do a daily skin inspection during care to report any skin changes. During a follow up interview and concurrent record review on March 16, 2026, at 11:55 AM, with the DON, the facility's policy and procedure (P&P), titled, Prevention of Pressure Injuries revised April 2020, was reviewed. The P&P indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema) . The DON acknowledged the policy and stated she expected staff to have provided care sooner.

Based on observation, interviews, and record reviews, the facility failed to ensure adequate supervision and safe environment to prevent elopement for one of five residents (Resident 175), reviewed for accidents. On January 7, 2026, Resident 175 (a resident diagnosed with Parkinson's disease [a brain disorder that causes tremors, slowed movement, poor balance, and difficulty with walking and coordination, increasing fall and wandering risks] and at high risk for falls) exited the facility through an alarmed emergency exit door, unsupervised. As a result, Resident 175 was found by the local police approximately one mile from the facility and was then transported by ambulance to the hospital for evaluation.This failure placed Resident 175 at risk for serious harm, injury or death including but not limited to traffic injury, exposure to environmental hazards, and inability to seek help. Resident 175 was found with a large bruise on his left hip, lacerations on his feet and on his knees.During a review of Resident 175's admission Record (contains demographic and medical information), indicated Resident 175 was admitted to the facility on [DATE], with diagnoses which included Parkinson's disease (a disorder that causes tremors, slowed movement, poor balance, and difficulty with walking and coordination, increasing fall and wandering risks) sequelae of cerebral infarction (a long term brain damage from prior stroke that can cause weakness, impaired judgment, confusion and poor safety awareness) and lack of coordination (difficulty controlling body movements ad balance, making walking unsafe and increasing risk for falls and injury).During a review of Resident 175's MDS (Minimum Data Set - a standardized assessment tool that measures health status in nursing home residents) Section C (Cognitive (involving conscious intellectual activity) patterns), dated January 6, 2026, indicated Resident 175 had a BIMS (brief Interview for Mental Status - tool used to screen how a resident is functioning cognitively) score of 12 (a BIMS score of 8-12 suggests resident is moderately impaired).During a continued review of Resident 175's MDS, Section GG (Functional Abilities) dated January 6, 2026, indicated: .J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet (about 15 meters) and make two turns, coded 88 (Not attempted due to medical condition or safety concerns), .K. Walk 150 feet: Once standing, the ability to walk at least 150 feet (about 46 meters) in a corridor or similar space, coded 88, .L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surface (indoor or outdoor), such as turf or gravel, was coded 88, .M. 1 step (curb): The ability to go up and down a curb and/or up and down one step, was coded 88.During a review of a document titled, SOC 341 (a document used by mandated reporters to document and report suspected abuse (physical, financial, neglect, etc.) of elders (60+ years old) or dependent adults (18-[AGE] years old)), dated January 7, 2026, the SOC 341 indicated, Patient [Pt - Resident 175], was brought in by ambulance and [name of local police department] (PD) after being found in the The Wash(a natural drainage channel or wash that runs through the city, used for flood control). Per PD, they received a call for service about Pt waking in a hospital gown and socks with blood on him. PD received a second call indicating Pt was seen in the wash. PD confirmed to have located Pt in the wash a mile down from [name of the facility]. PD contacted the facility and drove to the facility to confirm Pt was from the facility. Per PD, Staff reported Pt was last seen 7-8 hours prior to being found. Per PD, staff was unable to inform PD when and how Pt was able to leave the facility. Per PD, staff reported Pt has history of Parkinson's, Dementia (decline in mental abilities), and is a fall risk.During an interview on January 7, 2026, at 2:26 PM, with the Administrator (ADMIN), in her office, the ADMIN stated, Resident 175 was admitted to the facility on [DATE], with medical diagnoses of Parkinson's disease and dysphagia (difficulty swallowing). The ADMIN further stated in the morning of January 7, 2026, Resident 175 informed his nurse that he wanted to go out to get some fresh air. ADMIN further stated she was made aware of Resident 175 being transported to the hospital at approximately 9:30 AM after the local police arrived at the facility.During an interview on January 7, 2026, at 2:34 PM, with the Licensed Vocational Nurse / Treatment Nurse (LVN 1), the LVN 1 stated Resident 175 was admitted on [DATE] or 2, of 2026. LVN 1 stated the last time she saw Resident 175 was in the hallway walking with his wheelchair. LVN 1 stated Resident 175 appeared to be thinking about what he was going to do but not headed in any specific direction. LVN 1 stated Resident 175 was alert, oriented (a person who is aware of their identity, surroundings, and the current time), and ambulatory (a person who can walk or move independently). LVN 1 stated she was not aware of any behavioral issues, or special safety precautions in place for Resident 175. LVN 1 stated Resident 175 had a history of homelessness and had not observed any elopement behavior.During a further interview on January 7, 2026, at 2:36 PM, with LVN 1, LVN 1 stated Resident 175 had told his nurse (LVN 3)he wanted to go outside to get some fresh air and an Out on pass (OOP - a formal physician's authorization for patients to temporarily leave for a set period of time) physician's order was obtained, and she was the nurse who obtained the order.Subsequently, during a concurrent interview and record review conducted on January 7, 2026, at 2:38 PM, with LVN 1, Resident 175's OOP order dated January 7, 2026, at 10:21 AM (at approximately 3 hours after Resident 175 left the building), was reviewed. The OOP order indicated, May go out on pass for 4 hours. LVN 1 stated the OOP order was entered after Resident 175 had already exited the facility and there was no previous order for Resident 175 to be out on pass.During an interview on January 7, 2026, at 4:07 PM, with the acute hospital Social Worker (SW). The SW stated Resident 175 arrived at the hospital at approximately 9:15 AM, on January 7, 2026. The SW stated the Police Department received a call reporting that an individual was walking down the street on a hospital gown and socks, with blood on them, which caused concern. The SW stated two vehicles were sent to search for the individual. The SW further stated that law enforcement initially searched for the individual but did not locate him. Later, PD received a second call reporting that (Resident 175) was in the wash. The SW further stated PD found Resident 175 with lacerations on his feet and on his knees. He also had a large bruise on his left hip. The SW stated Resident 175 was found approximately one mile away from the facility. The law enforcement went to the facility and confirmed the resident (Resident 175) belonged to them. The facility informed PD Resident 175 had Parkinson's disease, dementia, and was at risk for falls.During an interview on January 7, 2026, at 4:25 PM, with the Director of Nursing (DON), the DON confirmed that Resident 175 was admitted to the facility on [DATE], with medical diagnoses of Parkinson's and dysphagia, and that he was ambulatory with assistance. The DON confirmed that the admission assessment was completed on admission.During a concurrent interview and record review on January 7, 2026, at 4:38 PM, with the DON, DON reviewed Resident 175's Nursing - Fall Risk Evaluation, dated January 2, 2026, at 10:41 PM. The evaluation indicated Resident 175 fall score was 14, . Category: high fall risk. 1. Mental status: 2. disoriented x 3 (person, place, and time) . 2. History of Falls: 3 or more falls in the past 90 days. 3. Ambulatory/Continence: 2. Wheelchair/bed bound (assist with elimination) . The Fall Risk Evaluation also indicated Resident 175 had diagnoses that could contribute to falls, and was taking 1 or 2 medications within the last seven days that could increase the risk of fall. The DON confirmed the evaluation indicated that the resident was disoriented, had a history of multiple falls, and required assistance for mobility.During a review of Resident 175's Change in Condition Evaluation, dated January 7, 2026, at 9:27 AM, it indicated 1. Signs and Symptoms identified. 31. Other change in condition, .1a. List the other change: resident had a fall outside, . 3. Review Findings and Provider Notifications. 4. Summarize your observations evaluation and recommendations: resident (Resident 175) had stated to staff that (he) wanted to go outside for some fresh air. Upon this walk he fell into the driveway of the facility. A police car was pass by and assisted the resident. They (the police) decided to all (call) the 911 and send the resident to the hospital despite us advising them we had the means to care for the resident in house. Resident 175's Change in Condition Evaluation, indicated vital signs (blood pressure, temperature, respiration, heart rate) were taken at the facility at 9:35 AM and the physician was notified on January 7, 2026, at 00:00 (midnight), the evaluation was signed by LVN 1.During a review of Resident 175's Nursing Admit/Readmit Data Collection and Baseline, dated January 2, 2026, at 10:38 PM, it indicated, A. admission Information. N. Pertinent diagnosis (es): CVA (Cerebral Vascular Accident - stroke) with mild right-side weakness, . 2. LOC (Level of Consciousness)/Orientation A. LOC. 1. Alert. B. Orientation, 1. Person (Self), 2. Place (location). 4. Skin condition, .40) left knee (rear): scattered (different areas) scabs, no open areas, . 41) Right lower leg (front): scattered scabs no open areas., 5. Pain/Fall Risk. Fall Risk. A. Is the resident at risk for falls? 1. Yes. A1. Fall Care Plan. Goal: The resident's risk for injury will be minimized through the review date. Interventions: Ensure that the resident is wearing appropriate footwear when ambulation or mobilizing in w/c (wheelchair). During a concurrent interview and record review on January 7, 2026, at 4:35 PM, with the DON, the DON confirmed that the SBAR (Situation, Background, Assessment, Recommendation - used to standardize and improve the clarity of information exchange between healthcare professionals), dated January 7, 2026, was completed by LVN 1 after the facility was contacted by law enforcement. The DON further confirmed there was no prior SBAR documentation indicating Resident 175's ability to leave the facility safely nor being assessed or approved by a physician. During a review of Resident 175's hospitals record provided by the facility, titled, Fall Risk Assessment (Morse Fall Scale - a tool healthcare providers use to predict a patient's likelihood of falling), dated January 7, 2026, at 09:16 AM, the record indicted Resident 175's Morse Fall Risk Score was assessed as 55 (High fall risk).During a review of Resident 175's facility provided hospital records, the ED (Emergency Department) provider Notes, dated January 7, 2026, at 9:38 AM, indicated, Resident 175 had a past medical history of stroke, COPD, (chronic obstructive pulmonary disease, a long - term lung disease that makes it hard to breath), Parkinson's, type 2 DM (Type 2 diabetes mellitus, a chronic condition where the body does not properly use insulin, causing high blood sugar), chronic anemia (a long term condition where the blood does not carry enough oxygen), CKD, (Chronic Kidney Disease - a long term condition where the kidneys do not work properly), paroxysmal A-fib (atrial fibrillation - an irregular heart rhythm that comes and goes, which causes dizziness) and hypertension (high blood pressure) is brought in by ambulance after law enforcement found patient walking outside in the cold this morning. Patient (Resident 175) has abrasions (injury to the surface of the skin cause by rubbing or impact) to bilateral (both) knees and bilateral feet, as well as bruising (bleeding under the skin caused by an injury, which can indicate tissue damage or internal bleeding) to left hip. Social history, alcohol use: Comment: patient confused no family at bedside. Physical Exam indicated, Skin. abrasions are present to bilateral knees and feet. There is bruising to the left hip (pictures were included in the ED report).During an observation on January 7, 2026, at 6:38 PM, with the ADMIN, in the presence of the DON, Assistant Director of Nursing (ADON), and Director of Clinical Operations (DCO), the facility 's video surveillance system footage was reviewed. The surveillance system video showed on January 7, 2026, at approximately 7:30 AM, Resident 175 exited his room wearing a white T-shirt, blue hospital-like pajama pants, and socks. Resident 175 began walking down the hallway toward the rear emergency exit. Two nursing staff were standing near nurses' station by the hallway where Resident 175 was walking. The video showed Resident 175 walking directly past the two-nursing staff without any staff approaching, speaking to, re-directing or accompanying the resident. The video then showed Resident 175 approached the rear emergency exit door, which was marked with a STOP and Emergency Exit Only signage, equipped with a push-bar exit mechanism, and an audible alarm system that requires a key to silence. Resident 175 removed the elastic band that had been placed across the door, pushed the alarmed exit door open, and exited the building without staff assistance or supervision. After exiting the building, Resident 175 was observed on video walking outside the facility toward the front of the building (by the main street), with an unsteady gait (a manner of walking or moving on foot) appearing off balance, but continued walking away from the facility. The video showed: 7:30 AM Resident exited his room. 7:32 AM Resident passed through the front parking lot. 7:34 AM Resident continue toward the alley and driveway leading to the main street. Facility leadership (ADMIN, DON, ADON, and DCO) who were present during the review acknowledged that the video surveillance did not show:Any staff responding to the alarm.Any staff attempting to stop the resident.Any staff turning off the alarm.Any staff following the resident to ensure his safety.Resident 175 fell into the driveway of the facility.A police car passed by and assisted Resident 175.An ambulance taking Resident 175 to the hospital.The video surveillance also indicated two local police vehicles arriving at the facility on January 7, 2026, at approximately 8:56 AM and leaving at approximately 9:09 AM. There was no resident, staff, nor ambulance visible on the video when the local police arrived.During a review of Resident 175's facility provided hospital records, the ED events, dated January 7, 2026, it indicated, ED Events, January 7, 2026, triage started (the first medical screening done when a patient arrives at the emergency room to quickly check how sick or injured, they are) 9:16 AM.During a concurrent record review and interview on January 7, 2026, at 5:31 PM, with the Director of Rehabilitation (DOR), Resident 175's Physical Therapy PT Evaluation & Plan Treatment, dated January 6, 2026 - February 4, 2026, was reviewed. The PT evaluation & plan of treatment, indicated, Reason for Referral / current illness: Patient referred to PT due to decline in strength, functional ambulation, dynamic balance and functional mobility., recent hospitalization to (name of hospital) on December 30, 2025 w/ (with) c/c (complaining of) Rt (right) side weakness and slurred speech on arrival pt (patient) endorses multiple mechanical falls cause by loss of balance, weakness, tripping), Dx: (diagnosis) CVA (stroke, loss of blood flow to the brain), AKI, (acute kidney injury, sudden kidney dysfunction causing weakness and confusion), DM (diabetes mellitus, high blood sugar, causing weakness and dizziness), Parkinson's disease. The DOR stated Resident 175 was able to ambulate with CGA (Contact Guard Assist - a caregiver or therapist maintains light, physical touch (like one or two hands on the torso) to prevent falls during activities like walking or transferring, without doing the actual work). The DOR stated Resident 175 had right-side body weakness and instability to be steady whenever he walks and someone needs to be with him. The DOR further stated Resident 175 was currently receiving physical therapy services.During a concurrent record review and interview on January 7, 2026, at 5:42 PM, with the DOR, the Resident 175's Occupational Therapy OT Evaluation & Plan of Treatment dated January 5, 2026 - February 3, 2026. The OT evaluation & plan of treatment, indicated Reason for skilled Services: Patient requires skilled OT services to develop and instruct in exercise program, develop and instruct on compensatory strategies, increase functional activity tolerance, increase safety awareness, maximize independence with ADLs (activities of daily living, as dressing bathing).,Risk Factors: due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: falls and increase dependency., Physical / Cognitive/ Psychosocial Performance: Patient presents with impairments in balance, mobility, strength, use of copying strategies and use of environmental modification strategies resulting in limitations and / or participation restrictions. The DOR stated Occupational Therapy (OT) evaluation was completed on January 5, 2026, and Physical Therapy (PT) evaluation was completed on January 6, 2026, and the evaluations were used by the facility to determine Resident 175's functional status.During a follow up interview on January 7, 2026, at 6:52 PM, with the DON, the DON stated the alarm for facility's rear exit door was turned on at the time Resident 175 exited the building, and the alarm requires a key to silence. The DON further stated licensed nurses carry the keys used to turn off the alarm. The DON acknowledged the surveillance video did not show any staff member turning off the alarm or responding to the alarm when Resident 175 exited the building. The DON stated the alarm activates when the emergency exit door is pushed.During an interview on January 7, 2026, at 6:48 PM, with Resident 175, in his room upon return from the hospital, Resident 175 was awake, lying down on his back in bed. When Resident 175 was asked about the current year, he stated it was 2000. Resident 175 had continuous tremors on both hands (involuntary, rhythmic shaking) and were present throughout the interview. Resident 175 stated he walked to the cement and crossed the street. When asked if he remembered what happened after that, Resident 175 stated he could not remember, he came from the hospital and I try to get healed. When asked who transported him to the hospital, Resident 175 stated he did not know; and was unable to identify whether police or ambulance were involved. Resident 175 stated he told a nurse he was going to go that way, but was unable to specify where. During this portion of the interview, Resident 175 speech was disorganized and frequently closed his eyes.During a concurrent observation and interview on January 7, 2026, at 6:55 PM, with Licensed Vocational Nurse (LVN 2) in Resident 175 room, LVN 2 conducted a body assessment of Resident 175. LVN 2 removed Resident 175's hospital socks, which were visibly stained with blood. Resident 175 stated his feet and legs hurt. Upon removal of the socks, LVN 2 exposed red tissue to an open area on the bottom of the right great toe, open areas on the left great toe and second toe. There were open red areas on Resident 175's bilateral knees and a large dark purple bruise extending from the left hip down to the mid-thigh. In addition, Resident 175 had bluish on both shoulders. LVN 2 stated the open areas on the knees, feet, left hip, and thigh were new. During a record review of Resident 175's Nursing Progress Note, dated January 7, 2026, at 7:25 PM, the following was indicated: Re admission assessment done, by LVN 1The nursing progress note indicated: Left knee abrasion (scraped skin) (measuring) 6 x 4 cm (about 2 1/2 inches long and 1 1/2 inches wide) (with) 100% granulation (new healing tissue) superficial (top layer of skin only) scant drainage, (small amount of fluid) no odor (no foul smell).Left plantar great toe abrasion (scrape on the bottom of the left big toe) (measuring) 0.7 x 0.7 cm, (about the size of a pencil eraser) (with)100% granulation (healing tissue) superficial, scant drainage, no odor.Left anterior toe abrasion (scrape on the front of the toe) (measuring) 1 x 1 cm (about the size of small coin) 100% granulation, superficial, scant drainage no odor.Left 2nd toe abrasion (scrape on the second toe) (measuring) 1 x 0.7 cm, (small coin - size) 100% granulation, superficial scant drainage, no odor.Right lateral great toe abrasion (scraped on the outer side of the right big toe) (measuring) 6 x 3 cm, (about 2 1/2 inches long and 1 1/4 inches wide) (with) 100% granulation superficial scant drainage no odor.Scab wound to 3, 4 and 5 right fingers, (dried, crusted wounds) (with)100% eschar, (thick dead tissue covering the wounds) no drainage no odor.Discoloration to left hip extending to left thigh (deep bruising from bleeding under the skin) 100% dark purple.Tattoos to upper chest (non - injury identifying marks).Right knee abrasion (scraped skin) (measuring) 2 x 2 (about the size of large coin) 100% granulation superficial, no odor scant drainageMd (Medical Doctor) made aware, orders received orders carried out and noted.During an interview on January 7, 2026, at 8:23 PM, with the leadership management including DON, ADMIN and DCO, the following documents were reviewed:-Baseline Care Plan (included on the VB - Admit/Readmit Data Collection and Baseline - V6), dated January 2, 2026, x. Fall Risk: A: Is the resident at risk for Falls? Yes, . A1. Fall care plan, Focus: the resident is at risk for falls, . Goal: the resident's risk for injury will be minimized through the review date. Interventions (no checks on interventions), confirmed with the DCO.-Fall Risk assessment dated [DATE], at 10:41, reviewed and confirmed with ADMIN, DON and DCO that Resident 175 was a high risk for fall.-PT/OT Evaluations dated January 5, 2026, and January 6, 2026, reviewed and DON, DCO and ADMIN acknowledged Resident 175, was on contact guard assistance related to his medical conditions including CVA, with right side of the body weakness. Parkinsons.-MDS dated [DATE], was reviewed.-Nursing Progress Note Dated January 7, 2025, at 7:25 PM was reviewed (includes the skin assessment) and VB-Nursing / Readmit Data Collection and Data Baseline - V6 Dated January 2, 2026, at 10:38 PM. was reviewed with the DCO. -Change of Condition dated January 7, 2026, at 9:27 AM was reviewed with DON, DCO.-Accident / Prevention Policy-Elopement Prevention Policy-Fall Risk Assessment PolicyDuring a concurrent interview and record review on January 7, 2026, at 8:27 PM, with the DON, ADMIN, and DCO, the facility Policies and Procedures (P&P) titled, Incident and Accident Policy, undated, was reviewed. The P&P indicated, . to ensure the safety, dignity and independence of residents while preventing responding to, and documenting incidents and accidents particularly for resident who require assistance with Activities of Daily Living (ADLs). DON, ADMIN, and DCO acknowledged the policy and stated it was not followed by their staff.During a concurrent interview and record review on January 7, 2026, at 8:31 PM, with the DON, ADMIN and DCO, the facility Policies and Procedures (P&P) titled, Elopement Prevention and Resident Decision - Making, undated, was reviewed. The P&P indicated, To prevent unsafe elopement while protecting the rights of alert resident who possess decision making capacity and the ability to exercise free regarding community access. Scope Applies to all residents and staff involved in resident assessment, supervision, and safety. Elopement is defined as: A resident who is cognitively impaired., leaves the facility unsafety or unknowingly, placing themselves at risk for serious harm. DCO stated Resident 175 was not at risk for elopement and acknowledged the policy applies to all residents.An Immediate Jeopardy (IJ-as a situation that has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was called under F689 S483.25(d)(2) which requires that each resident receive adequate supervision and assistance devices to prevent accidents) on January 7, 2026, at 9:16 PM, in the presence of the Director of Nursing (DON), the Administrator (ADMIN), and the Director of Clinical Operations (DCO). After reviewing observations, interviews and record reviews, it was determined that Resident 175 did not receive the supervision and monitoring required to maintain his safety and prevent elopement, when he left the facility unsupervised at approximately 7:30 AM of January 7, 2026. Resident 175 was later found by law enforcement approximately one mile from the facility and then transported him to the acute care hospital. An Immediate Jeopardy removal plan was requested.An IJ Removal Plan (a plan which includes interventions to remove the potential or actual harm of an immediate jeopardy situation) was reviewed and accepted on January 8, 2026, at 1:30 PM, which included the following: 1. IMMEDIATE ACTIONS TAKEN TO REMOVE THE JEOPARDYThe facility implemented the following actions immediately upon identification of theImmediate Jeopardy to ensure resident safety:Resident 175 was found outside of the facility by [name of the police department] and immediately transported to the acute care hospital via ambulance on 1/7/26 as directed by them for further evaluation and treatment. Resident 175 was readmitted back to the facility same day on 1/7/26 with plan of care updated by the IDT.After readmission to the facility from the acute hospital on 1/7/26, Resident 175 was placed on every hour visual monitoring by nursing staff that started on 1/7/26.A fall risk assessment was completed by the RN ADON on 1/7/26. Resident 175's plan of care is updated on 1/7/26 to address resident's risk for elopement.A Wander/Elopement Risk Evaluation was completed by the RN ADON on 1/7/26.Resident 175's plan of care is updated on 1/7/26 to address resident's risk for elopement.The DOR conducted a Rehab Post Fall Screen on 1/7/26 to continue PT, OT and ST program.Resident 175's individualized care plan was immediately updated on 1/7/26 to reflect:Staff to provide contact guard assist with transfers and utilize use of front wheel walker or wheelchair for ambulationStaff started on every hour visual check Environmental safety interventions were implemented immediately upon readmission on [DATE], including:Bed maintained in the lowest position while Resident 175 is on bedNon-skid footwear appliedCall light applied within reachThe resident's physician and facility's Medical Director, Dr. Sepehr Golboo, was informed of the resident's readmission on [DATE] at 6:57 PM and agreed with the treatment plan.These actions were completed immediately and verified to ensure the resident was no longer at risk for serious harm. 2. SYSTEMIC CHANGES IMPLEMENTED TO PREVENT RECURRENCETo address systemic issues and prevent recurrence, the facility implemented the followingactions:The DON, ADON, MDS Nurse, RNs and LVNs conducted a facility-wide audit to identify all residents at risk for falls on 1/7/26 to 1/8/26. A total of 112 residents at high-risk for falls; Care plans were verified to address the risk for fall.The DON, ADON, MDS Nurse, RNs and LVNs conducted a facility-wide audit to identify all residents at risk for elopement on 1/7/26 to 1/8/26. A total of 6 residents at high risk for elopement; Care plans were verified to address the risk for elopement.RN Supervisors to conduct head count of residents during shift-to-shift endorsements to identify any missing residents.Maintenance supervisor or designee to check emergency exit doors alarm system installed in each exit door daily for proper functioning and document result in the emergency exit door alarm check log.When an emergency exit door alarm is activated, facility staff must immediately inspect the door, determine the cause of the alarm, and address the issue. The RN Supervisor, or designee, shall verify that the exit door is fully secured and that the alarm system remains engaged and operational. When a resident is found right outside the emergency exit alarmed door, the facility staff must redirect the resident to get back in.3. STAFF EDUCATION AND TRAININGOn 1/7/26, The Director of Staff Development immediately started providing in-services and education to All direct care staff to be completed on 1/8/26 regarding the following: o Fall Prevention and Management o Safety and Supervision of the Resident o Identifying Change of Condition Occurrence & Reporting o Charting/Documentation4. MONITORING TO ENSURE ONGOING COMPLIANCEAll fall and elopement incidents and near-misses are reviewed daily by IDT.The Director of Nursing or Designee will conduct weekly audits of fall and elopement incidents for 30 days, followed by monthly audits thereafter.As an additional safety measure, the facility will install an enhanced security system to further ensure resident safety. While awaiting installation, staff will be assigned on a rotational basis to provide continuous monitoring of the front entry door to ensure close supervision of resident movement.The Maintenance Supervisor will be responsible for installing a door alarm on the front entry door. The alarm will be activated in conjunction with the locking of the front entry door during secured hours, defined as 8:00 PM to 5:00 AM.The RN Supervisor will be responsible for verifying that the front entry door is properly locked and the alarm activated at the designated times and for ongoing oversight to ensure compliance.The facility will review with QAPI committee any elopement or reportable missing person occurrence report for the month for review or recommendation to follow up on. The NHA or designee will be responsible to follow up on any recommendations.5. RESPONSIBLE PARTIESAdministrator / Executive DirectorDirector of NursingCharge Nurses and SupervisorsDirect Care Staff The acceptable IJ removal plan was verified with the facility to be implemented through observations, interviews and record review. The IJ was removed on January 8, 2026, at 8:40 PM, in the presence of DON, ADMIN, and DCO.

