Every finding on record at Rocky Point Care Center

Based on Interviews and record reviews, the facility failed to report an allegation of chemical restraint to the California Department of Public Health (the Department) within two hours after facility staff became aware of the allegation for one resident (Resident 3) of three sampled residents, when Licensed Nurse 2 (LN 2) was alleged to have administered medication to Resident 3 that was not his and without a physician's order.This failure decreased the facility's potential to protect Resident 3 from possible continuing chemical restraint.A review of Resident 3's Situation, Background, Assessment, and Recommendation (SBAR, a communication tool used among healthcare professionals) dated 8/26/26 at 5:39 p.m. indicated an allegation of administration of hydroxyzine hydrochloride (hydroxyzine, a prescription medication that calms the central nervous system by blocking receptors in the brain to help control short-term anxiety and tension caused by nervous and emotional conditions by causing drowsiness or fatigue) to Resident 3 without a physician's order for the medication.In an interview with LN 1 on 8/28/26 at 2:11 p.m., LN 1 stated on 8/20/26 LN 2 notified LN 1 that she gave Resident 3 hydroxyzine because Resident 3 was making animal sounds during her shift. On 8/23/26, LN 1 found Resident 2's hydroxyzine blister pack (a plastic packaging system with individual sealed pockets that hold single doses of medication tablets) stored among Resident 3's medication in the medication cart. LN 1 then removed Resident 2's hydroxyzine medication and slid it under the Director of Staff Development's (DSD) office door so it was inaccessible. When LN 1 returned to the facility on 8/26/26, LN 1 found Resident 1's blister pack of hydroxyzine among Resident 3's medication in the medication cart and reported it to the DSD on 8/26/26.In an interview with the DSD on 8/31/26 at 2:40 p.m., the DSD reported that she figured out why Resident 2's hydroxyzine blister packet was in her office a couple days later when LN 1 notified her that LN 2 had told her she gave hydroxyzine to Resident 3 without a physician's order. The DSD acknowledged LN 1 knew about the alleged abuse on 8/23/26 but reported it to the DSD on 8/26/26.In an interview on 8/21/26 at 3:14 p.m., the Administrator (ADM) stated LN 1 was a mandated reporter and could have reported the allegation of abuse without asking him for permission when LN 2 allegedly notified her of the abuse on 8/20/26.A review of the facility's policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating revised September 2025 indicated, If resident abuse.is suspected, the suspicion must be reported immediately to the administrator and to the other officials according to state law. The administrator or the individual making the allegation immediately reports.her suspicion to the following persons or agencies.The state licensing/ certification agency responsible for surveying/licensing the facility.The local/state ombudsman.The resident's representative.Law enforcement officials.The resident's attending physician.and the facility medical director. 'Immediately' is defined as within two hours of an allegation involving abuse.

Based on interviews and record review, the facility failed to ensure pharmaceutical services met the needs of three residents (Resident 1, Resident 2, and Resident 3) of three sampled residents when:Resident 1 and Resident 2's hydroxyzine hydrochloride (hydroxyzine, a prescription medication that calms the central nervous system by blocking receptors in the brain to help control short-term anxiety and tension caused by nervous and emotional conditions by causing drowsiness or fatigue) was found missing; and,Medication destruction was not conducted per State regulation and the facility's policy and procedure.These failures decreased the facility's potential to: accurately reconcile prescription medication and safely administer medications per professional standards.Findings:A review of Resident 1's admission record indicated admission to the facility in August 2026 with diagnoses which included mood affective disorder (a mental health condition which causes persistent, severe emotional states like extreme sadness or elation).A review of Resident 2's admission record indicated admission to the facility in August 2026 with diagnoses which included pruritus (an urge to scratch the skin).A review of Resident 3's admission record indicated admission to the facility in July 2026 with diagnoses which included insomnia (a common sleep disorder that makes it difficult for a person to fall asleep or stay asleep).A review of Resident 3's Minimum Data Set (MDS, an assessment tool) dated 7/8/26 indicated his thinking and memory processes were intact.A review of Resident 3's Medication Administration Record (MAR) dated August 2026 indicated no physician's order for hydroxyzine.A review of Resident 2's MAR dated August 2026 indicated Resident 2 had an order to receive hydroxyzine as needed for itching and was never administered any tablets that month. The MAR also indicated Resident 2's hydroxyzine medication was discontinued on 8/13/26 at 9:59 a.m.A review of Resident 1's MAR dated August 2026 indicated Resident 1 was administered one tablet of hydroxyzine as needed for anxiety on 8/19/26 at 12:41 a.m. The MAR also indicated Resident 1's hydroxyzine medication was discontinued on 8/20/26 at 10:02 a.m.A review of Resident 3's Situation, Background, Assessment, and Recommendation (SBAR, a communication tool used among healthcare professionals) dated 8/26/26 at 5:39 p.m. indicated an allegation of administration of hydroxyzine to Resident 3 without a physician's order for the medication.A review of Resident 3's progress note dated 8/27/26 at 9:26 p.m. indicated, Resident is on alert charting for alleged medication administration without an order from MD [physician]. Resident tired today. Seen slumped to the side in his wheelchair sleeping.In an interview with LN 1 on 8/28/26 at 2:11 p.m., LN 1 stated on 8/20/26 LN 2 notified LN 1 that she gave Resident 3 hydroxyzine because Resident 3 was making animal sounds during her shift. On 8/23/26, LN 1 found Resident 2's hydroxyzine blister pack (a plastic packaging system with individual sealed pockets that hold single doses of medication tablets) stored among Resident 3's medication in the medication cart. LN 1 then removed Resident 2's hydroxyzine medication and slid it under the Director of Staff Development's (DSD) office door so it was inaccessible. When LN 1 returned to the facility on 8/26/26, LN 1 found Resident 1's blister pack of hydroxyzine among Resident 3's medication in the medication cart and reported it to the DSD on 8/26/26.A review of the facility's LN schedule indicated the following LNs were assigned to care for Resident 3 between 8/23/26 and 8/26/26:8/23/26:AM (approximately 6 a.m. to 2:30 p.m.) shift - LN 1PM (approximately 2 p.m. to 10:30 p.m.) shift - LN 1NOC (approximately 10 p.m. to 6:30 a.m.) shift - LN 28/24/26:AM shift- LN 5PM shift- LN 4NOC shift- LN 38/25/26:AM shift- LN 4PM shift- LN 4NOC shift- LN 38/26/26:AM shift- LN 1 A review of the facility's untitled document dated 8/22/26 which came from the medication destruction log indicated that LN 2 destroyed Resident 2 and Resident 3's medications without a witness' signature. The medication LN 2 destroyed for Resident 3 did not include Resident 3's hydroxyzine.A review of a picture of Resident 1's hydroxyzine blister packet was conducted on 8/28/26 at 2:50 p.m. The label on the blister packet indicated the pharmacy dispensed 30 tablets of hydroxyzine to the facility on 8/18/26. The picture showed the blister packet contained 13 tablets of hydroxyzine rather than the 29 tablets that should have been present because Resident 1 was only given one tablet on 8/19/26 and the order was discontinued on 8/20/26.In an interview with Resident 3 on 8/31/26 at 9:40 a.m., Resident 3 stated he felt a little more drowsy than usual in the last couple of weeks. Resident 3 added he usually did not nod off when he was in his wheelchair, but staff have recently had to wake him up twice because he was nodding off. Resident 3 stated he was not aware of what his medications looked like because he knew there was a possibility that the medications they gave him at the facility could have a different brand name or shaped differently from the medications he took at home. Resident 3 stated he recalled a time when a nursing aide came to his room and notified him that he had been making chirping sounds in his sleep. Resident 3 stated he was unaware he was doing this and stated he may have been dreaming but had not intentionally done it. Resident 3 admitted to making grunting sounds when he tried to transfer himself from chair to bed and that sometimes he made a hooting sound but did not believe it had bothered other residents.In an interview with LN 2 on 8/31/26 at 1:04 p.m., LN 2 denied telling LN 1 she administered hydroxyzine to Resident 3. LN 2 stated she may have told LN 1 that Resident 3 would benefit from hydroxyzine to aid with sleep.In an interview with the DSD on 8/31/26 at 2:40 p.m., the DSD stated on 8/24/26 she found Resident 2's hydroxyzine blister packet on her office floor and it looked like it had been slid underneath her door. The DSD stated the blister packet did not have a note, so she did not know why it was there. The DSD reported that she figured out why Resident 2's hydroxyzine blister packet was in her office a couple days later when LN 1 notified her that LN 2 had told her she gave hydroxyzine to Resident 3 without a physician's order. The DSD acknowledged Resident 2's hydroxyzine blister packet was missing five tablets and Resident 1's blister packet was missing 14 tablets based on their August 2026 MARs.A review of a picture of Resident 2's hydroxyzine blister packet was conducted on 9/2/26 at 8 a.m. The label on the blister packet indicated the pharmacy dispensed 30 tablets of hydroxyzine to the facility on 8/5/26. The picture showed the blister packet contained 25 tablets of hydroxyzine rather than the 30 tablets that should have been present since Resident 2 was never administered hydroxyzine and the order was discontinued on 8/13/26.In an interview with the DSD on 9/2/26 at 1:35 p.m., the DSD stated when a medication was discontinued or if the resident passed away, (such as Resident 2) the LN was expected to remove the resident's medication from the medication cart and place it in the storage medication room for destruction. The nocturnal shift (NOC) was expected to destroy discontinued medication daily and document the destroyed medication in the destruction log. The discontinued medication was then placed in the medication destroyer jug which contains chemicals that deconstruct the medication. The DSD clarified uncontrolled prescription medication could be destroyed by one nurse without another nurse witnessing the destruction. The DSD acknowledged LN 2 worked the NOC shift on 8/20/26 because another nurse had called out. The DSD verified LN 2 logged the destruction of Resident 1 and Resident 2's medications on 8/22/26 and that both residents' hydroxyzine was not included in the destroyed medications. The DSD also confirmed LN 2 had not destroyed Resident 1 and Resident 2's hydroxyzine on 8/22/26 because the pictures of the blister packs were taken on 8/26/26.In a telephone interview with LN 4 on 9/10/26 at 5:12 p.m., LN 4 confirmed she worked the PM shift on 8/25/26 and was assigned to Resident 3. LN 4 stated she did not remember seeing another resident's medications within Resident 3's medications. LN 4 stated she had never destroyed medications at the facility nor has been asked to witness medication destruction on either the PM or NOC shifts she has worked. LN 4 verified medication destruction was usually conducted during the NOC shift. LN 4 acknowledged she has seen Resident 3 have difficulty sleeping throughout the night but had never observed Resident 3 yell out or make loud noises at night.In an email correspondence with the ADM on 9/11/26 at 8:53 a.m., the ADM indicated LN 3 would be unavailable for interview due to a family emergency. LN 3's return to work was unknown at the time.In a telephone interview with LN 5 on 9/14/26 at 10:26 a.m., LN 5 stated he had not observed other residents' medication stored with Resident 3's medication during his AM shift. LN 5 also stated he has never destroyed medications at the facility because medication destruction was a NOC shift responsibility.A review of the facility's policy and procedure (P&P) titled Storage of Medications revised May 2025 indicated, Drugs and biologicals used in the facility are stored in locked compartments.Only persons authorized to prepare and administer medications have access to locked medications.Discontinued.drugs or biologicals are returned to the dispensing pharmacy or destroyed.The medication disposition record will contain the following information.The resident's name; Date medication disposed.The quantity disposed; Method of disposition; Reason for disposition; and Signature of witnesses.Staff shall contact the provider pharmacy if they are unsure of proper disposal methods for a medication.A review of the California Code of Regulations section 72371(c)(2) indicated, Drugs not listed under Schedules II, III or IV of the Federal Comprehensive Drug Abuse Prevention and Control Act of 1970 shall be destroyed by the facility in the presence of a pharmacist or licensed nurse. The name of the patient, the name and strength of the drug, the prescription number if applicable, the amount destroyed, the date of destruction and the signatures of the person named above and one other person shall be recorded in the patient's health record or in a separate log. Such log shall be retained for at least three years.A review of the facility's P&P titled Discarding and Destroying Medication revised April 2024 indicated, Both controlled and non-controlled substances may be disposed of in the collection receptacle.A review of the undated manufacturer's user guidelines for the medication destroyer the facility used indicated, Log your waste in.drug inventory sheet.Load medications into the Rx Destroyer(R) bottle.Load pills.Tightly secure cap and gently agitate.A review of the facility's P&P titled Administering Medications revised April 2026 indicated, Medications are administered.as prescribed. Medications are administered in accordance with prescriber orders.The individual administering medications verified the resident's identity before giving the resident his.medications. Methods of identifying the resident include.if necessary, verifying resident identification with other facility personnel. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication.before giving the medication.Medications ordered for a particular resident may not be administered to another resident.and approved by the director of nursing services.

Based on interviews and record reviews, the facility failed to ensure one of four residents sampled for abuse, (Resident 1's) right to remain free from verbal abuse by Certified Nursing Assistant A (CNA A), when CNA A came to work under the influence of alcohol, acted erratically, and intimidated and yelled at Resident 1.This failure caused Resident 1 to feel frightened and concerned about retaliation from CNA A.A review of Resident 1's admission record indicated Resident 1 was admitted in 06/26, with diagnosis of Thoracic Vertebral Compression Fracture (occurs when a vertebral body in the middle or upper spine collapses, typically due to bone thinning or trauma, such as a fall). A review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 6/26/26, indicated Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident with a scoring range of 0-7 indicating severe cognitive impairment, 8-12 indicating moderate cognitive impairment, and 13-15 indicating cognitively intact) score of 15, indicating no cognitive impairment. During an interview on 7/20/26 at 12:25 p.m., in Resident 1's room, Resident 1 reported, on 7/4/26 at approximately 10 p.m., she heard CNA A screaming and fighting with someone over the phone in the hallway very loudly. Resident 1 called out for CNA A to please be quiet. Resident 1 stated, CNA A then entered her room and ripped open her curtain, and proceeded to yell at her, What do want now! It's only 10 o'clock. Resident 1 stated when CNA A came around the side of the bed to turn off the call light, CNA A lowered her mask to say something rude, and Resident 1 could smell alcohol on CNA A's breath. Resident 1 stated, I was frightened, and now I worry CNA A might retaliate, I wish they could lock the front door. Resident 1 stated she had written down what had occurred right after it happened and gave it to the Administrator (ADM). Resident 1 stated the ADM addressed her concerns right away, and Resident 1 had not seen CNA A since. A review of a written statement by Resident 1 detailing the incident, dated 7/4/26 at 10 p.m., indicated Resident 1 yelled at CNA A, Who are you, and CNA A stated her name with a, crazed look. The written statement further indicated Resident 1 felt the whole incident was a, Nightmare, and Resident 1 was fearful of retaliation. During an interview on 7/20/26 at 2:54 p.m., with CNA B in the hallway, CNA B stated she arrived for her shift on 7/5/26, at approximately 2 a.m., and CNA A was acting strange, was very loud, argumentative, and smelled of alcohol. CNA B stated, while caring for Resident 1, Resident 1 told CNA B that CNA A had screamed and yelled at Resident 1, and Resident 1 was scared. A review of a written statement by CNA B detailing the incident, dated 7/5/26, indicated CNA A smelled of alcohol, had been asleep and not answering call lights, and was argumentative. It further indicated, while Resident 1 reported the verbal abuse to CNA B, Resident 1 began to cry and asked to speak to the charge nurse. During an interview on 7/20/26 at 3:03 p.m., with Licensed Nurse A (LN A) in the hall outside the Director of Staff Development's office, LN A stated Resident 1 reported to LN A later in the morning on 7/5/26, that CNA A had screamed and yelled at Resident 1. LN A stated CNA A was more manic than usual when she arrived for her shift on 7/4/26. LN A stated CNA A was often loud and animated, but this day was different. LN A stated she recalled walking past Resident 1's room around 10 p.m., and saw CNA A in the room but had not heard what was being said. LN A stated CNA A was in a personal state of crisis, possibly under the influence, and yelling at residents was unacceptable. During a telephone interview on 7/21/26 at 11:35 a.m., with LN B, LN B stated CNA B approached her during the early morning on 7/5/26, and told LN B that something was not right with CNA A, and CNA B could smell alcohol on CNA A's breath. LN B stated CNA A was acting erratically, talking very loudly, and was becoming agitated with other staff. LN B stated another nursing assistant then approached LN B and reported seeing CNA A exiting Resident 1's room earlier that evening, and CNA A had yelled out, She is such a bitch. During an interview on 7/20/26 at 3:13 p.m., with the Director of Staff Development (DSD), the DSD stated she was aware of the incidents during the night and early morning shifts on 7/4/26 and 7/5/26, with CNA A. The DSD stated CNA A coming to work under the influence and yelling at residents was completely unacceptable and put residents and staff at risk. The DSD stated, due to the incident and some other infractions the decision was made to terminate CNA A's employment at the facility. During an interview on 7/20/26 at 4:45 p.m., with the ADM, the ADM stated he did a full investigation of the incident. The ADM stated he spoke to Resident 1 who reported her main concern was that she never would see CNA A at the facility ever again. The ADM stated he interviewed all staff involved and other residents in CNA A's assignment, and no other residents had complaints. The ADM stated, ultimately the decision was made to terminate CNA A's employment with the facility as of 7/17/26, and CNA A had not been allowed to return to work prior to her termination. A review of the facility Handbook, page 65-66, under, Employee Conduct and Work Rules, indicated, Use of threatening, vulgar, demeaning, aggressive or bullying language toward residents, family, visitors, fellow employees, and or management.and. Possession or use of illegal substances or alcohol on Company time or premises.and. Reporting to work under the influence of drugs or alcohol, or in an otherwise unfit condition to work safely . are considered serious misconduct.A review of a facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 04/2021, indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.These findings represent past non- compliance with this regulatory requirement. Interview and record review confirmed the facility acted immediately after the incident became known, and acted accordingly, resulting in the termination of the employee. Resident 1 was satisfied with the outcome and did not report ongoing concerns during the investigation. All staff involved were interviewed and gave written statements of the incident. There was sufficient evidence that the facility corrected the violation as of 7/17/26, and no other occurrences of noncompliance were identified. At the time of the survey, the facility was in substantial compliance with the regulatory requirement, and therefore, this violation does not require a plan of correction.

Based on interviews and record reviews, the facility failed to ensure resident-centered care and services were provided, as ordered, for one of two sampled residents (Resident 2), requiring 1:1 (one-to-one) close supervision, when Patient Companion A (PC A) had fallen asleep during his shift, and Resident 2 was found by Licensed Nurse B (LN B) in a dangerous and vulnerable position with her chest and torso facing upwards and sideways across the bed, and with her legs hanging off of the bed and onto the floor.This failure to provide continuous supervision, as ordered, put Resident 2 at risk for slipping or falling which could result in a serious injury such as a fracture or head trauma.A review of Resident 2's admission record indicated Resident 2 was admitted in 03/26, with the diagnoses of Severe Vascular Dementia with Agitation (involves advanced brain damage from reduced blood flow, causing extreme restlessness, distress, and behavioral outbursts), Chronic Pain (lasting or recurring physical discomfort that continues for more than three to six months) and Chronic Kidney Disease (when kidneys are damaged and cannot filter blood properly, causing waste to build up). A review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 6/26/26, indicated Resident 2 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident with a scoring range of 0-7 indicating severe cognitive impairment, 8-12 indicating moderate cognitive impairment, and 13-15 indicating cognitively intact) score of 00, indicating severe cognitive impairment. A review of Resident 2's active Physician Orders indicated an order for a patient companion 24/7 (24 hours a day 7 days a week) started on 1/20/26. A review of Resident 2's current Care Plan Report indicated Resident 2 required a 1:1 attendant due to cognitive impairment, balance problems, vascular dementia, muscle weakness, incontinence, communication deficit, poor safety awareness, inconsolable yelling out and anxiety, and physical behaviors such as scratching and biting. Due to these disease processes and symptoms, Resident 2 was at risk for dehydration, high risk for falls and injury, medication effects and side effects, self-care deficit, skin breakdown and isolation. During an interview on 7/20/26 at 1:17 p.m., with Resident 2's Responsible Party (RP), the RP stated she had come to visit Resident 2 a few weeks ago late at night and found the male companion, sitting with Resident 2, fast asleep. The RP stated she informed the Director of Staff Development (DSD) of her concern over the phone the next day. A review of the facility staffing schedule, dated 7/6/26, confirmed PC A was assigned for 1:1 supervision for Resident 2 during the night and early morning shift. During an interview on 7/21/26 at 11:35 a.m., with LN B, LN B stated on the morning of 7/7/26, while giving report to the oncoming nurse, a Certified Nursing Assistant approached both nurses and told them to come to Resident 2's room right away. LN B stated when they entered Resident 2's room, PC A was fast asleep in the chair, and Resident 2 was in a dangerous and vulnerable position with her chest and torso facing upwards and sideways across the bed, and with her legs hanging off of the bed and onto the floor. LN B stated they woke up PC A to ask him how Resident 2 got into this position, PC A stated he did not know and left the room. LN B stated Resident 2 was not able to respond to their questions and had a, Petrified look on her face. LN B stated PC A was currently the only male companion staff during the night shifts. During an interview on 7/20/26 at 3:13 p.m., with the DSD in her office, the DSD stated she was notified of the incident on 7/7/26, over texts by both LN B and the oncoming nurse. The DSD stated she had no documentation of the incident or documentation of the education or disciplinary action with PC A at this time. The DSD stated a patient companion falling asleep did not meet her expectation, as patient companions were supposed to provide constant supervision, prevent accidents, and keep residents safe. A review of a facility document titled, Patient Companion Job Description, not dated, indicated, Essential job functions are to provide continuous observation of the resident by remaining with them at all times. Reports significant observations to appropriate clinical staff including, but not limited to Nurses, Charge Nurse, Director of Nursing, and Physicians. Maintain appropriate documentation, charts, and related records. Ensure the comfort of residents. A review of a facility policy titled, Disciplinary Action, dated 2001, indicated, Prompt and courteous attention to the needs of our residents, the following of established job descriptions, work assignments, infection control techniques, etc., must be our common concern. Anything less than professional behavior is not only inappropriate but is a hindrance to the well-being of all concerned.

Based on interview and record review, the facility failed to provide written notices of bed-hold policies for two of three sampled residents (Resident 1 and 2) wo were transferred from the facility.This failure placed the two residents at risk for unlawful discharge from the facility.During a review of Resident 1's Face Sheet (a summary of the patient's essential personal, clinical, and insurance information), the Face Sheet indicated Resident 1 was admitted to the facility with diagnoses including severe dementia with behavioral disturbance (often manifested as agitation, aggression, and delusions), hiatal hernia (a condition where the upper part of the stomach bulges into the chest), chronic pain, encephalopathy (a syndrome of overall brain dysfunction), anxiety (fear and worry that is both intense and excessive), insomnia (difficulty falling or staying asleep), cerebral palsy (a brain disorder that affects body movement and muscle coordination), and recurrent depressive disorder (a mental health condition characterized by repeated episodes of loss of interest and feelings of sadness).During a review of Resident 1's SBAR Communication Form and Progress Note, dated 2/5/26, the note indicated Resident 1 had uncontrolled pain and a change in mental status, and a transfer to ER (Emergency Room) was requested by the family.During an interview on 4/2/26 at 11:39 a.m., Responsible Party (RP) stated Resident 1 was originally admitted to the facility on [DATE]. RP stated she did not receive any written bed-hold notice, nor any paperwork, from the facility during Resident 1's transfer to the emergency room on 2/5/26.During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility with diagnoses including acute respiratory failure (a condition where the blood does not have enough oxygen levels), chronic kidney disease (progressive loss of kidney function), chronic pain, unspecified dementia, and congestive heart failure (long-term condition where the heart muscle could not pump effectively).During a review of Resident 2's Progress Notes, dated 3/19/26, the note indicated Resident 2 was transferred out to the [GACH] for periods of unresponsiveness and panicked rapid breathing.During an interview on 4/2/26 at 2:54 p.m., the Director of Staff Development (DSD) stated there were no written bed-hold notifications provided to the residents or their responsible parties during transfers. The DSD stated the residents, or their responsible parties, were notified of bed-hold policies verbally via phone calls.During a concurrent interview and record review on 4/2/26 at 2:56 p.m. with the Director of Nursing (DON), Resident 1's medical records were reviewed. DON stated there was no record that a written bed-hold policy was provided to Resident 1's RP for her ER transfer on 2/5/26.During a concurrent interview and record review on 4/2/26 at 3:07 p.m. with the DON, Resident 2's medical records were reviewed. DON stated there was no record that a written bed-hold policy was provided to Resident 2 for her [GACH] transfer 3/19/26.During an interview on 4/2/26 at 3:10 p.m., the DON stated bed-hold notices should be written. The DON stated they needed a lot of staff re-education and a review of their policies and procedures.During a review of the facility policy titled, Bed-Holds and Returns, dated 2/2026, the policy indicated, All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided with written notice about these policies at least twice: a. notice 1: well in advance of any transfer (e.g., in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours) .

Based on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1) after hospitalization, referencing prehospitalization behaviors despite no change in Resident 1's health care needs.This finding resulted in the resident being transferred to another skilled nursing facility after hospitalization, further away from family who could advocate for his needs. This had the potential to result in Resident 1 experiencing unnecessary disruption in his care, emotional distress, and a lack of continuity in treatment and services.Findings:During a review of Resident 1's Face Sheet (a summary of the patient's essential personal, clinical, and insurance information), the Face Sheet indicated Resident 1 was admitted to the facility with diagnoses including severe dementia with behavioral disturbance (often manifested as agitation, aggression, and delusions), hiatal hernia (a condition where the upper part of the stomach bulges into the chest), chronic pain, encephalopathy (a syndrome of overall brain dysfunction), anxiety (fear and worry that is both intense and excessive), insomnia (difficulty falling or staying asleep), cerebral palsy (a brain disorder that affects body movement and muscle coordination), and recurrent depressive disorder (a mental health condition characterized by repeated episodes of loss of interest and feelings of sadness).During a review of Resident 1's SBAR Communication Form and Progress Note, dated 2/05/26, the note indicated Resident 1 had uncontrolled pain and a change in mental status, and a transfer to ER (Emergency Room) was requested by the family.During a review of Resident 1's Hospitalist Discharge Summary dated 2/26/26, the Discharge Summary indicated, Patient is in stable condition for transfer to SNF today.During an interview on 4/2/26 at 11:39 a.m., Responsible Party (RP) stated Resident 1 was originally admitted to the facility on [DATE]. RP stated she visited Resident 1 while she was at the hospital and was very involved in her discharge planning. RP stated she wanted Resident 1 to return to the facility after her hospitalization, but the facility repeatedly refused. RP stated the hospital first requested Resident 1's readmission to the facility on 2/13/26 but it was something about the medications that made them unable to readmit her. RP stated despite the hospital physician adjusting the medications, the facility still would not allow Resident 1's return. RP stated Resident 1 had a 1:1 sitter (a staff who provides continuous, direct observation of a single patient in a care facility) prior to her hospitalization, but on 2/25/26, she was asked by the facility Administrator if she would be able to pay for a private sitter if they readmitted Resident 1. RP stated it was frustrating when she stated she could not afford a private sitter, and the facility continued to refuse Resident 1's readmission due to not being able to meet her needs without explaining what those needs were. RP stated Resident 1 was eventually transferred the next day, 2/26/26, to another skilled nursing facility. RP stated it was hard to make regular visits to Resident 1 at the other facility because it was a lot farther and was concerned about Resident 1's adjustment to the new and unfamiliar place.During a review of Resident 1's [GACH] Update Care Coordination Note, the note indicated phone calls to the facility on 2/18/26 and 2/19/26 regarding Resident 1's return. A review of Resident 1's Update Care Coordination Note, dated 2/20/26, indicated, [facility] re-evaluating the referral after med changes since yesterday and today declined to take the pt stating they 'could not meet her needs.' CM requesting to know which needs they are unable to meet. Further review of Resident 1's Update Care Coordination Note indicated an attempted call to the facility Administrator on 2/24/26 to discuss her return. A review of Resident 1's Update Care Coordination Note, dated 2/25/26, indicated the facility Administrator visited Resident 1 at the hospital, and upon meeting with the case management team, asked for additional information about Resident 1 to provide to his nursing consultant. The note further indicated, When asked on needs that they were unable to provide for patient or concerned about providing for the patient, question (sic) went unanswered. @1715 (At 5:15 p.m.) Spoke with. daughter. provided update. [Administrator] at [facility] had called and was pushing back to see if patients family would pay for a 24 hour sitter to be with patient in their facility. daughter expressed she also was unable to obtain clear answers regarding what care they were unable to provide for her and that she felt her questions were danced around and avoided . A review of Resident 1's Final Case Management Note, dated 2/26/26, indicated, . Spoke with [Administrator] of [facility] who stated at this time they are unable to accept the patient as they are unable to meet her needs. SW (Social Worker) inquired on (sic) what needs of the patient that they were unable to meet, [Administrator] stated 'her behaviors, and they are only going to get worse .'During an interview on 4/2/26 at 12:41 p.m., the Director of Nursing (DON) stated all residents were permitted to return to the facility after hospitalization. DON stated she was not aware of the specifics about Resident 1's transfer to the other nursing home.During an interview on 4/2/26 at 1:17 p.m., the Administrator stated the facility was unable to take Resident 1 back after her hospitalization because they could not manage her care and help her at their current level. The Administrator stated Resident 1's initial admission was intended for short-term care only, and her behavior had worsened over time. The Administrator stated the facility did not have a psychiatric or locked unit. When queried if Resident 1's hospital discharge summary indicated the need for a psychiatric or locked unit, the Administrator did not answer the question. The Administrator stated the decision they made at the time that based on their experience, they were unable to manage Resident 1's care. The Administrator stated he visited Resident 1 at the hospital once, after the facility was contacted that she was ready to be considered for readmission. The Administrator stated he tried to talk to Resident 1, and although not completely coherent, Resident 1 said she wanted to go back. The Administrator stated he did not see the change in Resident 1 he was looking for and was unable to take her back. The Administrator stated the refusal of Resident 1's readmission was a group decision, comprised of members from the corporate level. The Administrator stated the members were neither physicians nor nurses but were corporate staff. The Administrator stated he could not recall if a physician was involved or consulted in the decision to refuse Resident 1's return to the facility.During a review of the facility policy titled, Bed-Holds and Returns, dated 2/2026, the policy indicated, The requirement that residents be permitted to return to the facility following hospitalization. applies to all residents. Residents are not discharged unless: a. the discharge or transfer is necessary for resident's welfare, and the facility cannot meet the resident's needs. Following a hospitalization, residents whom staff are concerned about permitting to return due to their clinical/behavioral condition at the time of transfer are evaluated based on their current condition, not their condition when originally transferred.