Based on observation, interviews and record review, the facility failed to ensure residents were provided with a dignified dining experience for two of six sampled residents (Resident 94 and 185) when Certified Nursing Assistants (CNA 1, 2, and 4) were standing over residents while assisting them to eat. This failure has the potential to cause Residents 94 and 185 to feel disrespected and negatively affect their psychosocial well-being and individuality. 1.During a review of Resident 94's clinical records, the admission Record (a document that gives a summary of resident information) indicated, Resident 94 was admitted to the facility on [DATE], with diagnoses which included, dysphagia (difficulty swallowing), hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (one side of the body is paralyzed or weak, often due to a stroke affecting the opposite brain side, impacting movement, balance, and coordination). During a concurrent observation and interview on January 05, 2026, at 1:03 PM in Resident 94's room, Resident 94 was lying on bed awake. CNA 4 brought the lunch tray and placed it at Resident 94's bedside table. CNA 4 proceeded to assist Resident 94 with lunch. CNA 4 was standing over Resident 94 and stated there was no chair available so she (CNA 4) can feed Resident 94 standing up. CNA 4 did not go out of the room to look for available chair During a concurrent interview and record review on January 6, 2026, at 1:34 PM, with the Director of nursing (DON), the DON reviewed the facility policy and procedure (P&P) titled, [name of the facility] Resident Rights Policy & Procedure undated. The P&P indicated, .Policy: [name of the facility] is committed to protecting and promoting the rights of all residents in accordance with CMS regulations (42 CFR 483.10) and California Title 22. Residents are treated with dignity, respect and individuality and are supported in exercising the rights while residing at the facility. Procedure. 1. b Care is provided in a manner that maintains privacy, dignity, and individuality. The DON acknowledged the policy and stated CNAs can feed standing up if the bed is up and the resident's head elevated. The DON further stated, usually we don't put chairs in resident's room. 2. During a review of Resident's 185 admission Record (clinical record with demographic information), the admission record indicated Resident's 185 was admitted on [DATE], with diagnoses that included epilepsy (a chronic brain disorder) and cerebral infarction (the death of brain tissue due to a sudden blockage of a blood vessel). During a concurrent observation and interview on January 5, 2026, at 12:40 PM, with a Certified Nursing Assistant (CNA 1) in Resident 185's room, CNA 1 raised Resident 185's bed to his waist level, positioned himself next to the resident, placed the bedside table in front of the resident, and proceeded to feed the resident while standing. CNA 1 stated, I normally stand while feeding residents, but it is not right, and I am not supposed to be standing while feeding. During a concurrent observation and interview on January 6, 2026, at 8:29 AM, with CNA 2 in Resident 185's room, Resident 185 bed was in the low position while CNA 2 was standing next to the resident, feeding her. CNA 2 acknowledged and stated she should not be standing while feeding residents. During a concurrent observation and interview on January 6, 2026, at 8:35 AM, with a Licensed Vocation Nurse (LVN 4) in Resident 185's room, LVN 4 raised the bed and stated CNA 2 should not be standing when feeding a resident and should be sitting to promote respect and dignity. During a concurrent interview and record review on January 7, 2026, at 8:08 AM with the Director of Nursing (DON), the facility policy and procedure (P&P), titled, [name of facility] Resident's Right Policy and Procedure, undated, was reviewed. The P&P indicated, .Policy: [name of facility] is committed to protecting and promoting the rights of all residents in accordance with CMS regulations (42 CFR 483.10) and California Title 22. Residents are treated with dignity, respect and individuality and are supported in exercising the rights while residing at the facility. Procedure .1. Rights Dignity, Respect and Quality of Life.a. Residents are treated with courtesy, consideration, and respect at all times.b. Care is provided in a manner that maintain privacy, dignity, and individuality. The DON acknowledged the policy was not followed and further stated it should have been.

Based on interview and record review, the facility failed to ensure the care plan (a personalized, written document that details an individual's health conditions, specific needs, goals, preferences, and the support required to achieve them) for two of ## sampled residents (Residents 162 and 23) was developed and implemented when: Resident 161 did not have a care plan allowing medication at his bedside.Resident 23 did not have a care plan for smoking.These failures had the potential for Resident 161 and Resident 23 to be at risk of injury, due to delayed intervention and supervision.1.During a review of Resident 161 admission Record (clinical record with demographic information), the admission Record indicated, Resident 161 was admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (a progressive lung condition that makes breathing difficult), hypertensive heart disease (heart problems caused by long-term high blood pressure), and acute kidney failure (sudden inability of the kidneys to filter waste and balance fluids).During a concurrent observation and interview on January 5, 2026, at 9:36 AM, with a Licensed Vocational Nurse (LVN 5), in Resident 161's room, Resident 161 was sitting on his bed with a bottle of Tums Oral Tablet Chewable (medication used to quickly relieve heartburn, acid indigestion, sour stomach, and upset stomach) at bedside. LVN 5 stated the Tums should not be kept at bedside.A continued interview on January 5, 2026, at 9:40 AM, with LVN 5, LVN 5 stated there is no care plan developed to keep medication at bedside for Resident's 161.During a review of Resident's 161's physicians' orders, dated December 18, 2024, it indicated, Tums Oral Tablet Chewable. Give 500 mg (milligram a unit of measurement for medication dosages) by mouth every 12 hours as needed for GERD (Gastroesophageal Reflux Disease- chronic digestive disorder where stomach acid frequently flows back into the esophagus, causing symptoms like heartburn) give 2 tablets.During a concurrent interview and record review on January 7, 2026, at 8:15 AM with the Director of Nursing (DON), the facility policy and procedure (P&P), titled, Medication Storage and Labeling Policy & Procedure (Title 22), undated, was reviewed. The P&P indicated, .1. General Storage Requirements.c. Access to medications is limited to authorized licensed personnel only. The DON acknowledged the policy was not followed and a care plan should have been created.2.During a review of Resident 23's admission Record, the admission Record indicated, Resident 23 was admitted on [DATE], with diagnoses that included T2DM (diabetes mellitus 2 - when the body does not produce enough insulin), chronic kidney disease (gradual loss of kidney function where damaged kidneys cannot properly filter waste and fluid from the blood) and hypertension (high blood pressure).During a concurrent observation and interview on January 5, 2026, at 10:45 AM, with Resident 23, in Resident 23's room, Resident's 23 was sitting on his bed. Resident 23 stated he smokes outside, at the designated area, and gets his cigarette from nurses on duty. During a concurrent observation and interview on January 6, 2026, at 2:00 PM, with Activities Specialist (AS 1) and the Activity Director (AD), Resident 23 was observed outside the Activities' room smoking unsupervised. AS 1 confirmed that Resident 23 had been smoking outside unsupervised. AD stated she was not aware there was no care plan for Resident 23 for unsupervised smoking.During a concurrent interview and record review on January 6, 2026, at 4:37 PM, with the MDS Director (Resident Assessment Coordinator- who oversees the federally mandated assessment process for nursing home residents, ensuring accurate documentation for care planning), the MDS Director stated during the admission assessment, Resident 23 denied that he is a smoker. The MDS Director further stated Resident 23 should have been re-assessed, and a care plan should have been created.During a concurrent interview and record review on January 7, 2026, at 8:15 AM, with the Director of Nursing (DON), the facility policy and procedure (P&P) titled, Rialto Post Acute Smoking and Tobacco Use Policy & Procedure, undated, indicated, .8. Documentation and Care Planning.Smoking status and safety assessments are documented.Supervision requirements and restrictions are included in the resident's care plan. The DON acknowledged the policy was not followed and a care plan should have been created.