Based on observation, measurement and interview, the facility failed to ensure resident bedrooms met the minimum required 80 square feet of living space per resident for 23 out of 31 resident rooms. This failure decreased the facility's potential to ensure residents' were provided a comfortable living environment to support the dignity, privacy and safe mobility within the room.Findings: In an interview on 3/10/25 at 11:06 a.m., Resident 51 stated, the room is small for 3 people.In a concurrent observation and interview on 3/10/26 at 11:28 a.m., the Maintenance Director (MD) measured room [ROOM NUMBER] and confirmed each residents' living space was 7 feet by 8 feet. The MD stated, Is there a minimum [room] size for residents? I don't know. In an interview on 3/10/26 at 11:34 a.m., Resident 6 stated, The room's a bit small to maneuver in; I'm mainly out in the halls. In an interview with the MD on 3/11/26 at 8:19 a.m., MD confirmed all square footag provided on the facility map were correct and the numbers in circles were the amount of people that could reside in a room. He amended the rooms where the numbers were incorrect. In an interview on 3/12/26 at 2:27 p.m., the Administrator stated he was unaware each resident was to have 80 square feet of living space.

Based on observation, interview, and record review, the licensed nurses failed to ensure the medication rate was below five percent when five errors were observed during 34 medication passes, which resulted in a 14.71% error rate.This failure decreased the facility's potential to ensure medication was administered as ordered by the physician and decreased the expected efficacy of the medication. (Cross-reference F760)Findings:During a medication pass observation on 3/11/26 at 8:17 a.m., Licensed Nurse 2 (LN 2) administered the following medications to Resident 32:Glipizide (an oral medication used to manage blood sugar levels) 5 milligrams (mg-a unit of measure) by mouth two times per day. Give 30 minutes before meals; and,Basaglar kwik-pen(R) (a long-acting insulin used to manage blood sugar levels) Inject 20 units subcutaneously (into the fatty tissue layer located under the skin).During this observation, upon entry to Resident 32's room, a eaten breakfast tray was on Resident 32's overbed table. LN 2 gave Resident 32 all the oral medications to take, followed by the Basaglar kwik-pen(R) injection to Resident 32's right lower abdomen. LN 2 immediately withdrew the insulin pen and did not hold against Resident 32's skin per manufacturer's instructions.A review of Resident 32's physician orders, dated 1/31/26, indicated, Glipizide 5 mg by mouth two times per day.Give 30 minutes before meals.During a medication pass observation on 3/11/26 at 8:47 a.m., LN 1 administered one spray of fluticasone (a medication used to treat allergy symptoms) nasal spray to both nostrils of Resident 27.A record review of Resident 27's physician orders, dated 1/21/26, indicated Fluticasone Propionate Nasal Suspension 50 mcg/act [micrograms per inhalation]. 2 spray [sic] in both nostrils one time a day for allergies.During a medication pass observation on 3/11/26 at 4:12 p.m., LN 5 administered the following medications to Resident 6:Metformin (an oral medication used to manage blood sugar levels) 1000 mg.Humalog kwik-pen(R) (a short acting insulin used to manage blood sugar levels) Inject 4 units subcutaneously.During this medication pass observation, LN 5 administered Humalog kwik-pen(R) insulin to Resident 6 by injecting it into the left side of the abdomen. LN 5 held the insulin pen against Resident 6's skin for three seconds, LN 5 did not hold the insulin pen to Resident 6's skin as per manufacturer's instructions. Additionally, at the time of metformin administration to Resident 6, dinner trays had not yet been served.A record review of Resident 6's physician orders dated 1/5/26, indicated, Metformin 1000 mg. Give 1 tablet by mouth two times per day.give with breakfast and dinner.A review of the manufacturer's instructions for use of Basaglar kwik-pen(R) dated 8/26/22 indicated, Insert the Needle into your skin. Push the Dose Knob all the way in. Continue to hold the Dose Knob in and slowly count to 5 before removing the Needle.A review of the manufacturer's instructions for use of Humalog kwik-pen(R) revised July 2023 indicated, Insert the Needle into your skin. Push the Dose Knob all the way in. Continue to hold the Dose Knob in and slowly count to 5 before removing the Needle.A review of the facility's policy titled Adverse Consequences and Medication Errors, revised February 2025, indicated, A medication error is defined as.the administration of drugs which is not in accordance with physicians orders.or accepted professional standards.failure to follow.accepted professional standards.A review of the facility's policy titled Administering Medications, revised April 2025, indicated, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation and interview, dietary staff failed to ensure palatability and nutritive value for 60 residents who were served food from the kitchen during the lunch meal on 3/11/26 when foods were held on the steam table for over 1.5 to 2 hours and the test tray of purred food and vegetables was found to be gummy and bland.These failures decreased the facility's potential to prevent weight loss and malnutrition among residents.Findings:A review of the resident council meeting minutes from June, July, October, and November 2025, indicated various complaints regarding poor food quality, texture of food was inedible, and being rushed during meals.During an interview on 3/10/26 at 2:37 p.m., Resident 46 stated the food was not of good quality and they cook the heck out of the vegetables.During an observation of meal preparation on 3/11/26 at 9 a.m., [NAME] 7 was observed opening a can of corn and placing its contents in a pot on the stove top to cook. [NAME] 7 placed the cooked corn on the steam table at 9:50 a.m. [NAME] 7 then prepared the gravy for the roast beef and the pureed roast beef adding thickener to obtain a pudding-like consistency. The pureed beef was then placed on the steam table at 10:30 a.m. Lunch was to be served at 12 p.m.During an observation of the Resident Council Meeting conducted on 3/11/26 at 10 a.m., residents who attended verbalized various food complaints which included poor quality, not palatable, and overall the food was not good.A test tray was completed on 3/11/26 at approximately 12:56 p.m. in the presence of the Corporate Registered Dietician (CRD). The meal consisted of regular and pureed textures of roast beef, scalloped potatoes, buttered corn and a bread roll. The regular textured buttered corn was bland. The pureed beef and corn were bland, the pureed potatoes and bread roll were bland and gummy. All the food appeared gray in color. The CRD stated they would look more closely at how the pureed foods were prepared.During an interview on 3/11/26 at 3:45 p.m. the Dietary Manager (DM) stated food was expected to be held on the steam table for approximately 45 minutes.A review of the facility's undated recipe for scalloped potatoes indicated three ingredients: scalloped potato mix, margarine, and hot water. The recipe did not include instructions to add any seasonings.A review of the facility's undated recipe for pureed cream style corn indicated two ingredients: canned creamed corn and thickener or frozen pureed corn. The recipe did not include instructions to add any seasonings.A review of the facility's policy titled Food and Nutrition Services revised October 2025 indicated, Each resident is provided with a nourishing, palatable.diet.A review of the facility policy & procedure titled, Food Service Temperature Control, not dated, indicated, Vegetable preparation. Vegetables should be prepared as close to serving time as possible.Care should always be taken to prevent destroying their nutritive value.In preparing commercially canned vegetables.Add the proper seasonings to the vegetables, and heat them to serving temperature as close to serving time as possible.Vegetables may be more appealing by varying their garnishes and seasonings.Seasonings.They are added to food to develop flavors, which make the food more interesting and add variety to the diet. Seasonings include herbs, spices, extracts, and flavors.

Based on observation, interview, and record review, the nursing and maintenance staff failed to ensure respiratory equipment was clean for four residents (Resident 30, 26, 42, 58) out of seven sampled residents when the oxygen concentrator (a medical device that provides supplemental oxygen to people with breathing-related conditions by pulling in ambient air, filtering out nitrogen, and delivering purified oxygen) in the resident's rooms had visible dust and debris in the vents and needed a filter change.This failure decreased the facility's potential to prevent bacteria and debris from directly entering the resident's lungs, placing them at risk for infection.Findings: 1. A review of Resident 30's admission record indicated admission to the facility on [DATE] with a diagnosis of Dementia (a progressive state of decline in mental abilities) and malignant neoplasm of the left breast (breast cancer). A review of an order listing report indicated Resident 30 had the following order dated 1/5/26 and revised on 1/6/26, Oxygen- @ [at] 2 Liters/Min [minute] via nasal canula [NC, a lightweight, flexible tubing that delivers oxygen to residents with low oxygen levels or trouble breathing] continuous [related to] medical diagnosis [of] SOB [shortness of breath] to maintain O2 [oxygen] sats [saturation, the percentage of oxygen in the blood] greater than 90% every shift for SOB. During a concurrent observation and interview with the Maintenance Supervisor (MS) and the Infection Preventionist (IP) on 3/10/26 at 3:20 p.m. in Resident 30's room, Resident 30 was lying in bed, asleep, with both prongs of the NC resting to the left of Resident 30's nostril. The MS opened the filter compartment of Resident 30's oxygen concentrator. The outside vent had dust on it and the inside compartment had large areas of dust build up. The MS confirmed the internal filter needed to be changed, and the oxygen concentrator needed to be cleaned overall. The IP confirmed the oxygen concentrator needed to be cleaned and the filter changed. The IP confirmed it could be harmful to the resident to be using a compressor (a mechanical device that converts power from an electric motor into potential energy stored in pressurized air) when the filter is so dirty. 2. A review of Resident 26's admission record indicated Resident 26 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD-a progressive lung disease that blocks airflow, making it difficult to breathe), Hypoxemia (abnormally low levels of oxygen in the blood) and history of recurrent Pneumonia (a lung infection where the air sacs fill with pus or fluid with an occurrence of two or more episodes of pneumonia within a single year, or three or more within a lifetime). A review of Resident 26's order listing report indicated Resident 26 had the following order, dated 1/5/26, Oxygen @ 2 Liters/Min [L/M] via nasal cannula continuous goal to maintain O2 sats greater than 90% every shift related to [COPD].Maintain [O2 sats] at greater than 90%. During an observation in Resident 26's room on 3/10/25 at 9:16 a.m., Resident 26 had oxygen being delivered at 2 L/M via an NC. This surveyor observed dust build-up on the outside vent of the oxygen concentrator with dust covering the outside of the machine. During a concurrent observation and interview in Resident 26's room on 3/10/26 at 3:25 p.m., the IP and MS opened the filter compartment of Resident 26's oxygen concentrator. The inside compartment had scattered areas of dust build-up. The MS and IP confirmed the internal filter needed to be changed, and the oxygen concentrator needed to be cleaned. 3. A review of Resident 42's admission record indicated admission to the facility on [DATE] with a diagnosis of Dependence on Supplemental Oxygen. A review of Resident 42's order listing report indicated Resident 42 had the following physician's order dated 1/5/26, Oxygen @ 2 L/M via NC continuous. for SOB. During an observation in Resident 42's room on 3/10/26 at 8: 52 a.m., Resident 42 was sitting up in bed with an NC in place in both nostrils. The oxygen concentrator was noted to have dust buildup on the outside vents. During a concurrent observation and interview in Resident 42's room on 3/10/26 at 3:20 p.m., the IP and MS opened the filter compartment of Resident 42's oxygen concentrator. The inside compartment was noted to have a layer of white dust and debris throughout. The internal filter appeared to be discolored. The MS confirmed the filter needed to be changed. The IP stated a dirty oxygen concentrator was not good for the resident receiving the oxygen therapy. The MS stated the housekeeping department should be cleaning the outside of the oxygen concentrator and the vendor of the machine had monthly visits to repair, troubleshoot, clean and change internal filters. The MS could not recall when the vendor's last visit to the facility took place. Resident 42 stated, No one has been cleaning that [oxygen concentrator]. 4. A review of Resident 58's admission record indicated admission to the facility on 9/24/25 with diagnoses of COPD and Chronic Respiratory Failure with Hypoxia (long term lung condition where the lungs cannot adequately transfer oxygen into the blood, causing persistent low oxygen levels which is treated with long term oxygen therapy). A review of Resident 58's order listing report indicated the following physician orders, dated 1/5/26, Oxygen @ 3 [L/M] via nasal cannula continuous. During an observation in Resident 58's room on 3/10/26 at 10:15 a.m., Resident 58 was sitting up in bed with an NC in place to both nostrils. The oxygen concentrator was noted to be administering oxygen at 2 L/M. The concentrator felt hot to the touch. The outside vent was noted to have a large amount of dust buildup and there was dust covering the entire machine. During a concurrent observation and interview in Resident 58's room on 3/10/26 at 3: 32 p.m., the IP and MS opened the filter compartment of Resident 58's oxygen concentrator. The MS confirmed this oxygen concentrator belonged to the facility and it would have been his responsibility to ensure facility owned equipment was operating effectively and in clean, working condition. The MS and IP confirmed that one of side filters hidden by a screwed in plate, had a thick layer of dust build up. Once the internal compartment was opened, the same thick layer of dust build-up was observed. The IP suggested the oxygen concentrator be removed from Resident 58 and replaced with a clean oxygen concentrator. This surveyor requested to see cleaning logs for all oxygen concentrators being used on the residents. During an interview in on 3/11/26 at 9:39 a.m., the MS stated his department had no cleaning logs for the facility owned oxygen concentrators. The MS provided a sheet titled Cleaning Guide which listed daily cleaning performed by the housekeeping staff;Oxygen concentrators were not found on this list. This surveyor requested to see vendor logs of monthly visits, and requested information on when the facility owned oxygen concentrator was put in place for Resident 58. During an interview in on 3/12/26 at 8:57 a.m., the IP stated the dusty oxygen concentrators posed an infection risk for the residents. She stated the dust and debris can hold bacteria, spores and other pathogens that can enter the resident's respiratory system. The IP stated this placed the residents at risk for a chronic cough, delayed healing or other respiratory diseases. During an interview in the facility hallway on 3/12/26 at 10 a.m., the Administrator (Admin) stated the two facility owned oxygen concentrators were delivered on 2/10/25 and 3/17/25. The Admin stated the MS had no record of what machine was placed for Resident 58 or when it was placed. This surveyor asked the Admin to retrieve vendor maintenance and cleaning logs for the oxygen concentrators. The Admin stated the MS was not at the facility today. During an interview in the maintenance department on 3/13/26 at 9:14 a.m., the MS stated he could not find the maintenance and cleaning logs from the vendor. The MS further stated the oxygen concentrator for Resident 58 was put in place on 3/17/25 and to his knowledge, it had remained there. A review of facility's policy titled Oxygen Concentrator Cleaning & Disinfection Policy, revised October 2025, indicated, To ensure oxygen concentrators are properly cleaned and disinfected between resident use and routinely maintained to prevent the transmission of infectious organisms and maintain safe equipment function.Routine cleaning (weekly or as needed): Nursing or designated staff shall perform routine cleaning of the oxygen concentrator.wipe the exterior surfaces.Filter maintenance: External filter.clean weekly or when visibly dirty.Internal filter.replaced according to biomedical or vendor maintenance schedule. A review of the facility owned oxygen concentrator Owner's Manual, dated 2020, indicated, more frequent cleaning and filter changes may be required if.you are operating the concentrator continuously.