Based on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications (medications that are controlled by government due to potential abuse or addiction) for one of six sampled medication carts (Medication Cart A-1) with narcotics when the Narcotic Count Sheet (a narcotic log used by the facility to verify counting of controlled medications at the change of shift, signed by the incoming and outgoing licensed nurses) had one missing signature for the outgoing licensed nurse on January 2, 2026,This failure had the potential to result in drug diversion (illegally obtaining or using prescription drugs), undetected medication discrepancies, or medication errors which could compromise the health and safety for the vulnerable population of 159 residents.During a concurrent observation and interview on January 6, 2026, at 9:58 AM with a Licensed Vocational Nurse (LVN 8), in Wing A at Medication Cart A-1, the Narcotic Count Sheet for January 2026, was reviewed. The Narcotic Count Sheet had one missing signature for nurse 1 (the outgoing nurse), on January 2, 2026, night shift. LVN 8 verified the missing signature and further stated the log should have been signed by two LVNs verifying the correct number of narcotics in the medication cart.During a concurrent interview and record review on January 6, 2026, at 2:06 PM with the Director of Staff Development (DSD), the facility's policy and procedure (P&P) titled, [name of the facility] Controlled Substances (Narcotic) Signing Policy & Procedure, dated January 14, 2025, was reviewed. The P&P indicated, . 5. Shift- to- Shift Count. a. Controlled substances are counted and reconciled at every shift change. b. two licensed nurses perform the count and verify accuracy. The DSD stated that the P&P was not followed. The DSD further stated the counts should have been verified by both nurses, and a missing signature could indicate an incorrect count or missing narcotic and should have been reported to the Director of Nursing (DON).During a concurrent interview and record review on January 7, 2026, at 12:45 PM, with DON, the facility's P&P titled, [name of the facility] Controlled Substances (Narcotic) Signing Policy & Procedure, dated January 14, 2025, was reviewed. The P&P, indicated, . 5. Shift- to- Shift Count a. Controlled substances are counted and reconciled at every shift change. b. two licensed nurses perform the count and verify accuracy. The DON stated that the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure storage of medications were properly secured for one of 12 medication carts (Medication Cart A-1) when one Licensed Vocational Nurse (LVN 7) left the medication cart keys, on top of the medication cart, unattended in the hallway in Wing A. This failure had the potential to result in unauthorized access to medications, including controlled substances, which could result in medication diversion (illegally obtaining or using prescription drugs), unauthorized access, misuse, and harm to a highly vulnerable population of 159 residents.During record review of Resident 96's admission Record (contains demographic and medical information), it indicated Resident 96 was admitted to the facility on [DATE], with diagnoses which included peripheral venous insufficiency (a circulation problem where veins, usually in the legs, struggle to send oxygen-poor blood back to the heart), congestive heart failure (the heart muscle can't pump blood efficiently enough to meet the body's needs, causing fluid to back up in the lungs, legs, and other tissues) and urinary tract infection ( bacterial infection in any part of your urinary system). During a concurrent observation and interview on January 7, 2026, at 5:25 AM, with LVN 7, LVN 7 was in the hallway in Wing A preparing medication, LVN 7 then proceeded to go inside Resident 96's room to discuss medication. The medication keys used to unlock Medication Cart A-1 were left on top of the medication cart unattended, outside Resident 96's room. LVN 7 verified the keys left on top of Medication Cart A-1 were the keys to open that medication cart LVN 7 further stated, The keys should not be left unattended but are left inside the binder on the cart so other LVNs can open the cart if they need to.During a concurrent interview and record review on January 7, 2026, at 12:38PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, [name of the facility] Medication Cart Key Control Policy, dated January 14, 2025, was reviewed. The P&P indicated, Key Control Guidelines. Each medication cart key must remain with the assigned staff member at all times. Keys must never be left unattended, including on carts, desks, or in the drawers. The DON stated the policy was not followed. The DON further stated it was important for staff to store the keys on them to prevent unassigned personnel from gaining access to the medications.

Based on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were followed when: One Certified Nursing Assistant (CNA 6) entered Resident 184's room, without performing hand hygiene and used the same gloves after emptying Residents 67's urinal (portable container, often bottle-shaped used to collect urine for urination) to turn off the call light,Resident 184's intravenous catheter (IV- a small, flexible plastic tube that a healthcare provider puts into a vein to deliver fluids, medicine, nutrition, or blood directly into the bloodstream) on the left wrist was found unlabeled.Resident 89's gastrostomy tube (g-tube- a feeding tube placed through the abdomen directly into the stomach, used to deliver nutrition, fluids, and medicine) water bag (a bag used to hold and deliver water through the g-tube) was found hanging more than 24 hours (per manufacturer's instructions to be discarded after 24 hours). These failures had the potential to result in cross-contamination (spreading harmful bacteria and germs from one person, surface, or object to another) causing a preventable infection to 159 highly vulnerable residents whose health conditions were already compromised. 1.During a review of Resident 67's admission Record (contains demographic and medical information), it indicated Resident 67 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (a common infection caused by germs, usually bacteria, getting into any part of your urinary system and multiplying), and Extended Spectrum Beta Lactamase (ESBL) resistance (bacteria that is resistant to some antibiotics, making the infections harder to treat). During a review of Resident 184's admission Record, it indicated Resident 184 was admitted on [DATE], with diagnoses which included systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction (inflammation throughout the entire body, without damage to major organs) and abnormalities of gait and mobility (deviation from a normal, smooth, and efficient walking pattern). During a concurrent observation an interview on January 6, 2026, at 10:49 AM, with CNA 6, CNA 6 was emptying out Resident 67's urinal with both hands, into a shared restroom. CNA 6 proceeded to walk behind the privacy curtain in Residents 184's room, holding Residents 67's urinal in her right hand, wearing the same gloves. CNA 6 proceeded to turn off the mounted wall call light (a nurse call button) in Resident 184's room with her left hand, opened the privacy curtain (used to divide the room) with the same gloves, and then return to Resident 67's urinal at his bedside. CNA 6 acknowledged and stated she should have returned Resident 67's urinal, removed gloves, and performed hand hygiene before answering Resident 184's call light. CNA 6 further stated the infection control process was not followed when handling Resident 67's urinal, placing the residents at risk for cross-contamination. During a concurrent interview and record review on January 7, 2026, at 12:49 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, [name of the facility] ADL Provision Policy & Procedure (Including Emptying of Urinals), dated January 14, 2025, was reviewed. The P&P indicated, .emptying of urinals, is provided in accordance with infection control standards. 3. Use and Emptying of Urinals. b. Urinals are emptied promptly into designated toilets or hoppers only. f. Hand hygiene is performed immediately after task completion. 4. Infection Prevention During ADLs. a. Hand hygiene is performed before and after resident contact. The DON stated the P&P was not followed. The DON further stated the CNA should have disinfected her hands before helping the other residents for infection control. 2. During a review of Resident 184's admission Record, it indicated Resident 184 was admitted on [DATE], with diagnoses which included systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction (inflammation throughout the entire body, without damage to major organs) and abnormalities of gait and mobility (deviation from a normal, smooth, and efficient walking pattern). During a concurrent observation and interview on January 6, 2026, at 11:02 AM, with License Vocational Nurse (LVN 1), in Resident 184's room, Resident 184's IV label was found undated. LVN 1 verified that there was no date, time of insertion, or staff initials labeled on the dressing. LVN 1 further stated that IV should be labeled, and it was the Registered Nurse's (RN) responsibility to ensure the IV dressing is labeled. During a subsequent observation and interview on January 6, 2026, at 11:03 AM, with the RN 2, in Resident 184's room, Resident 184's IV dressing was checked. The RN 2 verified Resident 184's IV dressing was unlabeled. During a concurrent interview and record review on January 7, 2026, at 1:03 PM, with the DON, the facility's &P titled, [name of the facility] IV Care and Maintenance Policy & Procedure, dated January 14, 2025, was reviewed. The P&P indicated .3. Dressing & Tubing Management a. IV dressings are clean, dry, intact, and dated. The DON stated the policy was not followed, and further stated that all IVs should be labeled, no exceptions. 3. During a review of Resident 89's admission Record (clinical record with demographic information), the admission Record indicated, Resident 89 was admitted on [DATE], with diagnoses that included hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body, affecting the arm, leg, or face, often resulting from brain injury) and type 2 diabetes mellitus (T2 DM - a chronic condition where the body either does not produce enough insulin) and gastrotomy tube (G-tube - a soft tube placed through the belly wall directly into the stomach, creating a shortcut to deliver food, liquids, and medicine). During a review of Resident's 89's physicians' orders, dated December 18, 2024, it indicated an order for, Enteral Feeding Order every shift for tube feeding Fibersource HN (nutritionally complete, high-protein, fiber-rich liquid formula for tube feeding) 1.2 Kcal (Kilocalories- unit of energy) running at 85 ml (milliliter - unit of volume)/hr (hour) for 20 hrs to provide 1700 ml/2040 Kcal via enteral pump (a medical device that accurately delivers liquid nutrition directly into a patient's stomach). Enteral Feed Order: every shift water flush via [brand name] pump (a device used for enteral feeding, delivering liquid nutrition (and sometimes hydration/thick formulas) directly into a patient's stomach) 40 ml every hour x (times) 20 hours to complete 800 ml QD (once a day) via G-tube, for hydration. During an observation on January 5, 2026, at 10:00 AM, in Resident's 89's room, Resident 89 was lying in bed, awake, with the head of the bed slightly elevated. Resident 89 was connected to a feeding pump that was turned off. There was an enteral formula [brand of formula] bag labeled with a date of January 4, 2026, at 2100 (9:00 PM) and a hydration bag containing water hanging on the pole next to Resident 89's bed, the water bag was dated January 3, 2026 (approximately 37 hours expired), at 21:40 (9:40 PM). During a concurrent observation and interview on January 5, 2026, at 10:19 AM, with the License Vocational Nurse (LVN 5) in Resident 89's room, LVN 5 stated the enteral formula, and the water hydration bags were hung by the previous nurse. LVN 5 verified the water bag was dated January 3, 2026 (1 day and 13 hours expired). LVN 5 further stated the water bag should not be used for more than 24 hours as indicated in the manufacturer instruction on the bag. During a review of [brand name] water flush bag 1000 ml (a separate bag) manufacturer's instruction, it indicated, The feeding set (bag and tubing, including the flush bag) itself must be replaced every 24 hours. During an interview on January 7, 2026, at 8:05 AM, with the Director of Nursing (DON), the DON stated that the facility does not have a policy specifying the required hang time for G-tube water bags, but nurses should follow the doctor's orders and the manufacturer's instructions. The DON acknowledge that the manufacturer's instruction was not followed.

Based on observation, interview, and record review, the facility failed to ensure confidentiality of resident's Electronic Health Records (EHR- medical records kept on a computer system) when a Licensed Vocational Nurse (LVN 7) left Resident 96's health information on the computer screen, unattended and visible to the public in the hallway. This failure had the potential to place Resident 96's private information to be at risk of being disclosed by an unauthorized person. During a review of Resident 96's admission Record (contains demographic and medical information), it indicated Resident 96 was admitted to the facility on [DATE], with diagnoses which included peripheral venous insufficiency (a circulation problem where veins, usually in the legs, struggle to send oxygen-poor blood back to the heart), congestive heart failure (the heart muscle cannot pump blood efficiently) and urinary tract infection (bacterial infection in any part of your urinary system).During a concurrent observation and interview on January 7, 2026, at 5:36 AM, with LVN 7, LVN 7 went inside Resident 96's room to administer medication. The computer screen was left open and unattended on the medication cart, in the hallway in Wing A, with Resident 96's name, picture, medication administration record, vital signs and weight available for anyone to view. LVN 7 acknowledged and verified the private health information presented on the unattended screen. When asked who is responsible for keeping resident information confidential, LVN 7 stated that it is not my responsibility for something, someone else sees.During a concurrent interview and record review on January 7, 2026, at 12:42 PM, with Director of Nursing (DON), the facility's policy and procedure (P&P) titled, [name of the facility] Computer Privacy Screen Policy, dated January 14, 2025, was reviewed. The P&P indicated, Guidelines. Staff must log off or lock computers when unattended. The DON stated that the policy was not followed and his expectation is for the staff to maintain resident's privacy.

Based on observation, interview, and record review, the facility failed to ensure call light (a device that allows patients to communicate with nursing staff when they need assistance) was within reach for two of 32 sampled residents (Resident 24 and 120).This failure had the potential to place Residents 24 and 120 at risk of harm when they are unable to summon staff during an emergency or when needing assistance. 1.During a review of Resident 120's admission Records (a document that gives a summary of resident information), the admission Records indicated, Resident 120 was admitted to the facility on [DATE], with diagnoses which included, end stage renal disease, (chronic kidney disease where kidneys lose almost all function) and history of falling. During a concurrent observation and interview on January 05, 2026, at 11:23 AM, in Resident 120's room, Resident 120 was lying on bed awake. The call light was not located on the bed. Resident 120 stated she did not know where the call light was. Resident 120 looked around the top and under the bed cover but was unable to locate the call light device. Certified Nursing Assistant (CNA 5) was at bedside and looked for the call light device on Resident 120's bed and was unable to find it. CNA 5 stated, she was not sure where the call light device was. CNA 5 then continued to look for the call light and found it on top of Resident 120's roommate oxygen tank. CNA 5 picked up the call light and placed it on resident 120's bed and stated the call light should be on the resident's bed. During concurrent interview and record review on January 6, 2026, at 8:51 AM, with the Director of nursing (DON), the DON reviewed the facility policy and procedure (P&P) titled [name of the facility] Call Light Policy and procedure, undated. The P&P indicated, . 1 Call lights are placed within reach of the resident at all times including after care, repositioning, or transfers. The DON stated the expectation is for all the staff to ensure the call lights are within easy reach of the residents. The DON acknowledged and stated that the policy was not followed. 2. During a review of Resident 24 admission Record clinical record with demographic information), the admission record indicated, Resident 24 was admitted on [DATE], with diagnoses that included bilateral primary osteoarthritis (a degenerative joint disease where protective cartilage wears down, causing bones to rub, leading to pain, stiffness, swelling, and reduced mobility), hypertension (high blood pressure) and depression (serious mood disorder causing persistent sadness, loss of interest, and impacting daily life). During a concurrent observation and interview on January 5, 2026, at 4:05 PM, in Resident's 24 's room, Resident 24 was sitting at the edge of the foot of the bed. Resident 24 was crying and stated she needed assistance to go out of the room, but she could not find her call light. Resident 24's call light was located on the head of the bed and placed under a pillow. During an interview on January 5, 2026, at 4:10 PM, with a License Vocational Nurse (LVN 2), LVN 2 stated the call light must be within resident's reach and should be accessible to them. During a concurrent interview and record review on January 7, 2026, at 7:50A M, with the Director of Nursing (DON), the facility policy and procedure (P&P), titled Call light Policy and Procedures, undated, indicated, .1. Call lights are placed within reach of the resident at all times, including after care, repositioning, or transfers. DON acknowledged the policy was not followed and should have been.