Based on observation, interview and record review, the facility failed to ensure licensed nurses did not administer oxygen per physician's orders for two residents (Resident 67 and Resident 58) of nine sampled residents when:Resident 58 did not have the ordered amount of oxygen being delivered and,Resident 67 did not have a humidifier attached to the oxygen concentrator (a medical device that provides supplemental oxygen to people with breathing-related conditions by pulling in ambient air, filtering out nitrogen, and delivering purified oxygen)These failures had the potential to place residents at risk for inadequate oxygenation and a potential decline in respiratory status.Findings: 1. A review of Resident 58's admission record indicated Resident 58 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD-a progressive lung disease that blocks airflow, making it difficult to breathe) and Chronic Respiratory Failure with Hypoxia (a long term lung condition where lungs cannot adequately transfer oxygen into the blood, causing persistent low oxygen levels). A review of Resident 58's care plans, dated 10/7/25, indicated Resident 58 was at risk for respiratory distress (a clinical state of difficulty breathing characterized by rapid, labored or inadequate breathing, where the body struggles to get enough oxygen). In order to reach Resident 58's goal to maintain comfort and avoid respiratory complications, the staff were expected to provide oxygen therapy as MD ordered. A review of Resident 58's physician orders, dated 1/5/26, indicated Resident 58 had an order for Oxygen @ [at] 3 Liters/Min [liters per minute-measures flow rate or volume of oxygen being delivered over one minute] via Nasal Cannula [a lightweight, flexible tubing that delivers oxygen to residents with low oxygen levels or trouble breathing] continuous. During an observation in Resident 58's room on 3/10/26 at 10:15 a.m., Resident 58 was sitting up in bed with a nasal cannula in place in both nostrils. The oxygen concentrator was noted to be administering oxygen at 2 L/M. During a concurrent observation, interview, and record review in Resident 58's room on 3/11/26 at 3:43 p.m., Licensed Nurse 6 (LN 6) confirmed the Resident 58's oxygen concentrator was set at 2 L/M, despite the current physician order directing oxygen to be delivered at 3 L/M. LN 6 stated she would need to locate a Registered Nurse to adjust the oxygen level to the ordered setting. A review of Resident 58's Medication Administration Record (MAR), dated March 2026, indicated licensed nursing staff had documented administration of continuous oxygen therapy at 3Liters/Minute [3 L/M] from March 1 through March 11, 2026. A review of Resident 58's progress notes dated between 1/5/26 to 3/10/26 revealed no documentation which explained why oxygen therapy was not provided as ordered, nor documentation of any notification to the physician regarding deviation from the prescribed treatment. During an interview on 3/12/26 at 11:30 a.m., the Director of Nursing (DON) confirmed that staff were expected to follow all physician orders, including those related to oxygen administration, and acknowledged that the facility failed to ensure oxygen was provided according to the physician's order. 2. A review of Resident 67's admission record indicated Resident 67 was admitted to the facility on [DATE] with a diagnosis that included COPD. A review of Resident 67's order summary report indicated Resident 67 had the following orders dated 2/27/26: -Change O2 [oxygen] humidifier Discard and replace the disposable.prefilled humidifiers as needed when consumed, when bubbles are no longer visible. -Change O2 humidifier Discard and replace the disposable.prefilled humidifiers every night shift every Sun [Sunday]. -Oxygen @ 2 L/M via Nasal Cannula continuous.[related to diagnosis].COPD/ SOB [shortness of breath] Goal To Maintain O2 sats [saturation- the percentage of oxygen in the blood] between 88%- 92% every shift. A review of Resident 67's care plans, dated February 2026 did not indicate a care plan was developed for Resident 67's oxygen therapy. During an observation on 3/10/26, at 10:15 a.m., Resident 67 was sitting up in bed with a nasal cannula in place in both nostrils. The oxygen concentrator was observed to be administering oxygen at 1.5 L/M there was no humidifier attached to the oxygen concentrator. During an interview on 3/11/26, at 11:30 a.m., the Infection Preventionist (IP) confirmed that Resident 67 did not have a humidifier attached to her oxygen concentrator. A review of facility policy titled Oxygen Administration, revised April 2025, indicated, .the purpose of this procedure is to provide guidelines for safe oxygen administration.Verify that there is a physician's order for this procedure.turn on the oxygen.start the flow of oxygen at [sic] ordered. A review of facility policy titled Physician Orders and Physician Notification, revised April 2025, indicated, The facility ensures that all resident care is provided in accordance with timely, complete, and authenticated physician orders.Orders shall be implemented promptly.Responsibilities.Licensed Nurses.Identify changes, notify physicians, document accurately, and implement orders.

Based on observation, interview, and record review, the facility's Interdisciplinary Team (a collaborative group of health care professionals who provide comprehensive, patient-centered care) failed to initiate a comprehensive care plan regarding Resident 46's hearing impairment and ensure hearing services were provided for Resident 46 of two sampled residents .This failure decreased the facility's potential to assist residents in gaining access to necessary care regarding her hearing impairment.Findings:A review of Resident 46's admission record indicated admission to the facility on [DATE] with a diagnosis that included Hypertensive Heart (structural and functional heart damage caused by long-term high blood pressure, leading to heart failure), Chronic Kidney Disease (long-term, progressive loss of kidney function, often causing waste buildup, high blood pressure, and anemia), and a History of Falling.A review of Resident 46's admission inventory list dated 12/30/25 indicated Resident 46 had right and left hearing aids.A review of Resident 46's care plans dated 12/30/25 did not indicate a care plan was developed for Resident 46's hearing impairment.A review of Resident 46's minimum data set (MDS, an assessment tool) dated 1/12/26, indicated Resident 46 used a hearing aid or hearing appliance and had adequate ability to hear (with hearing aid or hearing appliances if normally used) and had a Brief Interview for Mental Status (BIMS, an assessment tool that helps determine an individual's memory and orientation) score of 11 (indicates moderate cognitive impairment, and represents a moderate level of difficulty with memory). During an interview on 3/10/26 at 10a.m., Resident 46 was lying in bed awake with the head of the bed elevated. Resident 46 asked this surveyor to please speak loudly because she could not hear very well. When asked if she wore hearing aids she stated Yes, but they needed to be serviced and were not working. Resident 46 stated she has not been able to have her hearing aids serviced and to make an appointment to see her ear doctor for a check-up. When asked if the facility was helping her schedule an appointment she stated, No. During an interview on 3/11/26 at 11:45 a.m., LN 4 stated Resident 46 was hard of hearing, and added you must speak slowly and loud to her. LN 4 acknowledged he was unaware Resident 46 had hearing aids and stated facility staff could arrange an appointment for her to see the audiologist (a licensed healthcare professional specializing in identifying, assessing, and managing hearing, balance, and tinnitus disorders in patients of all ages.)During an interview on 3/11/26 at 11:50 a.m., the Medical Doctor (MD) stated Resident 46's hearing had declined but that she did understand our conversations, and it did not interfere with communicating with her. The MD stated, She gets by.A review of the facility's policy and procedures titled, Care Plans, Comprehensive Person-Centered, revised March 2025, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The .IDT, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment and no more than 21 days after admission. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.The comprehensive, person-centered care plan.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including.services that would otherwise be provided for the above.which professional services are responsible for each element of care.includes the resident's stated goals upon admission and desired outcomes.reflects currently recognized standards of practice for problem areas and conditions .

Based on observation, interview, and record review, the licensed nurses failed to ensure pharmaceutical services met the needs of each resident when:The facility did not sign delivery receipts for narcotic and non-controlled medications on 3/1/26, 3/2/26, 3/6/26 to 3/8/26, and 3/10/26 for a combined total of 1,036 doses.Licensed Nurse (LN) 1 left medications at Resident 44's bedside.These failures decreased the facility's potential to ensure safe and secure medication management, increased the risk of medication loss or diversion (the illegal transfer of prescription drugs to be sold for profit or for personal abuse) and decreased the potential for medications to be safely administered among residents.Findings:1. During a concurrent interview and record review with LN 4 at the South Nurses station on 3/12/26 at 11:42 a.m., the binder containing pharmaceutical delivery receipts was examined. LN 4 confirmed there were no signatures present on the delivery receipts dated 3/1/26, 3/2/26, 3/6/26 to 3/8/26, and 3/10/26. The absence of these signatures indicated the delivery and acceptance of residents' medications had not been properly documented. LN 4 said the significance of a signed pharmaceutical delivery receipt was to prove the medication has been delivered and placed in the medication cart.During a concurrent interview and record review with the Director of Nursing (DON) in the DON's office on 3/12/26 at 12:01 p.m., the DON confirmed the pharmaceutical delivery receipts for the specified dates in March 2026 had no signatures from either the pharmacy staff nor the facility licensed staff. The DON stated the expectation was that medications received from the pharmacy were reconciled (comparing the receipt of medications against medications delivered) immediately, any errors noted, followed by a signature to indicate acceptance of medication delivery. The DON stated unsigned pharmaceutical delivery receipts placed the facility at increased risk for diversion.A review of the facility's policy titled Accepting Delivery of Medications dated 2001, indicated, All staff follow a consistent procedure in accepting medications.before signing to accept the delivery, the nurse reconciles the medications in the package with the delivery ticket/order receipt.a nurse signs the delivery ticket, indicating review and acceptance of the delivery, and keeps a copy of the delivery ticket.2.A review of Resident 44's admission record indicated admission to the facility on [DATE] with diagnoses including Spondylolisthesis (a condition in the spine where one of your backbones slip forward out of its normal alignment onto the bone below) and disorders of bone density.A review of Resident 44's Minimum Data Set (MDS-a federally mandated assessment tool) indicated a Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident) score of 11 of 15 which indicated moderate cognitive (the process of obtaining knowledge and understanding through the use of thought, experience, and senses) impairment.During an observation, upon entry to Resident 44's room on 3/10/26 at 9:09 a.m., Resident 44 attempted to swallow a pill and spit it out. This surveyor observed two additional pills left on Resident 44's bedside table. Resident 44 attempted to take the same pill she spit out two more times while this surveyor was in her room. Resident 44 spit the pill out for a third time and left it on the bedside table with the 2 other pills. During a concurrent interview and record review at the North Med Cart on 3/10/26 at 9:21 a.m., LN 1 confirmed leaving medications at the bedside could be a safety issue; however, he felt Resident 44 was capable of taking her medications without supervision. A review of Resident 44's physician orders was conducted with LN 1, who confirmed Resident 44 did not have orders which indicated Resident 44 was safe to self-administer her medications. LN 1 further stated the pill Resident 44 spit out was acetaminophen (over the counter medication used to treat pain). LN 1 stated the acetaminophen was requested by Resident 44 to treat pain she had rated as a 7 on a 1 to10 pain scale (10 being the worst pain). LN 1 stated the other two pills left on the bedside tray were calcium (used to strengthen bones and treat osteoporosis [a bone condition characterized by bones have decreased density and structural deterioration]), and Vitamin B complex.During an interview on 3/12/26 at 11:30 a.m., the DON confirmed medications left at any resident's bedside without physician approval was a safety concern.A review of facility policy titled Administering Medications, revised April 2025, indicated, Medications are administered in a safe.manner. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.