Based on observation, interview, and record review, the facility failed to ensure a physician-ordered therapeutic diet was provided for one of six sampled resident (Resident 7), when nutritional supplements (Health shake and Sherbert) listed on the meal ticket were omitted in the lunch tray.This failure had potential to place Resident 7 at risk for weight loss and nutritional decline.During a review of Resident 7's admission Record (a document that gives a summary of resident information), the admission Record indicated Resident 7 was admitted to the facility on [DATE], with diagnoses which included, type 2 diabetes mellitus with hyperglycemia (blood sugar levels are consistently too high due to the body's inability to use insulin effectively (insulin resistance)), essential hypertension (high blood pressure with no single, identifiable medical cause) and anemia (a condition where your blood lacks enough healthy red blood cells).During a concurrent observation and interview on January 05, 2026, at 12:30 PM, in Resident 7's room, Certified Nursing Assistance (CNA 3) served lunch tray. The lunch meal ticket for Resident 7, dated January 5, 2026, indicated, Tray Instructions: 4 oz (ounce) Health shake and sherbert ice cream. CNA 3 stated health shake and ice cream were not served; and it did not come from the kitchen. Resident 7 stated, she did not receive health shake or Ice cream. CNA 3 further stated, I did not know she gets it every day.During observation on January 5, 2026, at 12:50 PM, CNA 3 removed Resident 7's lunch tray out of the room.During record review reviewed Resident 7 physician's order, dated November 14, 2025, indicated Health Shake three times a day for weight management 4 oz with meals, Sherbert BID (two times) (lunch/Dinner two times a day for weightDuring a concurrent interview and record review on January 6, 2026, at 3:02 PM, with Director of Dining (DD), Dietician Consultant (DC) and DON reviewed the facility's policy and procedure (P&P) titled, [name of the facility] Physician Order policy & Procedure, undated. The P&P indicated, .4. Implementation of Orders, a. Orders are implemented promptly and carried out exactly as prescribed. The DD stated staff should have followed what is on the meal ticket. The DC stated the kitchen staff should serve what was ordered by the doctor.

Based on observation, interview and record review, the facility failed to cross check discharge medications according to the facility policy for one of four residents (Resident 4), when a Licensed Vocational Nurse (LVN 1) improperly transferred Resident 4's Atorvastatin (a medication intended to lower cholesterol and prevent strokes, heart attacks, and chest pain), as well as Eliquis (a blood thinner that reduces blood clotting) to the caregiver of Resident 1 during discharge, despite Resident 1 not being prescribed these medications. This failure led to the loss of medications and increased the risk of a stroke for Resident 4, while also exposing Resident 1 to potential adverse effects from the medications, which could result in injury and harm. Findings: During a review of Resident 4's clinical record, the face sheet (contains demographic and medical information), indicated Resident 4 was admitted on [DATE], with diagnoses that included hypertensive heart disease with heart failure (the heart is failing to pump blood effectively, and this is due to long-term high blood pressure). During a review of the clinical record for Resident 4 ' s the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated March 12,2025, indicated, Resident 4 ' s score was a 13, which indicated Resident 4 had no mental impairment. During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses that included Encephalopathy (a change in how your brain functions), Cirrhosis of Liver (a lot of scars on your liver making it hard for the liver to do its job). During a review of the clinical record for Resident 1 ' s the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated March 12,2025, indicated, Resident 1 ' s score was a 12, which indicated Resident 1 had moderate cognitive impairment (there are significant changes in thinking and memory that begin to interfere with daily life and independence). During a concurrent telephone interview and record review on May 16, 2025, at 10:46 PM, with the LVN 1, the LVN 1 stated on the day of discharge, she inadvertently provided two medication carts belonging to Resident 4 to the caregiver of Resident 1, who had come to pick up Resident 1. She handed over two carts, one of which contained Atorvastatin, while she overlooked the other medication. She further stated that the Social Worker Director (SWD 1) later reported that the family indicated the second medication was Eliquis. She acknowledged her mistake and recognized that it was unacceptable. During a review of the medication records for Residents 1 and 4, she confirmed that Resident 1 is not prescribed Atorvastatin or Eliquis, whereas Resident 4 is. During a review of Resident 4 ' s Medical Administration Record (MAR) for May of 2025, it was noted that Atorvastatin Calcium oral tablet 40 mg (a unit of measurement of mass in the metric system) is prescribed to be taken as one tablet by mouth at bedtime to manage hyperlipidemia (a condition marked by elevated lipid levels in the bloodstream). Additionally, Eliquis oral tablet 2.5 mg (Apixaban) is to be administered as one tablet by mouth twice daily for the prophylaxis (intervention measure) of deep vein thrombosis (a condition characterized by the formation of a blood clot in a major vein, typically in the leg). During a review of Resident 1 ' s MAR for May 2025, it was noted that neither Atorvastatin nor Eliquis was included in the list of prescribed medications for Resident 1. During a telephone interview on May 16, 2025, at 11:14 PM with the SWD 1, the SWD 1 stated that the sister of Resident 1 reported that Resident 1 was sent home with medications that were prescribed to another resident, specifically Atorvastatin and Eliquis, which Resident 1 does not take. Upon receiving this information, she immediately notified the Director of Nursing (DON 1). During a telephone interview on May 16, 2025, at 11:21 PM with DON 1, DON 1 stated that resident 1 was discharged on Friday along with the medications of Resident 4, specifically Atorvastatin and Eliquis. She indicated that she had reached out to the family, who were under the impression that Resident 1 had been administered Eliquis during his stay at the facility, which led them to take Resident 1 to the hospital due to noticeable bruising on his skin. She assured the family that Resident 1 had never received the medications while in the facility, as it had not been prescribed. She emphasized that LVN 1 ' s failure to verify the medications is unacceptable. During a concurrent telephone interview and record review on May 16, 2025, at 1:48 PM, with DON 1, the facility Policy & Procedure (P&P) titled, Discharge Summary and Plan, dated December 2016 was reviewed. The P&P indicated, .3. As part of the discharge summary, the nurse will reconcile all pre-discharge medication with the resident's post-discharge medications. The medication reconciliation will be documented . DON 1 confirmed the accuracy of policy as outlined.

Based on interview and record review, the facility failed to uphold the dignity of one of three residents (Resident 1) when two Certified Nursing Assistants (CNAs) were observed by a surveyor exposing resident 1 ' s body while assisting with transferring Resident 1 in bed. This failure has the potential to expose clinically compromise Resident 1 to the public when they pass by the room. Findings: During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses that included Alzheimer ' s dementia (a general term for a decline in memory and other cognitive abilities that interfere with daily life). During observation on April 30, 2025, at 12:23 PM in Resident 1 ' room, the surveyor noted that two CNAs (CNA 1 and CNA 2) were assisting Resident 1 whose abdomen and diaper were exposed, as the curtain for privacy was not drawn and the door was left wide open. During an interview on April 30, 2025, at 12:26 PM with CNA 1 and CNA 2, CNA 1 expressed that it is inappropriate to lift Resident 1 while Resident 1 brief and abdomen are visible. She indicated that the curtain should have been drawn. Additionally, she emphasized that exposing Resident 1 compromises his dignity. CNA 2 agreed with CNA 1's assessment. During interview on April 30, 2025, at 2:10 PM with the Director of Nursing (DON 1), the DON 1 emphasized that CNA 1 and CNA 2 are failing to uphold resident privacy, which is a violation of established guidelines and is deemed unacceptable. During a review of Facility Policy and Procedure (P&P) dated February 2020, titled, Quality of Life - dignity indicated, .1. Residents are treated with dignity and respect at all times .

Based on interview, and record review, the facility failed to provide one-on-one supervision, (continuous monitoring of residents by a staff for safety reason. This may involve staff member staying within arm's reach at all times) and the wander guard (wander management system designed to help protect residents, particularly those with memory impairment, from elopement) was not applied for one of four sampled residents (Resident 1) who was a recent admit and on parole. These failures resulted in Resident 1's elopement ( refers to a resident leaving the facility without permission or staff knowledge) and possibly contributed to his death. Findings: During a review of Resident 1's Admission Record (contains demographic and medical information), it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (gradual decline in memory, thinking and other cognitive functions) with agitation (a state of being restless, anxious, or stirred up, like feeling overly excited or tense). During a review Resident 1's Internal Medicine Admission History and Physical Note from the General Acute Care Hospital (GACH), with a date of service of [DATE], it indicated Resident 1 .with dementia, recently released from jail, here for placement due to lack of caregivers, unable to care for self . During a review of Resident 1's History of Present Illness (HPI) from the GACH, with a date of service of [DATE], it indicated Resident 1 has a history of major cognitive disorder (mental health conditions that primarily affect cognitive abilities like memory, learning, and problem solving) and was sent to the emergency department due to concerns of dementia. Resident 1 upon evaluation did not understand why he had to come to the emergency department and repeatedly stated, I'm here because you know I was from there and then there's other people over there. Further evaluation suggested Resident 1 believed he was a [AGE] year-old from the 15th century. Social Worker (SW) contacted Resident 1 niece, and she shared that Resident 1 was previously residing in a skilled nursing facility (SNF is a place where people received medical care and rehabilitation after a hospital stay or injury) but had run away and ended up in jail for a parole violation. During a review of Resident 1's Notice of Admission from the GACH, dated [DATE], there was a remark at the very top of the document, which indicated, .needs a wander guard. During a review of Resident 1's Order Summary Report, which includes active orders as of [DATE], it indicated, Apply wanderguard [wander guard] to prevent resident from going out of the facility unassisted. Monitor presence of wanderguard [wander guard] every shift every shift. During a review of Resident 1's Nursing Progress Notes, dated [DATE], at 5:44 PM, documented by Licensed Vocational Nurse (LVN) 1, it indicated, Apply wanderguard [wander guard] to prevent resident from going out of the facility unassisted. Monitor presence of wanderguard [wander guard] every shift every shift wander guard not available. During a review of Resident 1's Nursing Progress Notes, dated [DATE], at 9:29 AM, documented by LVN 2, it indicated On rounds resident was found to be out of bed and absent from facility grounds. Resident was last seen at 0900 (9:00 AM). SB PD [San [NAME] Police Department] notified. Voicemail left with PO [Parole Officer] During a review of Resident 1's Nursing Progress Notes, dated [DATE], at 9:54 AM, documented by Registered Nurse (RN 1), it indicated, Called 911 at 9:30 AM informed of patient [resident] missing, last seen at 9 AM During a review of Resident 1's Nursing Progress Notes, dated [DATE], at 6:38 PM, documented by Registered Nurse Supervisor (RN Supervisor), it indicated, I spoke with [Name of the police investigator] police investigator on the case. To get more information from admission and diagnosis hx [history].The coroner case number is Coroner case [case number]. During a review of Resident 1 ' s Nursing Progress Notes, dated [DATE], at 9:34 AM, documented by Director of Social Services (SW), it indicated, Social services called [Name of responsible party] to follow up. She [responsible party]verbalized that the police found him deceased at a bus stop. Social services expressed condolences and will follow up as needed. During a review of Resident 1's Wander/Elopement Assessment Risk Evaluation (form to complete to determine if an individual requires necessary safety intervention), dated [DATE], it indicated Resident 1 was not at risk for elopement or wandering. The form was completed the same day Resident 1 eloped, and three days after he was admitted to the facility. During an interview on [DATE], at 3:45 PM, with the Director of Nursing (DON), the DON stated the nursing staff attempted to apply the wander guard on Resident 1 during his admission on [DATE]. The DON further stated the wander guard was not working properly so the facility initiated one on one (1:1) monitoring by assigning a Certified Nursing Assistant (CNA) to monitor Resident 1. Upon request, the DON was unable to provide documented evidence to show the one-on-one monitoring was provided to Resident 1. The DON confirmed the wander guard was never used on Resident 1. During an interview on [DATE], at 12:50 PM, with the DON, a request was made to interview the CNA who was assigned to supervise Resident 1 prior to his departure from the facility without staff noticing. The DON stated no one was assigned to Resident 1 at the time. The DON further stated the night supervisor was responsible for monitoring Resident 1 and left around 8:00 AM, after this point, no one else had been assigned to monitor Resident 1, and that is when Resident 1 left. During a concurrent interview and record review on [DATE], at 1:10 PM, with the DON, the facility's undated document titled, Order Listing Report was reviewed. The Order Listing Report indicated there were eight (8) residents who were at risk for elopement. The DON confirmed the list of these 8 residents assessed and identified by the facility to be at risk for elopement. During a telephone interview on [DATE], at 2:37 PM, with a SB PD Staff (SB PD Staff 1), Staff 1 stated he is only able to disclose limited information over the telephone regarding Resident 1 ' s case, the records indicate Resident 1 was reported missing on [DATE], at 9:27 AM, and was found deceased by a responding police officer at 12:48 PM, roughly 3 hours after reported missing at [address where Resident 1 found] which is about 2.5 miles away from the facility. The staff indicated that if more detailed information is needed, a request should be made by mail or online. However, obtaining the request information may take significant amount of time. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents dated [DATE], the P&P indicted, .Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment During a review of the facility's P&P for Elopement and Wandering, dated February 29, 2024, it indicated, . A Wander/Elopement assessment will be completed on all residents upon admission to the facility . An Immediate Jeopardy (IJ represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) was called under F 689 S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents) on [DATE], at 9:29 AM, after confirming Resident 1 did not receive supervision and monitoring required to keep Resident 1 safe on [DATE], when Resident 1 was found to have eloped from the facility and had been found by the police, deceased at a bus stop, which was 2.5 miles away from the facility, on [DATE], at 12:48 PM. (Roughly 3 hours after he was identified as eloped). An IJ was called in the presence of the Admin, DON, and Assistant Admin, and IJ removal plan (plan which documents the immediate action an entity will take to prevent serious harm from occurring or recurring) was requested. A revised IJ Removal Plan was received and accepted on [DATE], at 2:26 PM, and included the following: 1. Immediate Corrective Action a. On [DATE], [[DATE]] the DON provided a 1:1 in service to RN regarding 1:1 monitoring intervention to ensure it is followed. b. On [DATE], [[DATE]] the DON/ADON [Assistant Director of Nursing] provided in service to the nursing staff regarding 1:1 monitoring intervention to ensure it is followed. c. Ensure all new admissions from [DATE] [[DATE]] have a completed elopement risk assessment. d. On [DATE], [[DATE]] the NHA/CEO [Nursing Home Administrator/Chief Executive Officer] conducted an inspection of current residents with wander guard to check for placement and function i. On [DATE], [[DATE]] the NHA/CEO provided in service training to Maintenance Staff regarding wander guard alarm. On [DATE], return demonstration of Maintenance by Nursing Home Administrator/ Chief Executive Officer NHA/CEO was conducted and performed well. ii. On [DATE], [[DATE]] Licensed Nursing staff along with the Maintenance, checked all residents with wander guard with the alarm door, All functioning well. Wander guard will be checked by the licensed nurses for placement attached to the resident every shift and for wander guard to be functioning daily. iii. On [DATE], [[DATE]] the licensed nurses re-evaluated the Wander/Elopement Risk of the 8 [eight] residents at high risk for Wandering/Elopement iv. 8 [eight] residents [residents ' ] high risk for wandering/elopement with wander guard v. Licensed Nurses will conduct visual check of high-risk resident for wandering/elopement every 2 hours indicating location of the resident. e. On [DATE], [[DATE]] a designated RN conducted inspection of current residents on 1:1 monitoring to ensure proper implementation. Resident [Name of Resident ] started on 1:1 monitoring every hour by assigned CNA on [DATE] [[DATE]] to determine resident's activity and provide supervision. f. On [DATE],[[DATE]] RN Supervisor conducting actual physical head count of residents during shift to shift [shift-to-shift] endorsements. i. RN Supervisor prints the facility census indicating resident's name, room number and bed assignment. ii. Outgoing RN Supervisor together with the in-coming [incoming] RN Supervisor will conduct actual physical head count during room rounds. iii. Both RN Supervisors will confirm number of actual physical head count by writing the final count in the census print out. Both RNs will sign to confirm actual head count. iv. Completed census with actual head count will be filed in the RN Supervisor binder. The Immediate Jeopardy was removed after the IJ Removal Plan was verified to be implemented through observations, interviews, and record reviews on [DATE], at 3:26 PM, in the presence of DON and ADMIN.

Based on interview and record review the facility failed to protect residents from physical abuse when a Certified Nursing Assistant (CNA 1) was observed to provide excessively rough care when: 1. The CNA 1 placed an excessive amount of food onto the fork and forcefully entering into a resident's (Resident 1) mouth. 2. The CNA 1 pushed Resident 1 into bed, and 3. The CNA 1, while pushing a resident (Resident 2), in the Geri-chair, hit Resident 2's head against the handrail along the wall. This failure had the potential to jeopardize the health, safety and psychosocial well-being of Resident 1 and Resident 2. Findings: A review of the facility document titled, :Admission Record - (name of facility commonly known as the 'facesheet') showed Resident 1 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. -[MEDICAL CONDITION] (severe) due to excess of calories, -Major [MEDICAL CONDITION], -[MEDICAL CONDITION], -[MEDICAL CONDITION], -[MEDICAL CONDITION] not due to a substance or physiological condition, and -Non-psychotic mental disorders. 1. During an interview with the Licensed Vocational Nurse Student 1 (LVNS 1), conducted on [DATE], at 2:05 PM, LVNS 1 stated on [DATE], at 12:30, LVNS 1 walked into Resident 1's room, and heard the Certified Nurse Assistant (CNA 1) state She needs to eat and at the same time LVNS 1 observed the CNA 1 shoving a lot of mechanically soft meat into Resident 1's mouth. LVNS 1 stated Resident 1 has no teeth. During an interview with LVNS 3, conducted on [DATE], at 2:12 PM, LVNS 3 stated the CNA 1 was shoving food into Resident 1's mouth so we took over. During an interview with the Licensed Vocational Nurse Charge Nurse, (LVNCN) conducted on [DATE], at 2:39 PM, the LVNCN stated the LVN student nurse reported the CNA 1 was being rough with Resident 1. The LVNCN stated the student nurse reported the CNA 1 was shoving food into Resident 1's mouth. Concurrently, the student nurse stated she CNA 1 Resident 1 could choke. CNA 1 responded it was okay because Resident 1 knows how to swallow. Concurrently, the LVNCN stated he is not sure if it is safe for CNA 1 to be working with the residents, adding he would not feel safe with the CNA 1 feeding residents by herself. A review of the facility document titled, (name of facility) Progress Notes, dated [DATE], at 2:09 PM, the Quality Assurance Nurse (QAN) documented the following: .Resident experienced alleged abuse. Upon investigation the (name of school) Students/Instructor reported a staff member was being to rough with resident. There were three students who witnessed staff member put too much food in resident's mouth . A review of the facility document titled VCSL-SBAR/COC (RevXXX 4) dated [DATE], at 3:30 PM, under section .AA. SBAR Charting Notes reflects the following: It was reported to the DSD by (name of school) students/instructor that they witnessed a staff member being rough with resident during meal as Resident was being feed, CNA was putting too much food in resident's mouth . A review of the document authored by LVNS 1, dated [DATE], no time indicated, the document revealed on [DATE], LVNS 1 walked into Resident 1's room and observed CNA 1 feeding Resident 1 with an excessive amount of food on the fork, shoving it into Resident 1's mouth. LVNS 1 indicates she spoke to CNA 1 asking her to not feed Resident 1 so much, it could make the resident choke. CNA 1 responded It's okay, you and another student could do Cardio-Pulmonary Resuscitation (CPR). A review of the document authored by LVNS 3, undated, revealed on [DATE], in (room number), D bed, LVNS 3 indicated walking into the room to assist with changing Resident 1. LVNS 3 observed CNA 1 shove food into Resident 1's mouth, aggressively, without letting Resident 1 finish the food she had just begun eating. The document reflects CNA 1 jokingly saying LVNS 3 can give Cardio-Pulmonary Resuscitation (CPR) if anything happens. A review of the document authored by the Licensed Vocational Nurse Student Instructor (LVNSI), dated [DATE], revealed on [DATE], at lunch time CNA 1 appeared to be feeding large amounts of food to Resident 1 and not allowing Resident 1 adequate time to swallow before pushing another bite of food into Resident 1's mouth. A review of the facility document titled, Assistance with Meals, dated 2001 MED-PASS, INC. (Revised [DATE]), found the following: Policy Statement - Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy Interpretation and Implementation - Dining Room Resident: .3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity . 2. During an interview, with LVNS 1, conducted on [DATE], at 2:07 PM, LVNS 1 stated on [DATE], after lunch, Resident 1 asked to be taken back to bed. LVNS 2 stated CNA 1 told Resident 1 once she puts her back to bed she will leave her (Resident 1) in bed. LVNS 1 heard CNA 1 tell Resident 1 to Shut up. During an interview with the Licensed Vocational Nurse Student 2 (LVNS 2), conducted on [DATE], at 2:07 PM, LVNS 2 stated CNA 1 was asked by LVNS 1 and LVNS 2 to assist putting Resident 1 back to bed. LVNS 2 stated during putting Resident 1 back to bed, CNA 1 stated to Resident 1 she needs to stay in bed because she (Resident 1) is So big. LVNS 2 stated CNA 1 pushed Resident 1 on the abdomen. Resident 1 stating, Don't push me. LVNS 2 stated Resident 1 stated CNA 1 makes her anxious and nervous, and she talks with a loud angry voice to the residents. During an interview with the Licensed Vocational 3 (LVNS 3) conducted on [DATE], at 2:12 PM, LVNS 3 stated while assisting Resident 1 back to bed with the help of LVNS 2, LVNS 1, and with CNA 1, Resident 1 continually asked CNA 1 to stop pushing her. During an interview conducted on [DATE], the LVNCN stated the student nurse reported when they were assisting putting Resident 1 back to bed CNA 1 was pushing Resident 1 down in the bed with Resident 1 stating Please don't push me. LVNCN stated an assessment of Resident 1's body was conducted with bruising found. LVNCN stated based upon the allegations brought by the students, LVNCN is not sure it is safe for CNA 1 to be working with the residents. During an interview with Certified Nursing Assistant 2 (CNA 2), conducted on [DATE], at 3:08 PM, CNA 2 stated CNA 1 is a little rough, pushing to strong, when turning patients, she needs to be more gentle. During an interview with Resident 1, conducted on [DATE], at 4:02 PM, Resident 1 was tearful, with no verbal response, when asked if CNA 1 was verbally or physically abusive to her. A review of the facility document titled VCSL-SBAR/COC (RevXXX 4) dated [DATE], at 3:30 PM, under section .AA. SBAR Charting Notes reflects the following: It was reported to DSD by (name of school) students/instructor that they witnessed a staff member being rough with resident .when resident wanted to go to bed CNA was rough putting resident into bed. A review of the document authored by LVNS 1, dated [DATE], revealed LVNS 1 was walking in the hallway when Resident 1, sitting in her wheelchair, asked LVNS 1 if she could put her back to bed. LVNS 1 asked fell ow students LVNS 2 and LVNS 3 to assist her with putting Resident 1 back to bed, knowing CNA 1 was already in the room. LVNS 1 continues that CNA 1 told Resident 1 When I put you to bed you are staying there all day, don't ask to get back up. LVNS 1 continued in the document, the four of them (the three students and CNA 1) lifted Resident 1 into the bed. Once in bed, LVNS 1 documented, CNA 1 pushed Resident 1 down onto the bed, and threw Resident 1's legs onto the bed, with Resident 1 responding Don't push me and CNA 1 responded Oh, shut up. A review of the document authored by LVNS 2, dated [DATE], revealed LVNS 2 was asked by LVNS 1 to assist putting Resident 1 back to bed. LVNS 2's documents that after the CNA's actions, Resident 1 started crying and stated. Please stop and don't push me. A review of the document authored by LVNS 3, undated, revealed LVNS 3 was present in Resident 1's room when he observed CNA 1 pushing Resident 1 into the bed, aggressively, and heard Resident 1 request Please stop pushing me. A review of the document authored by the LVNSI, dated [DATE], revealed LVNSI documented on [DATE], at 10:45 AM, Resident 1 was waiting to be placed back in bed. The Student asked CNA 1 if they (Students) could assist in the transfer back to bed. The LVNSI conveys the Student reported to her CNA 1 refused and starting yelling at Resident 1, telling her the students were not allowed to put her back to bed. The document continues, the students checked with the Charge Nurse, confirming it would be okay for the LVN students to place Resident 1 back to bed. When assisting CNA 1 to place Resident 1 back to bed, the students reported to the LVNS I they observed CNA 1 to be very rough with Resident 1. The LVN students reported Resident 1 was asking CNA 1 to stop pushing her because it was hurting. A review of the facility document titled (name of facility) - Progress Notes dated [DATE], at 2:09 PM, the QAN documented the following: .Resident experienced alleged abuse. Upon investigation (name of school) students/instructor reported a staff member was being too rough with resident .the same staff member pushed resident into bed during transfer, in which resident asked staff member not to push her . A review of the facility document titled, Abuse Prevention Program, dated 2001 MED-PASS, Inc. (Revised [DATE]) Nursing Services Policy and Procedure Manual for Long-Term Care, found the following: Policy Statement - Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical, and physical or chemical restraint not required to treat the resident's symptoms, Policy Interpretation and Implementation - As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual . A review of the facility document titled Admission Record (name of facility) dated [DATE], at 3:46 PM, found Resident 2 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED].>-[MEDICAL CONDITION], -Muscle weakness, -[MEDICAL CONDITION], -[MEDICAL CONDITION], -Muscle wasting and atrophy, and -other medical disorders. 3. During an interview conducted on [DATE], at 2:05 PM, with the Licensed Vocational Nurse Student 1(LVN'S 1) the LVN stated on [DATE], at 8:09 AM, she observed the Certified Nursing Assistant 1 (CNA 1) pushing Resident 2 in the Geri-chair (a medical reclining chair designed to allow someone to get out of the confines of their bed and be able to sit comfortably in a variety of positions while being fully supported) in the hallway when CNA 1 pushed the chair into the wall, hurting Resident 2's head. During an interview with the Licensed Vocational Nurse Charge Nurse (LVNCN) conducted on [DATE], at 2:39 PM, the LVNCN stated he was told by the Student Nurse she observed CNA 1 pushing Resident 2 against the wall hitting her head against the hand bars residents use while walking. The LVNCN stated Resident 2 complained of pain to the left side of her head. A review of the facility document titled (name of facility) Progress Notes dated [DATE], the Interdisciplinary Team (IDT) Progress Note dated [DATE], at 2:50 PM, reflected Resident 2 complained of pain and was provided pain medication as ordered. A review of the facility document titles VCSL-SBAR/COC (RevXXX 4) in Section AA. SBAR Charting Notes .Resident was sitting in the Geri-chair in hallway and CNA pushed chair to move resident and resident bumped the left side of her head against hallway railing. Resident complained of pain ,[DATE] to left side of head; (Trade name) Extra Strength tablet 500 MG given . A review of the document authored by LVNCN, dated [DATE], LVNS 1 documented she observed CNA 1 pushing Resident 2, while sitting in the Geri-chair, hit the wall, resulting in Resident 2 hitting her head against the railing connected to the wall. A review of the document authored by the Licensed Vocational Nurse Student Instructor (LVNSI) the LVNSI documented the Student observed CNA 1 push Resident 2, who was sitting in the Geri-chair, into the wall, which resulted in Resident 2 striking her head against the wall or railing. Resident 2 confirmed she had hit her head against the wall. Policy Statement - Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical, and physical or chemical restraint not required to treat the resident's symptoms, Policy Interpretation and Implementation - As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual .

Based on observation, interview, and record review, the facility failed to ensure, for one of three sampled residents (Resident 1), that Resident 1, assessed as a high risk for elopement (leaving the facility without supervision) received supervision to prevent the resident from eloping from the facility. This failure had the potential to result in an accident or death. Findings: On (MONTH) 29, (YEAR) at 8:50 AM, the facility was entered to investigate a facility reported incident of Resident 1's elopement from the facility on (MONTH) 27, (YEAR) at approximately 4:30 PM. During an observation on (MONTH) 29, (YEAR) at 8:50 AM, of the facility entry and lobby area, it was observed that the main facility entrance was a glass door into a lobby area. There were double wooden doors that were closed but allowed entry into the facility. There was a receptionist window in the lobby. During a review of Resident 1's Face Sheet (a document that gives a patient's information at a quick glance), it showed the resident was admitted to the facility on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. Review of the Charge Nurse's Notes dated (MONTH) 27, (YEAR) at 11:14 PM, showed the following: around 3pm received resident lay on her bed comfortably awake alert verbally responsive with episodes of forgetfulness/confusion. talking to herself. 4pm went to resident room admin (administered) meds (medications) via po (by mouth) & compliance (took the medication). 4:15pm charge (nurse) seen resident out of her room ambulate (walk) with her walker facing by the station (Nurse's station) towards front door seen cna (Certified Nursing Assistant) chasing resident stopping her going out of the front door. one of the employees stated it's ok she just want her money in front office, cna noticed resident not back to her room. Notify charge nurse, supervisor check all rooms bathroom, facility premises, units, check watched camera in the whole facility noted resident passing through the front office employees drove to the stores, remain never to be found, MD (physician) conservator (responsible party) spoke to on call by (conservator's name) notify made aware, RN (Registered Nurse) notify (name of city) police to report missing resident officer (name) came in to the facility to get information about resident with case number # (number), & patient reported to have wander guard (device that sets off an alarm when the resident gets too close to an exit door) on her left ankle & active Will continue to look for resident. A review of the Medication Administration Record [REDACTED]. The resident was missing about 4:30 PM on (MONTH) 27, (YEAR) and the charge nurse documented the resident's whereabouts every two hours until 10:00 PM. The entry for 6:00 PM, 8:00 PM and 10:00 PM were crossed out and the reason for the crossed out entries was documented as an error as the resident was no longer in the facility. In a telephone interview with Licensed Vocational Nurse 1 (LVN 1) on (MONTH) 29, (YEAR) at 3:45 PM, LVN 1 stated when she received report at the change of shift, she saw her (Resident 1) in bed. When she talked to Resident 1 the resident was laughing and in a good mood. A little later she when she gave the resident medication she was in bed. She stated shortly after that she saw the Certified Nursing Assistant 1 (CNA 1) chasing her down the hallway because the wander guard alarmed. The resident went to business office to get money for dinner, she often did that. CNA 1 said it was OK she was just getting some money. She did not come back. It was about 4:30 PM. Called a Code Green (emergency code for a missing resident) and we searched for her. That is all I know. When asked about her crossed out entries on the MAR, she stated she doesn't remember crossing out her initials on the MAR. A review of Resident 1's Care Plan for At risk for elopement/wandering AEB (As Evidenced By) impaired safety awareness, initiated on (MONTH) 4, (YEAR), showed the following interventions: At high risk for elopement-Visual checks every 2 hours and document whereabouts/location. Charge nurses/QA (Quality Assessment nurse) & or RN check placement & function of Wander-guard q (every) shift. Psych (Psychiatric physician) consult and as needed. WANDER ALERT: Device located Lt. (left) ankle. Apply wander guard (a device worn by a resident that sets off an alarm when the resident approaches an exit door) at all times. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor resident location Q (every) 2 hours. Document whereabouts/location/wandering behavior and attempted diversionary interventions in behavior log/MAR. Reorient resident to room as needed. Keep a hazard free environment . The care plan did not address actions for staff to take when the wander guard alarm sounded, such as redirecting the resident or accompanying them to the outside to prevent leaving the facility premises. On (MONTH) 31, (YEAR) at 4:25 PM, an Immediate Jeopardy was called in the presence of the Director of Nurses (DON) and the Infection Control/QA nurse, for not developing an intervention specific care plan that included supervising the resident when nearing an exit, contributing to Resident 1's elopement from the facility. The Immediate Jeopardy was abated on (MONTH) 31, (YEAR) at 5:48 PM, after receiving an acceptable corrective action plan and conducting record review and interviews to ensure the corrective action plan was implemented. The action plan was as follows: All residents are been assessed for elopement risks. Provided education to current staff on elopement risks and will continue to educate staff throughout each shift on how to assist and monitor elopement risks residents. Licensed nurses are doing visual checks of residents and documenting in the MAR indicated [REDACTED] Certified nurse assistants are educated to go to the exit doors as soon as the wander guard alarm goes off to assist the resident. After assisting the resident, report to the charge nurse. Do not leave the patient alone by themselves. Re-direct them.