Based on observations, interviews and record review, the licensed nurses failed to ensure residents were free from significant medication errors for three residents (Resident 6, 32, and 8) of 10 sampled residents when:1. Residents 6 and 32 were not administered insulin pen injections as per manufacturer's instructions and;2. Resident 8 was not administered rifaximin (a medication used to kill bacteria that produces ammonia in the intestines and prevents toxins from reaching the brain and causing confusion or severe personality changes) for 36 doses.These failures placed the residents at risk for avoidable adverse clinical outcomes including uncontrolled blood glucose levels and exacerbation of liver disease.Findings:1. During a concurrent interview and medication pass observation on [DATE] at 8:17 a.m., Licensed Nurse 2 (LN 2) administered 20 units of glargine (long-acting insulin which provides steady 24-hr blood sugar control) via an insulin pen to Resident 32's right lower abdomen. LN 2 injected the insulin and removed the pen immediately. LN 2 did not maintain the needle in place as instructed by the manufacturer. LN 2 stated he was nervous and thought he had held the pen to Resident 32's skin.During a concurrent interview and medication pass observation on [DATE] at 4:13 p.m., LN 5 administered 4 units of lispro (fast acting insulin with a rapid onset and short duration) into Resident 6's left abdomen. LN 5 did not maintain the needle in place for the required duration, withdrawing the pen 5seconds after injection. LN 5 stated she was aware she pulled the pen away from Resident 6's skin slightly earlier than required.During an interview on [DATE] at 11:30 a.m., the DON acknowledged insulin pens required a certain duration held against the skin to ensure full insulin dose had been given. The DON stated an in-service was provided by the Pharmacy Consultant (PhC) in June of 2025 which covered this amongst other topics. This was not a mandatory in-service, but strongly recommended.During a phone interview on [DATE] at 1:51 p.m., the PhC stated he reviewed insulin pen administration during his in-service. The PhC stated he informed the licensed staff the insulin pens needed to stay intact on the skin for 6-10 seconds, depending on the type of insulin given; longer acting insulins require at least 10 seconds of hold time, shorter acting insulins can be removed after 6 seconds of hold time. The PhC stated removing the pen too early can result in underdosing the resident, possibly causing a spike in blood sugar levels.2. A review of Resident 8's admission record indicated admission to the facility on [DATE] with diagnoses of Alcoholic Cirrhosis (the final, most severe stage of alcohol associated liver disease characterized by extensive, irreversible scarring of the liver due to years of excessive drinking) andPortal Hypertension (elevated blood pressure within the portal system, which carries blood from the digestive system to the liver; usually caused by the scarring of the liver, which blocks blood flow, resulting in increased pressure).A review of Resident 8's physician orders, dated [DATE], indicated Resident 8 had an order to receive 550 milligrams (mg- a unit of measure) of rifaximin by mouth two times a day for prophylaxis (a treatment used to prevent the onset or spread of a disease) for hepatic encephalopathy (a reversible, serious decline in brain function due to severe liver disease).A review of the Medication Administration Record (MAR) key indicated the number 9 signified medication not available. A review of Resident 8's MAR dated February 2026 indicated 15 entries marked with a 9 for the ordered medication rifaximin, indicating the medication was not available and therefore not administered. A review of the MAR dated [DATE] presented an additional 14 missed doses of rifaximin, also documented with the 9 code. Seven doses were checked off as administered on [DATE],4,7,8,9 in between several days of medication not being administered. During an interview in Resident 8's room on [DATE]at 10:24 a.m., Resident 8 stated the facility stopped giving him his liver medication about one month ago because it was too expensive. He stated the facility is also giving him other medication to treat his liver disease, but that it is only part of his full treatment. Resident 8 stated he was worried his ammonia level was rising and that he was already starting to feel weird and falls asleep at abnormal times during the day. During an interview at the south nursing station on [DATE] at 8:04 a.m., LN 4 stated physician (MD) notification would be placed in the progress notes.A review of Resident 8's progress notes did not indicate any notification to either Resident 8's MD or the Director of Nursing (DON) regarding the critical missing medication.During an interview in the DON's office on [DATE] at 8:18 a.m., the DON stated she became aware of Resident 8 not receiving his rifaximin treatment at the beginning of the month when she received an authorization from the pharmacy for the rifaximin. The DON stated she called the pharmacy to escalate the urgency and notified the MD. The DON stated the physician increased Resident 8's lactulose (medication used to reduce blood ammonia levels in liver disease) on [DATE]. The DON further stated she understood the critical nature of obtaining this medication and has reached out to the pharmacy on at least four occasions. She was told they needed authorization to proceed with ordering the medication. She stated she was working with the MD and the pharmacy to expedite the process. The DON confirmed there were no nursing progress notes to indicate MD notification. She further confirmed the seven doses documented as given on Resident 8's MAR was documented in error. The rifaximin has not been issued from the pharmacy since [DATE]. The DON confirmed the total missed doses of rifaximin was 36. The DON also confirmed the nursing staff should have notified the MD and herself about the missing rifaximin.During an interview in room [ROOM NUMBER] on [DATE] at 10:21 a.m., the MD stated, If [Resident 8] does not get his rifaximin, he will die. He [Resident 8] is on the maximum dose of lactulose at 45 milliliters four times daily. There is nothing more we can do to stop the decline. We need the medication [rifaximin].During a phone interview on [DATE] at 1:51 p.m., the PhC stated he became aware of the situation with Resident 8 earlier that morning while speaking with the DON. He stated Resident 8's prior authorization for the medication had expired, and the physician needed to justify the prescription. When that task was completed, the pharmacy would submit to Resident 8's insurance plan for approval. The whole process should take 2-3 days.A review of facility policy titled Adverse Consequences and Medication Errors, revised 2/2025, indicated the facility, monitors medication usage in order to prevent and detect medication related problems.A medication error is defined as.the administration of drugs which is not in accordance with physicians orders.or accepted professional standards.examples of medication errors include: omission- a drug is ordered but not administered.failure to follow.accepted professional standards.promptly notify the provider [physician] of any significant error.

Based on interviews and record reviews, the facility failed to protect Resident 1's right to be free from verbal abuse when Resident 2 verbally abused Resident 1 by yelling profanities and calling her an expletive.These failures decreased the facility's potential to prevent mental anguish and emotional distress among residents.Findings:A review of Resident 1's admission record indicated admission to the facility in January 2026 with diagnoses which included anxiety disorder (excessive, persistent fear or worry that interferes with daily life) and depression (a mood disorder characterized by persistent sadness). Resident 1 was her own responsible party (RP, a person who can manage their own health and financial decisions).A review of Resident 2's admission record indicated admission to the facility in August 2025 with diagnoses which included depression. Resident 2 was his own RP.A review of Resident 1's Brief Interview for Mental Status (BIMS) score conducted on 11/5/25, indicated she had a BIMS score of 12 which meant she had moderate ability to think, reason, and learn.A review Resident 2's BIMS score conducted on 12/3/25, indicated Resident 2 had a BIMS score of 15 (no cognitive impairment).A review of Resident 2's progress notes indicated:On 12/25/25 at 2:06 a.m. indicated, [Resident 2] is aox4 [Alert and Oriented x4 is a term used to describe a resident's level of awareness. It means the resident is fully aware and can accurately identify four things: who they are (person), where they are (place), what it is (time), and what is happening around them (situation)] [Resident 2] in wc [wheelchair] and wheeled himself into [Resident 1's room] and started yelling at her to 'shut up, you don't need to be yelling for help if you don't need it.' [Certified Nursing Assistant] intervened and assisted [Resident 2] back to his room when he stated, 'suffocate the bitch.' Placed on alert charting for res to res [resident-to-resident] aggressor MD [doctor] .DON [Director of Nursing] notified .A review of Resident 1's progress notes indicated:On 12/31/25 at 8:39 p.m. indicated, [Resident 1] was at the nurse station watching a movie and yelling when .Another resident [Resident 2] came where [Resident 1] was residing and became agitated with her yelling. [Resident 2] became aggressive and started yelling 'Shut the fuck up bitch, there is no reason to be yelling on New Year's Eve, I'm going to choke you out. Somebody should choke you, [sic] I'm going to slap that bitch.' Writer [Licensed Nurse 1 (LN 1)] intervened and corrected aggressor [Resident 1] where he said, 'too late I already said it.' .DON/Administrator [ADM] notified .On 1/7/26 at 6:18 p.m. indicated, [Resident 2] as previously documented again came to the nurses [sic] station while [Resident 1] was sitting with [LN 1]. [Resident 1] was yelling as baseline and.[Resident 2] said 'shut up' [LN 1] tried to deescalate, and [Resident 2] continued 'shut up, I don't pay money to hear your bullshit. Tell her to shut up.'.[LN 1] said tried to redirect [Resident 2] into room, then [Resident 2] says 'I'll tell that bitch to shut up.' [Resident 1] got quiet.During a concurrent record review and interview on 2/9/26 at 11:40 a.m., LN 1 reviewed the progress note she documented on 1/7/26 and stated her documentation was accurate. LN 1 stated that on 1/7/26 at around 6:18 p.m., she was at Nurse Station 2 with Resident 1 when Resident 1 was yelling, Help me, help me but unable to say what she needed help with. LN 1 stated Resident 2 then came to Nurse Station 2 and told Resident 1 to shut up and called Resident 1 a bitch. LN 1 also acknowledged she reported the incident between Resident 1 and Resident 2 that occurred on 12/31/25. LN 1 stated she strongly believed the incident that occurred on 12/31/25 was verbal abuse.During an interview on 2/9/26 at 2:45 p.m., Resident 2 stated he heard Resident 1 yelling Help me every day. Resident 2 stated yelling for help meant somebody was having an emergency. Resident 2 stated he went to Resident 1 with the intention of making her shut up. Resident 2 stated Resident 1 was no longer at the facility.During an interview on 2/9/26 at 3:25 p.m., LN 3 acknowledged she was the nurse assigned to Resident 2 on 12/31/26. LN 3 stated Resident 1 looked scared and stated she was scared of Resident 2 after Resident 2 yelled at her and threatened to choke and slap her. LN 3 also stated she believed what Resident 2 stated was a threat of aggression.During an interview on 3/2/26 at 1:14 p.m., LN 2 acknowledged what was documented in Resident 2's progress notes on 12/25/25 and confirmed that was what happened.A review of a facility policy and procedure (P&P) titled, Elder/Dependent Adult Abuse, dated 5/29/25, indicated, The facility will protect the rights, safety and well-being of each resident regardless of physical or mental condition against any and all forms of abuse including freedom from neglect, exploitation.Abuse includes verbal [abuse].Verbal Abuse- Refers to any use of oral .or gestured language that includes threats and/or disparaging and derogatory terms, to or about residents .within hearing distance of any resident, regardless of their age, ability to comprehend, or disability; threats of harm; including saying things to frighten the resident.

Based on interviews and record reviews, the facility failed to report an allegation of verbal abuse within two hours to the California Department of Public Health (CDPH) for one resident (Resident 1) of two sampled residents when Resident 2 yelled and threated Resident 1 on 12/25/25, 12/31/25, and 1/7/26.This failure decreased the facility's potential to ensure residents were protected against abuse.Findings:A review of Resident 1's admission record indicated she has anxiety disorder (excessive, persistent fear or worry that interferes with daily life) and depression (a mood disorder characterized by persistent sadness). Resident 1 was her own responsible party (a person who can manage their own health and financial decisions).A review of Resident 1's Brief Interview for Mental Status (BIMS) score conducted on 11/5/25, indicated she had a BIMS score of 12 which meant she had moderate ability to think, reason, and learn.A review Resident 2's BIMS score conducted on 12/3/25, indicated Resident 2 had a BIMS score of 15 (no cognitive impairment).A review of Resident 2's progress notes indicated:On 12/25/25 at 2:06 a.m. indicated, [Resident 2] is aox4 [Alert and Oriented x4 is a term used to describe a resident's level of awareness. It means the resident is fully aware and can accurately identify four things: who they are (person), where they are (place), what it is (time), and what is happening around them (situation)] [Resident 2] in wc [wheelchair] and wheeled himself into [Resident 1's room] and started yelling at her to 'shut up, you don't need to be yelling for help if you don't need it.' [Certified Nursing Assistant] intervened and assisted [Resident 2] back to his room when he stated, 'suffocate the bitch.' Placed on alert charting for res to res [resident-to-resident] aggressor MD [doctor] .DON [Director of Nursing] notified .A review of Resident 2's SBAR [Situation, Background, Assessment, and Recommendation] communication form dated 12/25/25 at 1:57 a.m. indicated, [Resident 2] entered a female resident's [Resident 1] room to tell her to stop yelling out help .[Resident 2] has history of behavior-yelling out at staff and residents, curing-using profanities .[Resident 2] .wheeled himself into [Resident 1's] room and started yelling at her to 'shut up, you dont [sic] need to be yelling for help if you dont [sic] need it' .[while] assisted [Resident 2] back to his room when [Resident 2] stated 'suffocate the bitch'.A review of Resident 1's progress notes indicated:On 12/31/25 at 8:39 p.m. indicated, [Resident 1] was at the nurse station watching a movie and yelling when .Another resident [Resident 2] came where [Resident 1] was residing and became agitated with her yelling. [Resident 2] became aggressive and started yelling 'Shut the fuck up bitch, there is no reason to be yelling on New Year's Eve, I'm going to choke you out. Somebody should choke you, [sic] I'm going to slap that bitch.' Writer [Licensed Nurse 1 (LN 1)] intervened and corrected aggressor [Resident 1] where he said, 'too late I already said it.' .DON/Administrator [ADM] notified .On 1/7/26 at 6:18 p.m. indicated, [Resident 2] as previously documented again came to the nurses [sic] station while [Resident 1] was sitting with [LN 1]. [Resident 1] was yelling as baseline and.[Resident 2] said 'shut up' [LN 1] tried to deescalate, and [Resident 2] continued 'shut up, I don't pay money to hear your bullshit. Tell her to shut up.'.[LN 1] said tried to redirect [Resident 2] into room, then [Resident 2] says 'I'll tell that bitch to shut up.' [Resident 1] got quiet.A review of a Report of Suspected Dependent Adult/Elder Abuse form (SOC 341) dated 1/8/26 indicated notification of the verbal abuse from Resident 2 toward Resident 1 was faxed to CDPH on 1/8/26 at 4:14 p.m.During a concurrent record review and interview on 2/9/26 at 11:40 a.m. LN 1 reviewed the progress note she documented on 12/31/25. LN 1 confirmed she reported the incident to the DON and ADM.During an interview on 2/9/26 at 10:44 a.m. the ADM stated he reported the incident that happened on 1/7/26 to CDPH. The ADM stated he was aware the timeframe for reporting alleged abuse was within two hours and acknowledged the incident that occurred on 1/7/26 was not reported until the following day on 1/8/26 via fax. The ADM stated a call was not placed to CDPH prior to the faxed message.During a concurrent record review and interview on 2/9/26 at 3:25 p.m., LN 3 stated she texted the DON on 12/31/25 at 6:57 p.m. LN 3 notified them that Resident 2 went to the nurse's station and got in Resident 1's face, screamed at her to shut the fuck up and that someone should choke her out and he was going to slap that bitch [Resident 2] which was witnessed by LN 1. LN 3 indicated she was going to complete a SBAR form and asked the DON and ADM what else she needed to do regarding the incident. The DON replied that an SBAR was not needed, there was no change of condition, and to keep both residents separated. LN 3 then clarified that if an SBAR did not need to be completed then why did LN 2 complete the form when Resident 2 was aggressive toward Resident 1 on 12/25/25. LN 3 indicated she knew nurses were supposed to fill out the forms for allegations of abuse. The response she received from the DON was not to fill out the forms because it was yelling and no one was touched. LN 3 responded, It was [a] verbal threat to harm .During a concurrent record review and interview with the DON and ADM on 2/20/26 at 3:31 p.m., the DON verified that the incident which occurred on 12/25/25 involved Resident 1 and Resident 2. The DON and ADM both stated the LN 2 had not reported the incident that occurred on 12/25/25. The DON stated if the incident had been reported to her, she would have started an investigation. The DON and ADM both acknowledged they were made aware of the incident which occurred on 12/31/25 between Resident 1 and Resident 2 via text message from LN 3. The ADM stated he called the nurses and investigated. The ADM also acknowledged he had not reported this incident to CDPH because in the process of the investigation, he was made aware that the residents were together in one table and were okay. Both the DON and ADM confirmed that the initial text message by LN 3 sent to them on 12/31/25 indicated Resident 2 said to Resident 1, Someone should choke you and I'm going to slap that bitch.During an interview on 3/2/26 at 1:14 p.m., LN 2 stated acknowledged she completed the SBAR form and added the incident that occurred between Resident 1 and Resident 2 on the facility's 24-hour report log on 12/25/25. LN 2 stated the DON was supposed to review both the SBAR communication form and 24-hour report log every day. LN 2 stated the DON was aware of the incident that occurred on 12/25/25 because the DON had called her after the incident and instructed her not to use the word abuse in her progress notes.A review of a facility policy and procedure (P&P) titled, Elder/Dependent Abuse, dated 5/29/25, indicated, The facility will protect. [residents] from any type of abuse. Any mandated reporter who.has observed or has knowledge of an incident that reasonably appears to be any type of abuse.will report the known or suspected instance of abuse. as follows.All alleged violations-Immediately but not later than 2 hours.-involves any type of abuse.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a safe and sanitary manner when:1. Muffins with mold (mold is a type of fungus that can grow on food) were served on breakfast trays, and six residents consumed them.2. Dry goods were improperly stored when expired cocoa powder was in the storage area, a gravy packet had leaked, chocolate chips were in an open plastic bag without a date when it was opened.3. Deli meat in a refrigerator was ten days past its use by date.4. Frozen pancakes and frozen egg rolls did not have a date when they were received.5. Trash cans were uncovered during tray line (name of process where food was served on resident's plates). This failure had the potential to cause food-borne illness in 64 of 64 vulnerable residents.Findings:1. During an interview on 8/26/25 at 2:15 p.m., [NAME] A stated she received a report from Dietary Aide B (DA B) that moldy muffins were served to residents on [NAME] A's day off.During an interview on 8/26/25 at 4 p.m., Licensed Nurse C (LN C) stated the moldy muffins were served on a weekend. LN C was informed about the muffins during stand-up (a daily meeting where staff discussed significant events). LN C stated the Director of Nursing (DON) put residents who ate the moldy muffins on a 72-hour alert charting. LN C stated eating moldy muffins could have had serious effects on an immunocompromised (a condition where the system to protect the body from infections and other harmful substances was not working as well as it should) resident, or a resident with gastrointestinal (GI - having to do with the digestive tract) issues.During a concurrent record review and interview on 8/27/25 at 10:18 a.m., the DON confirmed the names of six residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) who were on alert charting after eating moldy muffins.During an interview on 8/27/25 at 11:10 a.m., Resident 1 stated he was served a moldy muffin, and he ate it because he thought the black spots were blueberries. Resident 1 stated a Certified Nurse Assistant (CNA) later told him the black spots were mold and not blueberries.During an interview on 8/27/25 at 11:18 a.m., Licensed Nurse D (LN D) stated CNA E reported mold on the muffins during breakfast service on 8/17/25. LN D and other nursing staff removed the muffins from the breakfast trays after six residents had already consumed all or part of the moldy muffins. The muffins were individually wrapped, and it was obvious there was white or black mold on the muffins when they were unwrapped by the CNAs delivering the breakfast trays.During an interview on 8/27/25 at 11:45 a.m., DA B stated a CNA had reported the moldy muffins on the breakfast trays to [NAME] F who then stopped putting them on the breakfast trays.A record review of the facility's policy titled Food Storage revised on 12/1/21 indicated, .prepare.and serve food in accordance with professional standards for food service safety.A record review of the Food & Drug Administration (FDA) 2022 Food Code, Annex 4, Table 2a indicated, Naturally occurring chemical hazards [in food] include mycotoxins [natural toxins produced by certain types of mold.].found in.corn products.other grains. require control measures.[including] do not use spoiled or moldy food. 2. During a concurrent observation and interview on 8/26/25 at 11 a.m. in the dry storage area of the kitchen, the Food Service Manager (FSM) confirmed a container of cocoa powder expired on 8/3/25; a package of gravy mix had thick, brown leakage on the outside of the package; an open bag of chocolate chips with a disposable plastic cup in the bag and no date to indicate when the bag was opened. The FSM stated the chocolate chips were stored incorrectly. The FSM stated the chocolate chips should have been taken out of the plastic bag, stored in an airtight container with a tight lid, and an open date and a use-by-date label should have been placed on the container. The FSM disposed of the three items.A record review of the facility's policy titled Food Storage revised on 12/1/21 indicated, .All open food items will have an open date and use-by-date per manufacturer's guidelines. 3. During a concurrent observation and interview on 8/26/25 at 12:25 p.m. in the refrigerator area of the kitchen, the Food Service Manager (FSM) confirmed a plastic bin containing packages of previously frozen lunch meat was labeled on 8/17/25 for use by 8/18/25. The FSM disposed of the lunch meat.A record review of the facility's policy titled, Procedure for Freezer Storage dated 2018, indicated .Once thawed.cured meats [curing involves adding salt and preservatives and is a common form of processing for lunch meats] to be used within 5 days. 4. During a concurrent observation and interview on 8/26/25 at 12:30 p.m. in the freezer area of the kitchen, the FSM confirmed a package of frozen pancakes, and a package of frozen egg rolls did not have a received date on them. The FSM stated the food items were improperly stored in the freezer. The FSM stated that improper food storage increased the risk of food born illness for the residents and disposed of both items. A record review of the facility's policy titled, Procedure for Freezer Storage dated 2018, indicated, All frozen food should be labeled and dated. 5. During a concurrent observation and interview on 8/26/25 at 12:20 p.m. in the kitchen during tray line, the FSM confirmed four trash containers were uncovered, including one that had trash overflowing on to the floor. The FSM stated the trash containers should have been covered. The FSM asked Dietary Aide B (DA B) where the lid to the trash container was. DA B stated he did not know where the lid was.A record review of the FDA Food Code 2022, Section 5-501.113, Covering Receptacles indicated, Receptacles and waste handling units for REFUSE, recyclables.shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled.

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared and served safely in accordance with professional standards of food service when:1. Soiled equipment was observed in a food prep area;2. The floor was noted to have solid food debris, built up dust, and dirt underneath the sink and behind the oven;3. Kitchen staff did not monitor the tray line food temperatures; and,4. Kitchen staff did not use facial hair nets.These failures posed the risk for food borne illnesses for 57 of 57 residents who resided in the facility and consumed food prepared in the kitchen.Findings:1. During an observation on 7/16/25 at 12:15 p.m., the following observations were made:The stovetop had black residue and debris in burner wells; The dishrack had visible grime and black residue; The ceiling vents over the steamtable had a large amount of dust build up; and the air conditioning unit had dust build up on the vents over the food prep table. During an interview on 7/17/25 at 12:20 p.m., the Corporate Registered Dietician (CRD) acknowledged the kitchen equipment needed to be cleaned. The CRD stated she ensured a deep cleaning was performed every month but did not have a cleaning log. The CRD further stated cleaning was not being monitored since the Dietary Manager (DM) left a few months ago. The CRD stated she was attempting to get dietary staff to take ownership for a clean kitchen.A review of a facility document titled Sanitization dated 2001, indicated, The food service area shall be maintained in a clean and sanitary manner. All.equipment shall be kept clean.According to the FDA Food Code 2022, Section 4-601.11, Food Contact Surfaces, Nonfood Contact Surfaces, and Utensils (A) Equipment, food contact surfaces, and utensils shall be clean to sight and touch, (C) Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.2.During an observation on 7/16/25 at 12:15 p.m., food debris located on the floor in the corner by the sink and behind the stove was noted. An accumulation of dust, dried liquid, and small black particulates was noted in the area directly beneath the sink. A sample was gathered for CRD confirmation.During an interview on 7/17/25 at 2:30 p.m., the CRD was unable to identify the bits of food taken from the corner underneath the sink. The CRD again stated she was attempting to gain staff buy in to clean the kitchen and will begin to establish a routine cleaning schedule. During a review of document titled Sanitization, dated 2001, indicated All kitchens, kitchen areas.shall be kept clean, free from litter and rubbish.According to the FDA Food Code 2022, Section 6-501.12 (a), Physical facilities, including floors, walls, ceilings, and other structural components, must be cleaned as often as necessary to keep them clean. This means facilities should establish and maintain a regular cleaning schedule based on the level of activity and potential for contamination in each area.3. During a concurrent interview and observation on 7/17/25 at 11:34 a.m., [NAME] 1 (CK 1) was taking temperatures of food on the steamtable in preparation for the lunch tray line and entering the temperatures in a logbook. She stated entries in the tray line temperature log must be made with every meal to prevent the residents getting sick. During a concurrent interview and observation on 7/17/25 at 11:55 a.m., there were several temperature entries missing for several days in the tray line logbook. The CRD confirmed the missing temperature entries and stated, Food temperature logs must be filled out with each meal, every day. This helps us to keep the hot food hot. The CRD stated food temperatures below 135 degrees will begin to multiply with bacteria growth that would cause food borne illnesses amongst the residents. A review of facility policy titled Meal Serving Temperatures dated 2023, indicated, .food temperatures will be taken while the hot food items are on the steamtable just prior to serving.these temperatures will be recorded on the form called Food Temperature Log.According to the FDA Food Code 2022, Section 3-501.16, the requirements for maintaining hot foods at safe temperatures. It stipulates that hot TCS (Time/Temperature Control for Safety) foods must be held at 135 F (57 C) or above. 4.During a concurrent observation and interview on 7/17/25 at 11:45 a.m., Dietary Aide (DA) was observed not wearing a facial hair restraint while in the kitchen prepping for tray line. The DA stated he was not aware he needed to wear one. The DA obtained a surgical mask to wear from the CRD.During a concurrent observation and interview on 7/17/25 at 11:50 a.m., the CK 2 was observed not wearing a facial hair restraint while in the kitchen preparing cookies. CK 2 stated there were no facial hair restraints available. CK 2 obtained a surgical mask to wear from the CRD.During an interview on 7/17/25 at 12:15 p.m., the CRD stated she had ordered more facial hair restraints, and the order had not arrived yet. She confirmed the necessity for facial hair nets was to prevent contamination of food with hair. The CRDO confirmed surgical masks would not contain hair from dropping into food or equipment used in food prep. During a review of facility document titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices dated 2001, indicated, Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens.According to FDA Food Code 2022 2-402.11 (A) Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles.

Based on observation and interview, the facility failed to create a homelike environment for a census of 57 residents when walls in multiple residents' rooms were damaged and carpeting throughout the facility was worn and stained.These failures decreased the facility's potential to ensure residents were provided a safe, clean, comfortable, homelike environment to support their overall well-being.Findings:During interval observations on 7/17/25 between 9:48 a.m. and 2:50 p.m., carpeting throughout hallways of the facility was noted to be worn with multiple stains of varying sizes and colors. The carpeting was matted down with dirt and heavy traffic at each doorway entry.During an observation on 7/17/25 at 10:16 a.m., torn wallpaper and wall damage with exposed drywall (building material) was observed in Resident 2's room. During a concurrent observation and interview on 7/17/25at 10:26 a.m., torn wallpaper in several areas in Resident 3's room was observed. Resident 3 stated, It's been that way for a long, long time. I don't know how it happened. But you can't miss it unfortunately.During a concurrent observation and interview on 7/17/25 at 10:36 a.m., torn wallpaper was observed in Resident 4's room. Resident 4 stated, It's not pretty.During an observation on 7/17/25 at 10:51 a.m., torn wallpaper and wall damage with exposed drywall was observed in Resident 5's room. During an interview on 7/17/25 at 2:51 p.m., the Administrator (ADM) acknowledged the wall damage and torn wallpaper existed in most of the residents' rooms. The ADM believed the damage had occurred due to the residents' head of beds hitting the wall with force. The ADM also stated he was aware of the old, stained carpeting and directed the maintenance team to clean it monthly. The ADM also acknowledged the carpeting made it difficult for residents to propel their wheelchairs and staff to move patient care equipment.A review of the facility's policy titled Homelike Environment dated 2001 indicated, The .management maximizes.the characteristics of the facility that reflect a. homelike setting.these characteristics include a clean, sanitary and orderly environment.