Based on interviews and record review, the facility failed to ensure the physician orders were followed for one of three residents (Resident A) who was to be transferred to the acute care hospital as ordered, due to abnormal laboratory values and increased confusion following a fall. This failure resulted in a delay of treatment and for Resident A to receive cardiopulmonary resuscitation (CPR- chest compressions and artificial breathing when a heart and breathing stops) against his Advanced Directives (written directions on what to do in a life threatening emergency). Resident A was pronounced dead at the emergency room (one day after the physician ordered him to be transferred). Findings: During a review of the clinical record for Resident A, the Admission Record (demographics), dated (MONTH) 16, (YEAR), indicated, Resident A was admitted to the facility with [DIAGNOSES REDACTED]. During a review of the clinical record for Resident A, the progress notes dated (MONTH) 25, (YEAR) at 6:48 AM, indicated, Resident was alert with periods of confusion, resident kept crawling out of his bed this shift. Mattress placed on the floor. Resident blood sugars were within normal limits. VS (vital signs) temperature (T) 98 degrees Fahrenheit (normal 97XXX,[DATE].6), pulse (P) 76 (normal ,[DATE] beats per minute), respiration (R) 18 (normal ,[DATE] breaths per minute), blood pressure (B/P),[DATE] (normal ,[DATE]). During a review of the nurses notes dated (MONTH) 25, (YEAR) at 2:47 PM, Resident A was being transferred back to bed from his wheelchair by one Certified Nursing Assistant (CNA 1) when Resident A leaned forward in the wheelchair and fell on to the mattress pad on the floor hitting his forehead. The nurses progress notes further indicated Resident A complained of pain and dizziness. During a review of Resident A's nurses progress note dated (MONTH) 26, (YEAR) at 3:01 AM, indicated Resident A had increased confusion after sustaining the fall on (MONTH) 25, (YEAR) at 2:47 PM. VS= T 96.2, P 66, R 20, B/P ,[DATE]. Urine collected. Resident will have x-ray of the skull and labs to be done (as ordered by the physician). During a review of Resident A's nurses progress notes dated (MONTH) 26, (YEAR) at 7:52 AM, indicate, (MONTH) have mattress on floor for safety precautions. Patient has been continuously rolling or getting out of bed onto the mat on the floor. Per MD (physician) order, place the mattress on the floor for safety precautions. A review of Resident A's Interdisciplinary Team Note (IDT- comprised of clinical staff) dated (MONTH) 26, (YEAR) at 4:12 PM, indicated Resident A was alert with confusion. Has history of falls and at risk for further falls due to impaired cognition and noncompliance with care. DX [MEDICAL CONDITION](high blood pressure), dm (diabetes-unstable blood sugar), [MEDICAL CONDITION] disease (impaired gas exchange in the lungs) and other co-morbidities. Resident (A) experienced a fall from bed. CNA reported to charge nurse during transfer, Resident A fell forward to the floor and landing and bumping his head on the floor mat next to his bed. Charge nurse assessed Resident (A) and noted a small red bump to the forehead. MD notified with no new orders. Recommendations: Monitor for C[NAME] (change of condition) for 3 days, 72 hour neuro check (a neurological check for pupil reaction and ability to move extremities to command), ensure bed in lowest position, floor mat in place. Daughter notified and is in agreement with P[NAME] (plan of care). Resident is at risk for further falls due to weakness, impaired condition, poor safety awareness and poor impulse control. During a review of the clinical record for Resident A the nurses progress notes dated (MONTH) 26, (YEAR) at 7:31 PM, indicated the physician was contacted (29 hours after Resident A fell ) to give the results of a critical lab value ordered. An order was obtained to transfer Resident A to (name of the hospital) for an elevated BUN of 82 (blood, urea, and nitrogen level. Normal BUN is ,[DATE]) for evaluation and treatment ASAP (as soon as possible). However, the nurses note indicated when the Registered Nurse Supervisor (RNS 1) called the (name of hospital) and the RNS 1 informed the supervisor at the (name of hospital) the admission was to be a direct admit and she will call back to follow up for bed via direct admit and will set up transportation once confirmed. During a review of the clinical record for Resident A, the nurses progress notes dated (MONTH) 27, (YEAR) at 11:10 AM, indicated Resident A was found non responsive, pupils were fixed and dilated, and the nurses were unable to obtain a heart sound or blood pressure. No respirations were noted. The skin was warm to touch and a Code Blue (staff are called immediately to start CPR) was initiated. During a phone interview with the attending physician on (MONTH) 16, (YEAR) at 5:00 PM, he stated he gave a telephone order to transfer Resident A to (name of the hospital) and if there were no beds available to transfer Resident A to the nearest hospital as soon as possible (ASAP). During an interview with the Registered Nurse Supervisor (RNS 1) on (MONTH) 18, (YEAR) at 12:45 PM, she stated she received a critical laboratory result for Resident A for the BUN level on (MONTH) 26, (YEAR) at 7 PM. RNS 1 stated she contacted the physician and gave the physician the BUN result. RNS 1 stated she took a telephone order to transfer Resident A to (name of hospital) as soon as possible (ASAP) for further evaluation regarding the critical lab results. RNS 1 stated she did not write a telephone order to transfer Resident A to the hospital as soon as possible (ASAP), but wrote an order to transfer Resident A to (name of hospital) as a direct admit and further stated she has never written a order ASAP. RNS 1 stated she did not call the physician back to notify him there was no bed available at the (name of hospital). RNS 1 stated she was told by the supervisor of (name of the hospital) to fax orders to the (name of the hospital) indicating Resident A was to be transferred when a bed was available as a direct admit. When asked for the policy not to document an order to be carried out ASAP she was unable to provide a policy. A review of the facility policy and procedure titled, Telephone Orders dated revised (MONTH) 2014, indicated under Policy Interpretation and Implementation .2 The entry must contain the instructions from the physician, date, time and the signature of the person transcribing the information During an interview and concurrent record review with RNS 2 on (MONTH) 18, (YEAR) at 12:50 PM, she stated the evening and night shift staff did not follow up with the (name of the hospital) or notify the physician the (name of the hospital) had no beds available. She reviewed the clinical record for Resident A and was unable to find documentation that there had been follow up by the other shifts to check for bed availability. The facility policy and procedure titled, Change in a Residents Condition Status dated (MONTH) (YEAR), under the section titled: Policy Interpretation and Implementation 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an) .d. significant change in the resident's physical/emotional/mental condition . During a review of the clinical record for Resident A, the Physician's Order for Life Sustaining Treatment (POLST) dated (MONTH) 20, (YEAR), indicated Resident A was Do Not Attempt to Resuscitation/DNR for CPR. During an interview with RNS 2 on (MONTH) 18, (YEAR) at 1:00 PM she reviewed the clinical record, the POLSTand her nurse's notes dated (MONTH) 27, (YEAR) at 11:10 AM, and stated she did CPR without checking Resident A's POLST/DNR status. Resident A was taken to the emergency room and was pronounced dead on (MONTH) 27, (YEAR) at 12:12 PM. A review of the death certificate indicated the cause of death to be acute [MEDICAL CONDITION] minutes; [MEDICAL CONDITION]-months.

Based on interview and record review, the facility failed to provide the necessary intervention to prevent a fall for one of three sampled residents (Resident A) by failing to provide a tab alarm (Fall prevention device that can be used on wheelchair, chair or bed to alert caregivers when a fall risk resident attempts to transfer/walk/get out of chair/bed unassisted. This type of alarm is clipped to the resident's clothing and with the string attached to the clip, a small piece of metal is magnetically in place in the tab alarm. If the resident gets up or moves further then the string length, the metal magnet connection is broken and the alarm sounds) when Resident A was in bed. This failure resulted in Resident A experiencing a fall on [DATE], sustained a subdural hematoma (bleeding on the brain) and required hospitalization . Finding: During an interview with the complainant on [DATE] at 12 PM, she stated Resident A had fallen at the facility on [DATE] at 2 AM. Resident A was sent to the acute hospital on [DATE] at 8 AM and was found to have a subdural hematoma. An unannounced visit was made to the facility on [DATE] at 1:15 PM to investigate a complaint regarding the quality of care. A review of Resident A's clinical record reflected Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the licensed nurse's progress notes dated [DATE] at 8:22 PM reflected the following documentation: Resident A was readmitted to the facility for rehabilitation which included physical therapy and occupational therapy. Resident A's readmission [DIAGNOSES REDACTED]. The note indicated the physician had agreed to continue the same plan of care. During a review of the care plan at Risk for Fall dated [DATE], documentation showed Resident A was at risk for falls related to generalized muscle weakness, impaired safety awareness . Further review of the care plan intervention, documented that a tab alarm was to be implemented. During a review of the licensed nurse's progress notes dated [DATE] at 3:09 AM, reflected the following documentation: I charge nurse (LVN 1) was preparing to begin my charting at 2:00 AM when I heard a loud bang come from the resident's room. When I went to resident's room I found the resident laying on the floor on his left side near the closet. Further review of the nurse's note, there was no documented evidence a tab alarm was in place when Resident A fell . During an interview with LVN 1 on [DATE] at 2:18 PM, LVN 1 confirmed Resident A did not have a tab alarm in place when the resident fell on [DATE]. When asked why Resident A did not have the alarm on at the time of the fall. LVN 1 responded I did not get around to it. During an interview with the Registered Nurse (RN 1) on [DATE] at 4:45 PM, she stated she was working on the floor at the time of the incident when Resident A fell on [DATE]. RN 1 stated that she did not hear or see a tab alarm when Resident A fell . RN 1 further stated that all residents are to have a tab alarm placed for three to seven days after admission or readmission to the facility. A review of the facility policy and procedure titled Alarms, dated [DATE] indicated the purpose of the policy To alert staff of unassisted transfers .To minimize risk of falls associated with unsafe transfer attempts. During an interview with the Director of Nurses (DON) on [DATE] at 4:45 PM, she confirmed that all residents that are admitted or readmitted to the facility are to have a tab alarm in place for three to seven days to help prevent falls. The DON stated Resident A should have had a tab alarm in place when Resident A was readmitted to the facility on [DATE]. A review of the Neurological Assessment form for Resident A, dated [DATE], indicated the pupil size assessment between 2:30 AM- 6:10 AM were at 5, and reactive to light (Pupils constrict when light shown in the eye). At 7:10 AM, the resident's pupil assessment was increased to 6 and non reactive to light. During an interview with LVN 1 on [DATE] at 2:18 PM, he stated On [DATE] between ,[DATE]:30 AM, he found Resident A was non responsive (unable to awaken) with pupils at 6 , non reactive to light. Resident A was transferred to the hospital. A review of the Death Summary from the acute hospital for Resident A, dated [DATE], documented the following: Traumatic (brain dysfunction caused by an outside force,usually a violent blow to the head) brain injury and subdural hematoma. A review of the Record of Death from the acute hospital for Resident A, undated, documented the following: (Resident A) expired (died ) [DATE] at 7:50 AM from brain death (a condition when there is no brain activity to sustain life).

Based on observation, interview and record review, the facility failed to prevent falls and ensure the safety for 2 of 24 sampled residents (Residents 15 and 16) and 1 of 8 unsampled residents (Resident E). 1. For Resident 16, the facility did not ensure that equipment used to transfer residents was in good condition. This failure resulted in Resident 16 falling from a Hoyer lift (a mechanical lift used to transfer residents from one surface to another, using a sling (a device attached to the Hoyer lift, that is placed underneath the resident for transfer)) during the transfer on May 8, 2014. This failure resulted in Resident 16 sustaining multiple bruises to the right side of her face, the right jaw, right neck, right ribs, left thumb, left hand and left wrist. Resident 16 also experienced pain with each activity that involved movement such as, position changes in bed, and transfers during shower times. 2. For Resident E, the facility failed to ensure that staff were trained to use equipment for transfers, in accordance with the facility's policies and procedures. This failure had the potential to result in Resident E sustaining serious bodily injuries not limited to bruises and bone fractures during a bed to shower chair transfer on May 23, 2014. 3. For Resident 15, the facility failed to ensure that the wheels of a wheelchair were locked, to stabilize the wheelchair, prior to staff transferring the resident from the bed to the wheelchair. This failure resulted in a fall and a skin tear to Resident 15's right lower arm on May 15, 2014. Findings: 1. During an initial tour of the facility on May 19, 2014 at 9:15 AM, accompanied by the Quality Assurance/Licensed Vocational Nurse (QA Nurse/LVN), Resident 16 was observed lying in bed with bruising to right side of her face and to left hand. During a concurrent interview with the QA Nurse/LVN when asked if she knew how Resident 16 sustained the bruises, she stated she would have to seek clarification. A review of the clinical record for Resident 16 was conducted. A review of the history and physical indicated that Resident 16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Resident required a Hoyer lift during transfers. A review of the nurses note titled, "SBAR/COC" (Situation, Background, Assessment, and Recommendation/Change of Condition), dated May 8, 2014 at 11:44 PM, indicated that during transfer of Resident 16 from the shower chair to the bed with the Hoyer lift, after the resident received her shower, 3 loops of the sling snapped and the resident landed on the floor. Resident 16 complained of pain with hematoma (collection of blood under the skin) and a skin tear to the right eyebrow with pain to right ribs. During an observation on May 20, 2014 at 6:55 AM, Resident 16 was sitting upright in bed. Resident 16 was observed to have the following injuries: a. A purple/yellow bruise to the right temple of her forehead. b. A purple/yellow bruise to her right upper/mid cheek. c. A purple/yellow bruise to her right jaw. d. A purple yellow bruise to the outer right side of her neck. e. Bruising to the her entire left thumb that extend to her left wrist. f. A purple/ yellow bruise to the right back and rib area. During an interview with certified nursing assistant ( CNA 9), on May 20, 2014 at 6:55 AM, when asked if she knew how Resident 16 sustained bruising to her face and left hand, she stated that Resident 16 fell from the Hoyer lift when it broke. She further stated that the Hoyer sling used should not have been used, because it was not in good condition. CNA 9 declined to comment any further. During an interview with Resident 16 on May 20, 2014 at 6:45 AM, she was noted to be intermittently confused (thoughts were not clear all the time) and she was unable to verbalize how she sustained bruising to her face and left hand, but complained of right chest pain. During a interview with Resident 20 (Resident 16's roommate) on May 20, 2014 at 6:55 AM, she stated that she woke up to Resident 16 screaming after the fall from the Hoyer lift. Resident 20 further stated that Resident 16 complains of pain when staff turns her. During an interview with the Director of Staff Development (DSD) on May 21, 2014 at 1:55 PM, she stated that the threading that held some of the loops on the sling had torn, which resulted in Resident 16 falling on to the floor on May 8, 2014. She stated that the CNAs were instructed to remove any slings identified as unsafe, such as those that showed signs of being torn, frayed, or appeared faded. The DSD also stated that that she did weekly checks of the facility's slings for fading, worn threading around the loops, and if any slings were identified as being compromised were to be thrown out. The DSD was unable to show any documented evidence to show that she did weekly checks of the facility's Hoyer lift slings. During an interview with the Maintenance Director, on May 20 2014 at 9:15 AM, he stated that he did not check the integrity of Hoyer lift's slings. During an interview with Laundry Staff 1, on May 20, 2014 at 9:20 AM, she stated that the laundry staff did not always check for for rips and tears after laundering the Hoyer lift's slings. During an interview with CNA 6, on May 21, 2014 at 3:45 PM, CNA 6 stated that on May 8, 2014, in preparation for Resident 16's shower, with the Hoyer lift he assisted CNA 5 to transfer Resident 16 from the bed to the shower chair. CNA 6 stated he did not remember if he checked the integrity of the Hoyer lift sling prior using it. CNA 5 was not available for interview during the survey. During an interview with CNA 2, on May 21, 2014 at 3:50 PM, she stated that she was present with CNA 5 when Resident 16 fell out of the sling on May 8, 2014. CNA 2 stated that she was called into the resident's room to assist CNA 5 to transfer Resident 16 back to bed from the shower chair. She stated that the sling was already under the resident and hooked to the Hoyer lift when she arrived. CNA 2 also stated that she pressed the controls on the Hoyer lift and raised Resident 16 out of the shower chair. As she moved the shower chair out of the way, the sling broke and Resident 16 fell to the floor. CNA 2 further stated that the right side of Resident 16's face turned purple right after the fall and she complained of pain. CNA 2 stated that she did not check the sling prior to raising the resident in the Hoyer lift, "I just came to help, and I thought CNA 5 did it." During an interview with the Director of Nursing (DON) on May 22, 2014 at 4:00 PM, the DON stated that 3 loops on the Hoyer lift's sling tore on May 8, 2014, while Resident 16 was being transferred from the shower chair back to bed. The DON stated that the CNAs were supposed to check the slings for tears, rips, loose threading prior to each use. 2. During an observation and a concurrent interview, on May 23, 2014 at 9:00 AM, CNA 3 was observed using a Hoyer lift on Resident E. The legs of the Hoyer lift were not in an open positioned to ensure the lift was stabilized when in use. CNA 3 stated that she should have opened the Hoyer lift legs to better accommodate the weight distribution of Resident E. During an interview with CNA 4 (a CNA who was assisting CNA 3), on May 23, 2014 at 9:05 AM, she stated that she placed the Hoyer sling underneath Resident E, and that she checked it for tears, rips and other signs of wear and tear. On May 23, 2014 at 9:07 AM, an observation of the Hoyer lift sling was conducted with CNA 4. The Hoyer lift sling that had previously been underneath Resident E was inspected and the following was noted: a. Fraying (worn) on the black strap to which the purple, green and blue loops were attached behind Resident E's right shoulder area. b. The green loops on all 4 corners of the sling used to transfer Resident E were noted to be a very light faded and pale green color. c. Also observed was color fading of all 4 purple loops to light pale purple and all 4 blue loops to a light pale blue on the sling. On May 23, 2014 at 9:07 AM, CNA 4 demonstrated how she checked the integrity of the sling prior to use in the transfer of Resident E, but failed to notice the fraying on the black strap or the fading of the colors on the sling loops. On May 23, 2014 at 9:15 AM during an interview and concurrent observation with the DON in Resident E's room, she confirmed the following: a. The position of the shower chair at the end of the bed was incorrect and the DON stated that it should have been closer to the resident next to the bed. b. The black strap was ripped/frayed and the sling loop colors were faded indicating that the integrity of the sling was compromised and should not have been used. c. The half side rails at the head of the bed should have been in the down position during the transfer. The DSD stated that CNA 4 did not attend the in-service training titled "Labeling new slings with dates, checking sling integrity prior to use" that was mandatory for all CNAs and licensed staff on May 9, 2014. The DSD further stated that part of the new hire orientation was to watch a manufacturer's DVD (digital versatile disc-digital storage format) on using the Hoyer lift, with a section on how staff should check the integrity of the sling prior to use. The DSD was unable to show any documentation that CNA 4 received the training on hire. On May 23, 2004 at 10:30 AM, during an interview with the Executive Director, she stated that some CNAs would hide the Hoyer slings, so they were more easily accessible to them when needed, making it difficult for the facility to conduct weekly integrity checks of all slings used by the facility. On May 23, 2014, a review of Owner's Operator and Maintenance Manual, titled " Patient Slings " (undated), for patient slings general guidelines indicated: "WARNING"-"DO NOT move a person suspended in a sling any distance. The (company name) patient lift or sling are NOT transport devices. They are intended to transfer an individual from one resting surface to another (such as a bed to a wheelchair). Otherwise, injury or damage may occur". "WARNING"- "After each laundering (in accordance with instructions on the sling), inspect sling(s) for wear, tears, and loose stitching. Bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately". A review of facility policy and procedure titled " Safe Resident Handling Policy " dated January 14, 2014, included the following: "Delegation of authority and responsibility" "B. Employees shall": "2. Use proper techniques, mechanical lifting devices (equipment used to lift, transfer, reposition and move residents. Examples include: full body lifts and sling), and other approved equipment/handling aids during during the performance of resident handling tasks" . "3. Ensure mechanical lifting equipment and other approved equipment/handling aids are in proper working order, and stored conveniently and safely". "4. Remove equipment that is not in proper working order from operation". "C. Maintenance and Central Supply Department shall inspect and coordinate the maintenance of mechanical lifting equipment/handling aids to ensure they are in proper working order". "D. Mechanical lifting devices and other equipment/handling aids": "2. Maintenance and Central Supply Department shall visually inspect and coordinate the maintenance of mechanical lifting equipment/handling aids to ensure they are in proper working order". . 3. During the initial tour of the facility on May 19, 2014 at 9:15 AM, Resident 15 was observed lying in bed with a bandage to her right lower arm. During an interview with Resident 15, on May 19, 2014 at 9:15 AM, Resident 15 stated that she had a skin tear to her right lower arm. Resident 15 stated she fell when the certified nursing assistant (CNA 10) attempted to transfer her from the bed to a wheelchair. Resident 15 stated CNA 10 did not lock the wheels of the wheelchair, and the wheelchair rolled from under her as she tried to sit down. Resident 15 stated she scraped her arm on the bottom of the wheelchair as she fell and tore the skin on her right lower arm. During a review of Resident 15's clinical record, the admitting face sheet noted that Resident 15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 15 was alert, oriented and responsible for herself. During a review of the nurses' progress notes, dated May 15, 2014 at 12:18 PM, noted the following: "Topic: Witness fall/skincare to right lower arm." "Note: Resident was found sitting on the floor next to her bed facing the wall with the wheelchair behind her, close to the TV. CNA at bedside with resident during fall. Per resident the CNA had her stand next to the bed while she went to go get the wheelchair. When the resident went to sit down in the wheelchair she fell to the floor scraping her right lower arm on the leg of the wheelchair. Per resident the wheelchair was not locked and rolled away from her when she tried to sit." "Resident complained of pain to right arm 7/10 (on a 1 to 10 scale with 1 being the least pain and 10 being the worst pain). Medication given and effective." "(Name of CNA 10) in-serviced on proper transferring technique-bed to chair." During a review of physician and telephone orders, dated May 15, 2014, it noted that Resident 15 had an order to clean the skin tear to her right arm with normal saline and apply steri strips (small bandage strips that are used to close small wounds) every three days and as needed for 14 days. During an interview with the Director of Staff Development (DSD), on May 22, 2014, at 9:30 AM, the DSD stated, she interviewed CNA 10 regarding Resident 15's fall. The DSD stated CNA 10 told her (the DSD) she was unsure if the wheelchair wheels were locked prior to attempting to transfer Resident 15. (CNA 10 was not available for interview during the time of the investigation.) The facility policy and procedure titled "Lifting Machine, Using a Portable", revised October 2010 noted the following: "3. To transfer a resident from a bed to a chair, you should:" "a. Position the chair. If it is a wheelchair, be sure the wheels are locked."

Based on observation, interview and record review, the facility staff failed to ensure that 3 of 24 sampled residents (Resident 10, 19, 23) maintained acceptable parameters for nutritional status as evidenced by: 1. Resident 10 lost 75 pounds in eleven months, or 31.7 percent of her body weight. Although the resident wanted to lose weight, the facility failed to ensure the weight loss was within acceptable parameters. This failure resulted in the resident experiencing a severe weight loss, decreased blood protein, recurrent pressure sores, and a decline in her ability to feed herself. 2. For Resident 19, the facility staff failed to follow up on weight loss identified on May 28, 2013. This had the potential for the resident to become malnourished (caused by improper nutrition or insufficient diet) which could have resulted in medical complications [REDACTED]. 3. For Resident 23, the facility failed to replace her upper dentures that were lost after admission to the facility. This failure resulted in Resident 23 losing 17.8 pounds, the equivalent of 12.7% weight loss over the span of 20 days. This had the potential for the resident to become malnourished (caused by improper nutrition or insufficient diet) which could have resulted in medical complications [REDACTED]. Findings: 1. According to the Academy of Nutrition and Dietetics standard of practice, suggested parameters for evaluating significance of unplanned and undesired weight loss are: 5% weight loss in 30 days 7.5% weight loss in 90 days 10% weight loss in 180 days Weight loss greater than this considered severe weight loss. On June 5, 2013, a review of the facility's policy titled "Weight Assessment and Intervention" dated April 2007, noted that, "The nursing staff and the Dietitian will cooperate to prevent, monitor and intervene for undesirable weight loss for our residents." It further defined significant weight changes as more or less than 5% within 30 days; and more or less than 10% within 6 months. 1. On June 4, 2013 a review of the medical record for Resident 10 noted that the [AGE] year old resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Also, the resident had [MEDICAL CONDITION] (swelling of the arms and legs) which was noted to be improved as exhibited by the resident having wrinkled skin on feet and hands per the June 25, 2013 physician's note. While observing Resident 10 during lunch and breakfast meal time from June 3, 2013 - June 5, 2013, she was alert and awake. She appeared thin and frail with bony fingers and toes. A review of the Minimum Data Set (MDS, a comprehensive resident assessment), Sections C1000 completed on June 26, 2012 and December 27, 2013, identified Resident 10 as having no impairment of cognition (able to make decisions, has ability to reason and understand), was able to make her needs known and required limited assistance for eating. A review of the Nutrition Care note completed by the Registered Dietitian (RD) on June 24, 2013, noted that Resident 10's weight on admission was 237.2 pounds. It also noted that resident 10 stated her usual height was 5 foot 10 inches. There was a physician order [REDACTED]. The same Nutrition Care note dated June 24, 2012, further noted that Resident 10 was at risk for weight loss due to obesity, recent hospitalization and variable PO (food intake) and recorded meal intakes of 50-75%. It also noted that the resident was at risk for skin breakdown related to decreased mobility and decreased food intake. The Resident Goals of the Nutrition Care note dated June 24, 2012, were listed as, "1. PO (food intake) 75-100% of estimated needs, 2. Promote/maintain healthy weight (no significant weight change), 3. Maintain skin integrity." A review of the Resident Care Plan dated June 21, 2012, noted Resident 10 was at risk for altered nutritional status related to [MEDICAL CONDITION], CAD [MEDICAL CONDITIONS], diabetes and CKD ([MEDICAL CONDITION]). The goals for the Care Plan included, "Will have no significant/further weight loss." The Resident Care Plan further noted that Resident 10 was at risk for pressure sore (bed sore) onset due to decreased mobility, bowel and bladder incontinence (loss of control), and her [DIAGNOSES REDACTED]. On July 1, 2012, Resident 10's weight was listed as 236.3 pounds, a decrease of one pound in the first 10 days of admission. A physician's note dated July 3, 2012, noted that the resident had no [MEDICAL CONDITION] (swelling). The Weight Variance Meeting note dated August 6, 2012, noted that Resident 10's weight was 230.8 pounds, a 6.4 pound weight loss in 47 days since admission on June 20, 2012. The recommendations on the note included, "assess for [MEDICAL CONDITION]." A review of the medical record did not note that an assessment was done. A Resident Plan of Care (Short Term) dated August 7, 2012, noted a goal that Resident 10 would have no further significant weight changes in 30 days. A Nutritional Progress Note completed by the RD dated August 9, 2012, noted that Resident 10 was eating 50-100% of her meals. It further noted that the 5.5 pound weight loss in one month to 230.8 pounds was desirable due to obesity. There were no recommended safe weight loss parameters noted in the note. There were no interventions recommended in the note to prevent significant weight loss which was the goal from the RD note on June 24, 2012. A review of the Resident 10's meal intake records from July 31 through August 31, 2012, noted that for 44% of her meals, she consumed 50% or less. The Weight Variance Meeting note dated September 6, 2012, noted Resident10's weight was 219.9 pounds, a 17.6 pound weight loss since admission (on June 20, 2012), which is a 7.4% loss in two and one half months. The recommendations on this note included: monitor the resident food intake, weigh the resident weekly for 4 weeks and continue the current treatment. There was no signature from the RD signifying that she attended the Weight Variance Meeting. A review of Resident 10's Braden Scale (a tool for predicting pressure sore risk) dated September 26, 2012, noted a risk score of 15. According to the Braden Score form, a score of 15-18 represents mild risk for pressure sore. The resident was not at high risk for pressure sore development according to the facility assessment. A review of the Weekly Pressure Ulcer Record for Resident 10 dated September 30, 2012, noted that the resident developed a Stage II pressure sore (the skin was open) on her right buttock (the first one). A review of Resident 10's meal intake records from September 1 through 30, 2012, noted that for 55% of her meals, she consumed 50% or less. The Weight Variance Meeting note dated October 16, 2012, noted resident 10's weight was 212.1 pounds, a total of 25.1 pounds (10.6%) lost in four months (120 days). The factors contributing to total weight loss were noted to include "Desire Weight Loss secondary to obesity." There was no mention of the new pressure sore to the resident's right buttock and how that affected her nutritional status. Recommendations included: monitor meal intake, weekly weights times 2 weeks and a speech therapy evaluation." There were no recommendations to alter the resident's diet or nutritional intake to prevent further significant weight loss or promote wound healing. There was no signature from the RD contained in the note to signify that she attended the Weight Variance Meeting. A Resident Care Plan (Short Term) date October 16, 2012, noted the goal was for Resident 10 to lose weight in 30 days and the resident would not have significant weight loss in 30 days. Weight loss was the goal as long as it was not significant (less than 5% in 30 days, 7.5% in 90 days or 10% in 180 days). A Weekly Pressure Ulcer Record for Resident 10 dated October 30, 2012, noted she developed a Stage II pressure ulcer on her left thigh. This was the second pressure sore to develop. A review of Resident 10's meal intake records from October 1 through 31, 2012, noted for 32% of her meals she consumed 50% or less. A review of Resident 10's medical record noted that there was no documentation noted from the RD in September and October of 2012. A review of the physician's orders [REDACTED]. A Nutritional Progress Note dated November 6, 2012, noted Resident 10's weight was 206.3 pounds. This was a 5.8 pound (2.7%) weight loss in one week. The report noted that the resident was eating 40-90% of meals. The note further noted the resident's desired weight loss and she wanted to "at least get to 175 pounds." The note did not include documentation that the RD discussed with the resident, the risks and benefits of rapid weight loss. It did not note that Resident 10 had a current pressure sore. It also did not include recommendations to improve the Resident10's nutritional status, slow the rapid weight loss or promote wound healing for the pressure sore. On November 6, 2012, the Resident Care Plan was updated to include a problem of "Resident with significant weight loss, desired weight loss, per resident goal weight 175 pounds." The goals continued to include "Will have no significant/further weight loss" and "Will consume at least 75% of meals." There were no new interventions to accomplish these goals. A Weekly Pressure Ulcer Record for Resident 10 dated November 7, 2012, noted that she developed a new Stage II pressure ulcer on her right buttock, the third pressure sore to develop. Another Weekly Pressure Ulcer Record dated November 12, 2012, noted she developed a second Stage II pressure sore on her right buttock, the fourth pressure sore to develop since admission (on June 20, 2012). A review of Resident 10's meal intake records from November 1 through 30, 2012, noted that for 61% of her meals, she consumed 50% or less. A Weight Variance Meeting note dated December 12, 2012, noted the Resident 10's weight was 200.3 pounds, a weight loss of 11.5 pounds (5.4%) in one month. This weight also represented a 37 pound weight loss (15.6%) in just under six months (180 days) since admission. There was no mention of the recent pressure sores the resident developed. The recommendations regarding the weight loss included: monitor oral intake and continue current treatment. There was no recommendation to weigh the resident weekly or interventions to improve the resident's nutrition status to prevent further skin breakdown. The note did not contain the signature of the RD to signify that she attended the Weight Variance meeting. A Nutritional Progress Note dated December 27, 2012, completed by the RD, verified that Resident 10 had significant weight loss in one month, over 3 months and over 6 months. According to the note, the resident's current weight was 200.3 pounds. The note further verified the resident had "open areas" to the left thigh and right buttock. The note included information that the RD educated the resident on healthy weight loss versus weight loss related to decreased nutrition. There was no documented evidence that a healthy loss, including parameters, had been discussed with Resident 10 prior to December 27, 2012 and her 37 pound weight loss. A review of the physician orders [REDACTED]. A review of the Resident 10's weights showed that on December 31, 2012 (3 days later), her weight was 190.5 pounds. Her weight had dropped another 10 pounds from December 12 to December 31, 2012 (19 days). Resident 10's total weight loss since admission (6 months earlier) was 47 pounds or 20% of her body weight. A review of the Resident 10's meal intake records from December 1 through 31, 2012, noted that for 70% of her meals, she consumed 50% or less, with 5 meals refused. A Weekly Pressure Ulcer Record for Resident 10 dated January 5, 2013, noted that she developed a Stage II pressure ulcer on her right buttock again. This was the fifth pressure sore to develop. A review of the Resident 10's meal intake records from January 1 through 30, 2013, noted that for 39% of her meals she consumed 50% or less. The resident's meal intake records from February 13 through 28, 2013, noted that for 67% of her meals she consumed 50% or less. Resident 10's weight on March 12, 2013, was recorded as 177.6 pounds. This weight represented a 60 pound (25%) weight loss over 8 and a half months. A Weekly Pressure Ulcer Record for Resident 10 dated March 29, 2013, noted that she developed a Stage II pressure ulcer on her right buttock again, the sixth pressure sore to develop. A Weekly Pressure Ulcer Report dated April 6, 2013, noted that a Stage II pressure sore developed on the resident's coccyx (tailbone), the seventh pressure sore to develop. A review of the most current MDS, Section G, completed on March 29, 2013, noted that Resident 10 required extensive assistance for eating. This was decline in functional ability from the previous MDS, dated [DATE] and December 27, 2012, which noted that Resident 10 was able to feed herself. A review of the Resident 10's meal intake records from March 1 through 31, 2013, noted that for 76% of her meals, she consumed 50% or less, with 15 meals refused. The resident's meal intake records from April 1 through 30, 2013, noted that for 81% of her meals, she consumed 50% or less, with 11 meals refused. A review of the physician order [REDACTED]. The recorded weight in the medical record for Resident 10 on May 6, 2013, was 170.1 pounds. This weight represented a total of 67 pounds 28% weight loss over 11 months and was less than the weight goal the resident desired. A review of Resident 10's meal intake records from May 1 through 30, 2013, noted that for 65% of her meals, she consumed 50% or less, with 8 meals refused. Weight Variance Meeting notes dated January 16, March 12 and May 14, 2013, listed [MEDICAL CONDITION] as contributing factors to weight loss. These notes dated January 16, March 12 and May 14, 2013 continued to list "Desire weight loss" as a factor contributing to weight loss despite the resident's weight dropping below her stated weight goal. A Weight Variance Meeting note dated May 28, 2013, noted that the resident's weight was 161.9 pounds. Resident 10 had lost over 75 pounds (31.7%) in 11 months. [MEDICATION NAME] (an appetite stimulant) was recommended and ordered on May 29, 2013. A review of the Resident 10's laboratory values revealed that while the resident ' s weight loss was occurring from June 20, 2012 - May 30, 2013, the facility did not monitor her protein level until May 30, 2013 when the resident had lost 75 pounds in 11 months. On May 30, 2013, her pre-[MEDICATION NAME] (a blood protein used to evaluate nutritional status) level was 12 milligrams/deciliter (mg/dl) which was low (normal range equals 17-34 mg/dl). A review of Resident 10's medical record from June 20, 2012, until June 5, 2013, showed that there was no multivitamin with minerals recommended or ordered, despite the resident's continued inadequate (not enough food eaten to support nutritional needs) food intake, [DIAGNOSES REDACTED]. A review of the medical record, from June 20, 2012, until June 5, 2013, showed that although the physician's progress notes noted Resident10's weights on each visit, there was no assessment addressing the weight loss by the physician. A physician's progress note dated June 6, 2013, noted only that Resident 10 had severe [MEDICAL CONDITION]. On June 5, 2013, a review of the facility's policy titled "Nutrition Hydration to Maintain Skin Integrity" dated December 2008, noted that, "Although poor nutritional status is associated with increased risk of pressure sore development, no specific nutritional interventions have been proven conclusively to prevent or heal pressure sores." It further noted "When there is a decline in a resident's appetite, nutritional intake, weight, or overall condition, caregivers should first attempt to discover factors compromising nutritional status and offer support with eating." On June 5, 2013, at 1200 noon, Resident 10 was interviewed and stated, "I did not want to lose that much weight. Now they want me to gain weight. They have me drinking 3 different kinds of milk. I gain and lose weight." During an interview with the RD on June 6, 2013 at 9:00 AM, she stated that the weight loss for Resident 10 was labeled "desirable" because the resident wanted to lose weight. She stated that the amount and rate of weight loss that the resident experienced was not considered "healthy weight loss." She stated that Resident 10 became weaker over the time of the weight loss and required a return to a pureed diet texture due to chewing and swallowing difficulty. She further stated that the resident did not like the pureed texture diet. She verified that she had not recommended vitamin and mineral supplements for the resident. She stated that it would have been appropriate for the resident to receive vitamin and mineral supplements for wound healing and because her food intake was inadequate. The RD stated, "Looking back, we could have monitored and done more." During an interview on June 6, 2013, at 10:05 AM with a relative of Resident 10, she stated, "She has no appetite. When I bring in food she barely eats it. She is not like she used to be. I'm not happy with the weight loss. I do not like seeing her like this. I did not realize how much weight she had lost. She was losing weight too fast. We have been taking pictures when we come and visit and since she has been here she has lost a lot of weight. It makes me sad, she has changed." During an interview with the Director of Nursing (DON) on June 6, 2013, at 11:00 AM, she verified that the RD did not usually attend the Weight Variance team meetings. She was unable to explain why the RD did not attend the meetings since the RD works three days a week. She verified that there was no other nutrition professional that attended the meetings. A telephone interview was conducted with the physician (MD) for Resident 10 on June 6, 2013, at 11:10 AM. The MD stated that although the resident's ideal body weight was 130 pounds, it did not mean that the resident should have kept losing weight. He further stated that he did not like rapid weight loss and that he was hoping her weight would stabilize. He verified that the weight loss put the resident at greater risk for wounds and skin breakdown. He stated that the resident was admitted to the facility with poor nutrition. He stated that the goal was to stabilize her nutrition status and the facility had the resident on a "watch list." Although Resident 10 expressed a desire to lose weight, it was the facility's responsibility to educate the resident on what constitutes a safe and healthy weight loss. The facility was responsible to ensure that other parameters of nutritional status did not decline as the resident experienced a desired weight loss. 2. On June 6, 2013, Resident 19's medical record was reviewed. It noted that the resident was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. A review of the Minimum Data set (MDS a comprehensive assessment of the resident) completed on April 30, 2013, noted that the resident was able to make his needs known, required supervision and set up for eating and activities of daily living. The resident weighed 123 pounds. A review of the "Weights Form" in the medical record, noted the following: January 2013, refused monthly weight. February 2, 2013, the weight wad 122.8 and on February 9, 2013, the weight was 122.9 pounds March 2013, refused monthly weight April 2013, refused monthly weight May 2013, weight was 108.0 pounds. There were no initials on the Weight Form that the nurses acknowledged the weight loss and documented in the medical record, the physician and family/responsible party were notified and the care plan was updated. A review of the Registered Dietitian (RD) annual "Nutritional Care", assessment completed on October 30, 2012, noted that the resident was 64 inches and weighted 129 pounds. The resident's ideal body weight (IBW) was 130 pounds) and his usual weight was 124 - 141.6 pounds. The goal was for no significant weight loss and for the resident to consume 75 -100 % of his diet. A review of the physician recapitulated (summarized) orders for June 1 - 30, 2013, included the following: On September 3, 2010, [MEDICATION NAME] (an antidepressant medication used to stimulate appetite) 15 mg tablet at bedtime for depression m/b (manifested by or clearly shown by) poor appetite. On October 27, 2011, NAS (no added salt) diet. On April 23, 2012, Resource 2 CAL (a high calorie protein drink) 120 ml 4X (four times) daily. A review of the "Interdisciplinary Assessment and Progress Notes" dated April 23, 2012, noted that the resident was being administered an antidepressant for poor appetite. There was no documentation of the recommendations. A review of the "Nutrition Quarterly Note", completed by the Dietary Services Supervisor (DSS) on May 5, 2013, noted no significant weight change. The Goals were: 1. Nutritional prescription to meet 75 - 100% of estimated need. 2. No significant/unintentional/avoidable weight changes. 3. No signs and symptoms of dehydration The recommendation was to continue current nutritional plan of care. A review of the "Weekly Progress Notes" noted the following: a. "April 4, 2013, appetite 50-60%." b. "April 12, 3013 and April 19, 2013, appetite 50 -100%." c. "May 3, 2013, appetite 0-100%." d. "May 10, 2013, appetite refused -50%." e. "May 17, 2013, 50 -100 %." "Patient refuses what's on his tray but always ask for alternatives he loves apple juice and peanut butter and jelly sandwiches." f. "May 31, 2013, appetite 50 %." "[MEDICATION NAME] 15 mg Patient refuses what is on his tray for meals and always wants 2 peanut butter and jelly sandwiches with 2 glasses of apple juices." A review of the care plan titled, "Potential for Significant Weight Loss, Related to Poor Appetite", initiated September of 2010, (per DON), noted the following goals: a. Resident will gain of 1-3 pounds a week. b. Maintain weight between 130, plus or minus 10 pounds. c. Resident will have no significant weight loss. The following interventions were reviewed on 4/13: a. Weight per protocol. b. Give diet and fluids per MD order. c. Encourage food intake of 90-100% every meal. Offer alternatives when intake is below 75%. d. Refer to weight variance program or weekly weights for close monitoring of weight prn. e. RD evaluation. f. Notify MD of any significant weight changes. A review of the care plan titled, "Risk for Altered Nutritional Status and/or Dehydration due to Dementia and Depression", initiated on July 24, 2011, noted a desired goal weight of 125 pounds, plus or minus 5 pounds. The interventions included: a. "RD evaluation/recommend." b. "Honor food preferences within diet parameters." c. "Offer substitute if meal refused." d. "Provide 4 ounces of shake two times daily with meals." An interview was conducted on June 6, 2013, at approximately 9:00 AM with LVN 3, who was responsible for the supervision of Resident 19's care. LVN 3 stated that the resident had been refusing the diet served but requested 2 peanut butter and jelly sandwiches and 2 glasses of apple juice for meals. About 2 weeks ago the resident was not drinking the Resource (high protein) 2.0 supplement but started to drink it again. On June 6, 2013, at 9:02 AM, Resident 19 was observed pushing his wheel chair as he ambulated in the hallway. An interview with the resident was unsuccessful. An interview was conducted on June 6, 2013, at 9:05 AM, with Certified Nursing Assistant (CNA) 9, who was assigned to provide care for Resident 19. CNA 9, stated that she had not provided care for the resident in a while but was told that he was doing well, except that he was not eating the meals served. An interview was conducted on June 6, 2013, at 9:27 AM with the Dietary Services Supervisor (DSS). She stated that she became aware of Resident 19's weight loss on May 28, 2013, and met with the IDT (Interdisciplinary Team) which included the DON and Social Services and they discussed the weight loss. There was no documented evidence in the medical record of the IDT meeting that was conducted on May 28, 2013. The DSS stated that the resident had been refusing to be weighed and that the weight was not available for several months. The decision was made at that time not to do anything until a care conference was conducted with the family. An interview was conducted on June 6, 2013, at 9:33 AM, with the DON. She stated he was a difficult resident that wanted to do his own thing, and that they respected his choices. The DON was asked what was the current plan to address the resident's weight loss. She responded, "Continue to monitor the patient; encourage patient to obtain weight for baseline; encourage more nourishments/snacks, picky eater and update food preferences. Call for IDT weight variances to monitor him". An interview was conducted on June 6, 2013, at 10:09 AM, with the Social Services Designee (SSD). She stated that the IDT met on May 28, 2013, and discussed the Resident's weight loss. She stated that the family had not been responding to the facility's phone calls and had not been visiting the resident because he had been mean to them when they visited. She stated that the IDT wanted the family involvement in addressing the resident's weight loss. The SSD was asked at what point the facility would implement interventions to address the resident's weight loss. She stated that the IDT would meet, but the meeting was not scheduled, as of June 6, 2013, at 10:15 AM. An interview was conducted on June 6, 2013, at 10:00 AM, with the RD. Resident 19's weight loss was discussed. The RD stated that she was not aware of the resident's weight loss. She stated that she visited the facility 3 days a week and was in the facility 2 days this week and was not notified of the resident's weight loss. The RD stated that usually she received a consultation request from nursing to evaluate the resident; if it was urgent the DSS would notify her with a telephone call. 3. A clinical record review for Resident 23 on June 5, 2013 was conducted. Resident 23 was admitted from an acute care hospital on May 6, 2013, after a fracture of her right hip with open reduction internal fixation (surgical placement and repair), weakness, Alzheimer's, senile dementia (significant loss of intellectual abilities, such as memory capacity, that is severe enough to interfere with social or occupational functioning.) At the time of admission, the resident weighed 139.6 pounds. During record review of Resident 23's health record on June 5, 2013, the admitting inventory of personal belongings, dated May 6, 2013, noted that she had a set of full upper dentures. During further clinical record review for Resident 23 on June 5, 2013, it was noted that on May 7, 2013,a care plan titled "Risk for altered nutritional status and/or dehydration (inadequate amount of fluid in the body to sustain life), "reflected the following goals: Will have adequate compliance with therapeutic(specialized for a specific disease process) diet daily x (times) 90 days. Will consume at least 75% of meals x 90 days. Will be satisfied with food x 90 days. Will have no s/s (signs or symptoms) of dehydration x 90 days. Will have adequate protein to improve [MEDICATION NAME] (protein in the blood) x 90 days. Will have adequate nutrition to support skin/wound healing x 90 days. Will provide diet, supplement as accepted, and tolerated x 90 days. During further clinical record review for Resident 23 on June 5, 2013, the facility's weights form for Resident 23 showed: May 6, 2013 139.6 pounds May 11, 2013 131.8 pounds This represented a loss of 7.8 pounds. During further clinical record review for Resident 23 on June 5, 2013, a "Diet Order and Communication," dated May 11, 2013 noted, "Soft texture diet until dentures found!!" During further clinical record review for Resident 23 on June 5, 2013, it was noted that a "Weight Variance Meeting" was held. On May 13, 2013, a weight loss of 7.8 pounds was noted. Equaling a 5.6% loss. Recommendations were to monitor meal intake, recommend feeder program, Registered Dietician (RD) to assess, and to continue weekly weights as ordered. Signatures included the Dietary Services Supervisor (DSS) among others, but did not include the RD. During further clinical record review for Resident 23 on June 5, 2013, the facility's weights form for Resident 23 noted: May 18, 2013 127.6 pounds This reflected a weight loss of 4.2 pounds since May 11, 2013. During further clinical record review for Resident 23 on June 5, 2013, a "Weight Variance Meeting", was dated May 20, 2013 with further weight loss of 4.2 pounds equaling 3.2% body weight lost since the last weight on May 13, 2013. During further clinical record review for Resident 23 on June 5, 2013, the facility's weights form for Resident 23 and it noted: May 26, 2013 121.8 pounds This weight reflected a loss of 5.8 pounds. During further clinical record review for Resident 23 on June 5, 2013, initiated on May 28, 2013, a care plan was implemented for "Weight Loss 4.5% in 7 days" it reflected the following goals: Will be able to stabilize lost weight in 30 days. Resident will have no further weight changes in 30 days. No revisions were noted to the earlier care plan. During further clinical record review for Resident 23 on June 5, 2013, a "Weight Variance Meeting", dated May 28, 2013 reflected a weight loss of 5.8 pounds equaling 4.5 % since the last weight on May 20, 2013. Recommendations were to add [MEDICATION NAME] (an appetite stimulating medication) 400 milligrams PO BID (by mouth twice daily) with meals. Continue with feeding program. Continue with house nourishment each morning. Recommend fortified (foods [MEDICATION NAME] with proteins, fiber and or vitamins and minerals) diet. Recommend Resource (a liquid dietary supplement) 90cc (cubic centimeters, a liquid measure) TID at Med Pass (three times a day with medications.) The RD and DSS were two of the team members present. During an interview conducted with the Assistant Social Services Designee (ASSD), on June 5, 2013, at 3:00 PM, she stated, in regards to the missing dentures, the family wanted to wait until Resident 23's MediCal insurance coverage began to cover the replacement of the dentures. The ASSD stated that the facility would not have taken any furthur action to replace the dentures. During an interview with Resident 23's significant other, on June 5, 2013 at 3:10 PM, when asked when the dentures were lost, she stated that the dentures were lost not long after the resident's admission. She also stated that the dentures, "Were lost while the resident was in the facility and they should replace them." When asked when the MediCal coverage would begin, she stated that it would be around 45 days. During an interview with the Director of Nursing (DON), on June 5, 2013, at 3:25 PM, she stated, when asked if she was aware that Resident 23 was missing her dentures, she stated that she, "Was unaware of this," and stated that she would speak about it with the Administrator since dentures are very expensive. During an interview with RNA 3 on June 6, 2013, at 8:30 AM, the RNA was observed exiting Resident 23's room with a breakfast tray. She stated that the tray belonged to Resident 23 and that she refused her meal. During clinical record review of Resident 23's logs for meal percent