Based on observation, interview, and record review, the facility failed to protect one resident (Resident 1) of three sampled residents from physical abuse by Resident 2, when Resident 2 deliberately placed his hands on Resident 1 ' s chest and pushed him which caused Resident 1 to fall during an argument over a television (TV) channel inside their room. This failure resulted in a skin tear (a wound caused by direct force which separates the skin ' s layers) and an abrasion (a scrape) on Resident 1 ' s left forearm. Findings: A review of Resident 3 ' s Minimum Data Set (MDS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) dated 3/1/25, indicated a Brief Interview for Mental Status (BIMS- a screening tool used to assess a person ' s memory and cognition (ability to think, understand, remember, and problem-solve)) score of 15, which meant his cognition was intact. A review of Resident 2 ' s MDS dated [DATE], indicated his BIMS score was 13, meaning his cognition was moderately (an observable delay) intact. A review of Resident 1 ' s MDS dated [DATE] indicated Resident 1 ' s BIMS score was 10, meaning his cognition was moderately impaired (diminished). During a concurrent observation and interview on 5/2/25 at 10 a.m. Resident 2 was sitting in his room watching TV. Resident 2 stated Resident 1 changed the channel of Resident 2 ' s television using Resident 1 ' s TV remote control. Resident 2 stated he pushed Resident 1 by placing both his hands on Resident 1 ' s chest to push him. Resident 2 stated Resident 1 fell on the floor. Resident 2 stated there were no staff in the room during that time, but Resident 3 was also in the room. During a concurrent observation and interview on 5/2/25 at 11 a.m., with Resident 1 and Resident 3, Resident 1 showed the Surveyor the island dressing (a highly absorbent layer with an adhesive border) located on his left forearm which measured 2 centimeters (cm- a unit of measure) by 2 cm. Resident 1 stated Resident 2 placed both his hands on his chest and pushed him, causing him to fall. Resident 1 pointed to the part of his bed where he hit his left forearm. Resident 3 stated each resident ' s TV remote controlled all three TV sets in the room. The Surveyor observed Resident 3 use his remote to change the channel of his TV which also changed the channel of Resident 2 ' s television. A review of Resident 1 ' s facility document titled Situation Background, Assessment, Recommendation [SBAR] dated 4/28/25 at 3:15 p.m. indicated, Incident started on 4/28/25, at 3:15 p.m.[Resident 2] pushed [Resident 1] resulting in a fall with injury .Things that make the condition or symptom worse are .TV control for [Resident 1] controls both his and [Resident 2 ' s] TV .Other relevant information .2 cm X [by] 2 cm S/T [Skin Tear] with 5 cm X 1 cm abrasion to LFA [left forearm]. A review of Resident 1 ' s progress note dated 4/28/25 at 3:15 p.m., indicated, [Certified Nursing Assistant B (CNA B)] alert [LN A] to [Resident 1] sitting on floor . [Resident 1] states resident [Resident 2] pushed him causing him to fall to floor onto buttocks . A review of Resident 2 ' s progress note dated 4/28/25 at 3:54 p.m., indicated, [Social Service Director] followed up this res [Resident 2] in regards to res-res [resident to resident] altercation this res [Resident 2] being the aggressor when I asked him why he pushed his roommate he stated ' because he changed the tv station he is fine he is not hurt. ' I explained to him [Resident 2] that we due [sic] put our hands at anyone . During a concurrent observation and interview on 5/2/25 at 11:40 a.m., the Maintenance Supervisor (MS) stated each TV in Resident 1 and Resident 2 ' s room had its own remote control and a control box. The MS acknowledged if a resident pointed their remote control toward his roommate ' s TV control box, it could change the channel. The MS stated he had received previous complaints from other residents about this, but this TV system had been in place for a while now. During an interview on 5/5/25 at 1:25 p.m., LN A stated on 4/28/25 at about 2:55 p.m., CNA B alerted him about a fall. LN A stated he saw Resident 1 sitting on the floor with his feet up on the foot of his bed facing the door. LN A stated Resident 2 admitted he had pushed Resident 1 to LN A, the Director of Nursing (DON), and CNA B. Resident 2 stated he had pushed Resident 1 because Resident 1 had changed the channel on Resident 2 ' s TV. LN A stated there was no doubt the push was deliberate, and Resident 2 had admitted it. LN A also stated Resident 1 reported he was pushed by Resident 2. During an interview on 5/5/25 at 2:08 p.m., the DON stated LN A informed her Resident 2 admitted to pushing Resident 1. The DON stated it was determined during the investigation that Resident 2 ' s action was deliberate and intentional. The DON stated she determined the reason for the altercation was there was no individuality to the TVs. The DON stated she informed the MS and the Administrator of the cause of the incident and was told by both staff that they would work on it. A review of the facility ' s policy and procedure (P&P) titled, Elder/Dependent Adult Abuse, undated, indicated, .The facility will protect the rights, safety, and well-being of each resident regardless of physical or mental condition, against any and all forms of abuse including freedom from neglect and exploitation .Abuse is .defined .as: ' The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . '

Based on observation, interview and record review, the facility failed to provide a safe living environment, free of physical altercations by not providing appropriate supervision for six out of 10 sampled residents (Resident 1, 7, 11, 18, 28, and 32), who had a combined total of 19 episodes of aggression over a two-month time period, dating from 10/17/19 to 1/1/20). On 1/7/20 at 4:15 p.m., due to the facility's failure to provide appropriate supervision, Administrative Staff A and the Director of Nursing (DON) were verbally notified of the Immediate Jeopardy. The Health Facilties Evaluator Nurse informed Administrative Staff A and the DON of the multiple episodes of aggression which were associated with lack of appropriate supervision. Immediate Jeopardy is a situation in which a provider's noncompliance with one or more requirements of participation has caused or is like to cause serious injury, harm, impairment or death to a resident (Standard Operations Manual, Appendix Q). On 1/10/20, at 2:25 p.m., the facility presented a correction plan of action, including one-to-one supervision for Residents (7 and 32) amongst others. On 1/10/20 at 2:25 p.m., the abatement (lifted) of Immediate Jeopardy occurred in the presence of Administrative Staff A and the Director of Staff Development (DSD) after interviews and observations confirmed the facility implemented the corrective plan of action to provide appropriate supervision. On 1/10/20 at 2:25 p.m., Administrative Staff A and the DSD were notified of Substandard Quality of Care identified and the facility was on an Extended Survey. Substandard quality of care means one or more deficiencies related to participation requirements under Quality of Care 483.25 (d) (2), which constituted Immediate Jeopardy to resident health and safety (level J, K, or L) (Standard Operation Manual, Appendix P) These failures resulted in emotional and physical harm (Resident 1, 7, 18, 28, and 32) to the affected residents and the creation of an unsafe (Resident 11) and fearful living (Resident 28) environment for the residents residing at the facility. Findings: 1. During a review of, Resident Face Sheet, (undated), Resident 7, a [AGE] year-old female, was admitted to the facility on [DATE], with a history of [MEDICAL CONDITION] (a group of lung diseases that block airflow and make it difficult to breathe), muscle weakness from [MEDICAL CONDITION] (blood vessels in the brain break, causing bleeding inside of the brain), [DIAGNOSES REDACTED] (a group of brain disorders that affect the personality, behavior and language of the brain), [MEDICAL CONDITION] disorder (mental health condition including mood disorder symptoms). During a review of Resident 7's quarterly, Minimum Data Set (MDS -- a clinical assessment process providing a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 11/13/19, indicated Resident 7's cognitive skills (core skills your brain uses to think, read, learn, remember, reason and pay attention) were severely impaired (never/rarely made decisions). During a review of a, Care Plan for Resident 7, dated 8/18/18, indicated she had a problem with behavioral symptoms by episodes of inappropriate, disruptive and combative behaviors, along with altered behaviors including a potential for screaming, cursing, threatening, kicking, shoving, scratches, grabbing, throwing items and rummaging through other people's belongings. The approach or interventions to be used in keeping Resident 7's behavior appropriate was for 1:1 supervision, as needed, to calm her if distress occurred, allow a safe distance between Resident 7 and staff, to prevent her from striking or becoming increasingly agitated, monitor behaviors that could endanger herself or others, monitor her wandering behaviors that may become unsafe, remove her from group activities when her behavior had been unacceptable and seat Resident 7 where constant or near constant observation would be possible, all dated, 8/18/18. Resident 7's plan of care was updated on 3/14/19, to include a problem of Resident 7 ambulating around the facility until she was exhausted, while walking into things like doors, equipment and other residents. The approach or interventions suggested included monitoring Resident 7 while ambulating to ensure she used her front-wheel walker. Resident 7's, Plan of Care was updated on 1/2/20, to include a problem with making physical contact with a female resident in the dining room. The approach or interventions suggested to keep Resident 7 from harming other residents, including redirecting her from heavily populated areas if she appeared to be in an unpredictable mood or if angry, offering diversion activities if her mood appeared to be angry until she returned to a calmer state, allowing a safe distance between Resident 7, with peers and staff, and monitoring her behavior as it related to endangering herself with other residents or staff, and intervening as necessary. During a review of, Nursing Progress notes for Resident 7, dated 10/28/19 at 10:03 a.m., she was observed yelling at the housekeeper who was in an office emptying the trash. Resident 7 then repeatedly slapped the housekeeper who was attempting to assist her out of the office area due to safety concerns around equipment and cords, which might create a fall risk. The medical record did not indicate how or why Resident 7 was able to enter an office not designated for resident use. During a review of Resident 7's Nursing Progress Notes, dated 11/1/19 at 8:25 p.m., indicated she was observed to have her hand on Resident 11's door while attempting to talk to her. Resident 11 then shut the door abruptly, injuring Resident 7, as she stated, ouch. On 11/2/19 at 4:53 p.m., Nursing Progress Notes indicated Resident 7 subsequently developed a hematoma (blood or bleeding under the skin due to trauma of any kind) as result of the door being shut in her face. During a review of Nursing Progress Notes dated 12/3/19 at 12:15 p.m., Resident 7 was observed in the dining area attempting to take belongings from Resident 28, who was sitting at a table. Resident 28 stated to Resident 7, You can't take my stuff, and, at that point, Resident 7 made contact with her open hand to Resident 28's left cheek. During an interview on 12/18/19 at 11:43 a.m., Resident 28 stated Resident 7 slapped her in the face, thought to be due from something she (Resident 28) said. Resident 28 stated she had to be careful around Resident 7 because, in the past, Resident 7 grabbed her knee, causing pain. Resident 28 stated Resident 7 was someone who just walked everywhere and did not know what she was doing and behaved unpredictably as you just did not know what she would do. During a review of, Nursing Progress notes dated 12/8/19 at 11:29 a.m., Resident 7 was indicated to be exhibiting aggressive behaviors by striking a nurse in the face, cursing at staff and was placed on a 1:1 supervision. During a review of, Nursing Progress notes dated 12/18/19 at 11:45 a.m., Resident 7 was indicated to continue to be on 1:1 supervision, while trying to prevent her from striking other residents and throwing plastic bins, while ambulating around the facility, calling anyone in the hallways curse words and throwing plastic bins at staff. The medical record did not indicate the interventions identified from the, Plan of Care, used to keep Resident 7 or the other residents safe from the aggressive behaviors, or how the 1:1 supervision was effective in eliminating the aggressive behaviors. During an observation on 12/18/19 at 11:08 a.m., Administrative Staff A was escorting the surveyor down the hallway, and Resident 7 was ambulating with her front-wheeled walker in the hallway. Administrator Staff A called out to her (Resident 7), but she did not respond and continued to ambulate at a consistent pace. Administrator Staff A indicated Resident 7 would not respond unless there was tactile stimulation or face-to-face contact. When greeted, while making eye contact, Resident 7 smiled, stated she was fine and then bent her head down and proceeded to ambulate with her front wheel-walker. In an interview on 12/18/19 at 11:16 a.m., Unlicensed Staff X indicated Resident 7 continued to roam or walk throughout the facility, consistently, from the time she got up until the time she went to sleep. Unlicensed Staff X stated Resident 7 would sit for a few minutes to eat, but then returned to roaming the hallways. Unlicensed Staff X indicated Resident 7 would wander into other residents' rooms, and if they would yell at her to get out, that would trigger her to yell back or to strike out. Unlicensed Staff X stated, Resident 7 roamed the hallways, at times crowded with other residents in their wheelchairs, prompting some residents to yell at Resident 7 to watch out and be careful (not to bump into them). Those described incidents would provoke Resident 7 to cuss or strike out at the person yelling at her. During an interview on 12/18/19 at 12:05 p.m., Unlicensed Staff Z indicated Resident 7 would wander throughout the facility presenting problems by wandering through the dining room for instance, consistently touching other peoples' stuff. The residents would yell at Resident 7, even though she might have just picked something up to look at and then put it down and again, this would trigger aggressive behaviors, like yelling profanity or striking out physically. During a review of the, Investigation Notes, dated 1/2/20 at 12:30 p.m., Resident 7 was in the dining room and made contact, with an open hand, to Resident 1's forehead, resulting in a bruise. During a review of the, Social Services Progress Note dated 1/3/20 at 4:30 p.m., Resident 1 stated she had no memory of the event. During a review of the, Interdisciplinary Team Note dated 1/7/20 at 12:31 p.m., indicated Resident 7 may appropriately verbalize her needs at times, but often times she would make unintelligible statements. Resident 7 was indicated to be often times confused and wandering throughout the facility aimlessly, requiring redirection. Resident 7 was encouraged to be redirected from heavily populated areas if she appeared to be in an unpredictable mood or angry. During an interview on 1/7/20 at 11:53 a.m., Unlicensed Staff W stated Resident 7 tended to bump into things (equipment/furniture), staff and other residents. Unlicensed Staff W stated, when she took care of Resident 7, she and all of the staff, watched out for her and what she was doing. Unlicensed Staff W stated she could get busy with providing care for other residents and agreed, while Resident 7 roamed the hallways, sometimes there were no staff members in the hallways to watch out for her behaviors. During an interview on 1/7/20 at 12:12 p.m., with Licensed Staff H, she stated everyone watched out for Resident 7, and agreed there were times during the course of the shift there were no staff members in the hallways to watch out for her. Licensed Staff H indicated the safety concern for Resident 7 was not her being aggressive with other residents, but more of the other aggressive residents striking out if she (Resident 7) were to bump into them or get too close to them, while unsupervised. During an interview on 1/7/20 at 12:31 p.m., Unlicensed Staff S stated Resident 7 would not make eye contact, even if you were right in front her, and indicated there were no other staff members identified to watch the hallways or certain residents. Unlicensed Staff S restated, if she were to call out to Resident 7 not to go into another resident's room, for example; Resident 7 would not be able to redirect herself, thus creating the potential for a resident-to-resident altercation. During an interview on 1/7/20 at 1:02 p.m., Administrative Staff CC stated Resident 7 fell a few times because she did not stay with her walker and left it behind. Administrative Staff CC stated Resident 7 would leave her walker behind and then start using the back of a chair or the hand rails, along the side of the hallway, for assistance in getting around. Administrative Staff CC agreed Resident 7 was unable to remember to consistently use her walker and had little-to-no safety awareness. Administrative Staff CC indicated Resident 7 would no longer continue with physical therapy for gait balance because she could not follow the instructions, due to her lack of cognition. During an interview on 1/7/20 at 2:12 p.m., with the DON, she reviewed Resident 7's plan of care and stated the following explanations, regarding the approaches or interventions indicated on the plan of care: 1) allowing a safe distance would be determined by an arm's reach, but the DON agreed not all of the facility staff would have that same understanding for determining a safe distance. The DON agreed a safe distance would be difficult or impossible when the hallways would become crowded with multiple residents in wheelchairs, which happened every day. The DON could not state Resident 7's specific behaviors, as indicated on the, Plan of Care, which would require monitoring, or who specifically would monitor Resident 7's wandering behaviors if all staff were busy providing resident care. The DON agreed, if Resident 7's behavior were inappropriate during an activity, she would then be removed, but this would occur after-the-fact, as the behavior had already occurred. The activity person would not be able to prevent the inappropriate behavior from occurring since they would be conducting the activity and could not focus completely on Resident 7's behavior. The DON could not explain how Resident 7's behavior would be monitored, with regard to keeping a safe distance away from known aggressive residents and how to keep Resident 7 safe from being the victim of resident-to-resident altercations. Two separate observations were made on 1/7/20: 1) at 1:50 p.m., Resident 7 was walking without her front-wheel walker at the front of the building, with multiple staff members walking past her and not acknowledging she was not using her front-wheel walker, but rather using the hand rail or any other piece of equipment to navigate the hallway; and, 2) at 3:30 p.m., Resident 7 was navigating down a different hallway without her front-wheel walker, instead using the hand rails and wall to steady her gait, while multiple staff members passed her, and only one staff member verbally called out for her to get her walker. Resident 7 did not acknowledge the request and did not stop her wandering behavior to retrieve her walker. Resident 7's walker was not in sight of the hallway, and it was unclear exactly where the walker was located. During a concurrent observation and interview on 1/10/20 at 11:25 a.m., Unlicensed Staff Z she was sitting next to Resident 7, who was coloring in the dining room. Unlicensed Staff Z stated Resident 7 would sit for an activity if someone was with her, sitting next to her, and then she could stay focused on an activity, versus attending a group activity. Resident 7 would not stay focused very long for a group activity, maybe a minute or two and would then go back to walking the hallways. Unlicensed Staff Z stated Resident 7 would roam through the dining room throughout the day, but rarely stopped to participate in an activity. During an interview on 1/10/20 at 11:52 a.m., Unlicensed Staff Q stated Resident 7 liked to go outside where the smoke breaks occurred and often times would leave her walker in random places and needed lots of encouragement to use her walker. During an interview on 1/10/20 at 4:37 p.m., Licensed Staff L indicated Resident 7 would be in a certain mood in the morning and this would set the tone for the day, meaning; staff would know if she was in a bad mood and would have to watch out for her and how she reacted with other residents. Licensed Staff L stated Resident 7 generally walked the hallways all day, had a tendency to leave her walker behind, and then would use the wall for support. Licensed Staff L stated everyone (all staff) watched out for her, but agreed that many times there would be no staff present in the hallways to watch her, as they would be providing care to other residents, and then no one would be watching her. 2. During a review of Resident 32's face sheet, (undated), Resident 32, an [AGE] year-old male, was admitted to the facility on [DATE], with a history of [DIAGNOSES REDACTED] (a disease associated with abnormal protein deposits, which affects a person's thinking, movement and behavior), Alzheimer's (a progressive disorder causing brain cells to waste away and die, resulting in a decline of thinking, behavioral and social skills, which disrupted a person's ability to function), and high blood pressure. During a review of Resident 32's quarterly, Minimum Data Set (MDS -- a clinical assessment process providing a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 11/5/19, indicated Resident 32's cognitive skills (core skills your brain uses to think, read, learn, remember, reason and pay attention) were severely impaired (never/rarely made decisions). During a review of Resident 32's, Care Plan dated 3/27/19, indicated he had a problems with refusing personal care after being incontinent, whereby he would become combative toward staff, by yelling, kicking or hitting. The approach or interventions suggested to allow staff to assist in personal care, thereby preventing him from staying in his urine and feces, were: Allowing him to pick out his clothes and let him wipe himself down, explain the importance of personal care, and if Resident 32 denied care being provided, then have another staff member make an attempt to provide care. During a review of a, Care Plan, for Resident 32 dated, 10/25/19, indicated he had a problem with behavioral symptoms by being the aggressor in resident-to-resident altercations. The approach or interventions suggested to prevent him from harming himself or others, were: Monitor for changes in behaviors, monitor whereabouts when propelling through the building and allowing a safe distance between resident and staff. During a review of a, Care Plan, for Resident 32 dated, 11/2/19, indicated he had a problem with episodes of inappropriate, disruptive behaviors with/and/or combative features. The approach or interventions suggested to prevent him from harming himself or others, were identified as: Offering to take Resident 32 for a stroll in his wheelchair, allow a safe distance between resident and staff, to prevent him from striking staff, and to promote activities such as painting, reading and watching television. During a review of the, Nursing Progress Notes, dated from 10/17/9 to 1/9/20, Resident 32 had 14 separate physical and/or verbal altercations with either residents or staff, from 10/17/19 to 1/1/20. On 10/17/19 at 2:45 p.m., Resident 32 attempted to throw hot coffee on a Certified Nursing Assistant (CNA). On 10/21/19 at 4:33 a.m., he attempted to strike and kick staff, while staff were trying to provide personal care. On 10/25/19 at 2 p.m., Resident 32 was observed hitting Resident 7 in the lower back area with his hand. On 10/27/19 at 7:30 p.m., Resident 32 and Resident 13, were involved in a wheelchair collision, whereby Resident 13 struck Resident 32, who then hit Resident 13. On 10/29/19 at 3 p.m., Resident 32 squeezed Resident 28's arm, resulting in pain and bruises. On 11/2/19 at 4 p.m., Resident 32 put his right hand on another resident's wrist (unclear if it was Resident 13). On 11/6/19 at 2:47 p.m., Resident 32 was combative with staff attempting to provide routine personal care. On 11/11/19 at 3:45 p.m., Resident 32 struck Resident 28 and Resident 18. On 11/20/19 at 3:52 p.m., Resident 32 was combative with staff while they were attempting to providing personal care. On 11/22/19 at 5:55 a.m., Resident 32 was agitated and combative when staff were attempting to provide incontinent care. On 12/6/19 at 4:58 a.m., Resident 32 was combative with care, as indicated by yelling and attempting to strike staff. On 12/9/19 at 12 p.m., Resident 32 was involved in a resident-to-resident altercation, where Resident 18 yelled profanities, and then Resident 7 kicked him in the leg. On 12/16/19 at 10:30 a.m., Resident 32 was observed to shout profanities and attempted to punch a staff member. On 1/1/20 at 6:37 a.m., Resident 32 was observed to attempt to punch staff while trying to provide incontinent care. During an interview on 12/18/19 at 11:16 a.m., Unlicensed Staff X stated Resident 32 was the only resident which scared her, as he had a certain look and a sort of grimace. Unlicensed Staff X stated she would ask for help when providing care for Resident 32, due to his unpredictable behavior and propensity for being combative. Unlicensed Staff X stated she would try and get him out of bed in the morning, but if he did not answer in a happy tone then she would know it would be a bad day. Unlicensed Staff X stated she would attempt to change his clothes if they were dirty, and during the process of providing care, he might squeeze her arm very tight and then might try and strike at her; either way it would hurt if he squeezed her arm really tight. Unlicensed Staff X stated she never observed Resident 32 reading a book, painting or watching television. Unlicensed Staff X indicated Resident 32 injured her during the course of providing care. During an interview on 12/18/19 at 12:05 p.m., Unlicensed Staff Z stated Resident 32 might be walking down (resident used a wheelchair) the hallway, he might just flip someone off and or start swearing at them, usually at male residents and for no apparent reason. She stated the approach to deal with Resident 32 was try and distract him, and agreed that it would be difficult or impossible if staff were in resident rooms providing care, and he was unsupervised. During an interview on 1/7/20 at 12:12 p.m., Licensed Staff H stated she was concerned regarding Resident 32 and his unpredictable combative behavior. Licensed Staff H stated Resident 32 could be very aggressive and unpredictable, making it difficult to watch out for him and the safety of other residents, who liked to gather in the hallways and sit. Licensed Staff H indicated the hallways became crowded with residents, who liked to be out of their rooms sitting in the hallways daily. During a review of the facility's job description, titled, Job Description For Sitter (not dated), indicated, The sitter is to protect and promote the residents rights and assist the resident to maintain independence and control to the greatest extent possible Have the ability to interact effectively with individuals who are cognitively and/or physically impaired Have the ability to respond to changes productively and to handle additional task/projects as assigned.

Based on observation, interview, and record review, the facility failed to ensure two residents (Residents 34 and 32) were free from abuse, when facility staff did not: 1) Ensure Resident 34's safety from a known risk of verbal and physical abuse posed by Resident 3. Due to the facility's failure to ensure Resident 34's safety from abuse, the Administrator and Director of Nursing were verbally notified of an Immediate Jeopardy situation on 1/7/20, at 4:15 p.m. The Administrator and Director of Nursing were informed of the observations, interviews with staff, and record reviews, which evidenced a gap in care exposing Resident 34 to harm. On 1/7/19, at 7:06 p.m., the facility presented and implemented a corrective Plan of Action, including, but not limited to: Use of one-to-one assignments for managing resident behaviors to mitigate safety risks, competency training for all staff assigned to one-to-one assignments, and development of individualized care plans to guide clinical management for residents at risk for abuse or receiving one-to-one supervision. Removal of the Immediate Jeopardy occurred in the presence of the Administrator, Director of Staff Development (DSD), Licensed Staff I, Corporate Area President, Corporate Staff GG, Corporate Staff HH, and Corporate Staff II on 1/10/20, at 2:52 p.m., after observations, interviews and record reviews confirmed staff members tasked with a one-to-one assignment had been trained consistently and implemented one-to-one assignments consistently, and the facility developed the necessary care plans; and, 2) Ensure Resident 32's safety from being the victim of abuse, a risk of which the facility was aware. These failures did not ensure a safe environment and exposed Residents 34 and 32 to the abusive behavior of other residents. Findings: 1) Resident 3's Minimum Data Set (MDS, an assessment tool), dated 10/30/19, indicated Resident 3 was admitted to the facility from an, acute hospital on [DATE]. The MDS indicated Resident 3 received a, summary score of 03(/15) during a cognitive assessment, indicating he had severely impaired cognition. The MDS indicated Resident 3 exhibited no adverse behaviors or moods affecting his psychosocial well-being. The MDS indicated Resident 3 had no, neurological or psychiatric/mood disorder, diagnoses, but was diagnosed with [REDACTED]. Resident 34's Minimum Data Set (MDS, an assessment tool), dated 11/5/19, indicated Resident 34 was admitted to the facility from an, acute hospital on [DATE]. The MDS indicated Resident 34 received a, summary score of 07(/15) during a cognitive assessment, indicating she had severely impaired cognition. The MDS indicated Resident 34 exhibited no adverse behaviors or moods affecting her psychosocial well-being. The MDS indicated Resident 34 had no, neurological or psychiatric/mood disorder, diagnoses. During an observation on 12/20/19, at 10 a.m., a female staff member sat in an office adjacent to the facility's front door. A, STOP sign, secured across the office's doorway, precluded ingress and egress to the office. An unidentified female resident sat in a wheelchair staring out of the front door toward the driveway. During a concurrent interview and record review on 1/6/20, at 10:45 a.m., Administrator A stated she was the Abuse Coordinator at the facility. Administrator A stated she was accountable for investigating allegations of abuse in the facility, and she, the Social Services Director (SSD), and Director of Nursing (DON) facilitated abuse investigations at the facility. Administrator A stated the facility recently, separated residents who were, husband and wife, due to behaviors between the two residents. Administrator A stated Resident 3 required a, one-to-one assignment, in the evening. During a concurrent observation and interview on 1/6/20, at 12:45 p.m., Resident 20 called out in a loud volume audible from an adjacent room: Get out! This is not your room! On entering her room, Resident 20 was lying in bed. No staff were inside Resident 20's room or in the hallway. When asked about her concern, Resident 20 pointed in the direction of her bathroom. Resident 3, a male resident, sat in a wheelchair inside Resident 20's bathroom. Resident 3 stated he was, just trying to find . , but did not finish his sentence. Resident 3 exited Resident 20's bathroom and then the room. Resident 20 stated she had, hit the call light, but no staff had responded. Resident 20 stated this was the, first time she observed Resident 3 inside her room. Resident 20 stated she knew of Resident 3: His wife is here. They sleep in separate rooms. Resident 20 stated Resident 3, pursues me more since his wife moved rooms. During an observation on 1/6/20, at 12:50 p.m., a, STOP sign was placed across Resident 20's doorway. During an interview on 1/6/20, at 12:50 p.m., Resident 3 stated he entered Resident 20's bathroom because he was, waiting for a car to pick me up. Resident 3 stated there was, nothing in Resident 20's room, that I need. During an interview on 1/6/20, at 12:56 p.m., Unlicensed Staff EE stated he was a Certified Nurse Assistant (CNA) familiar with Resident 3's care needs. Unlicensed Staff EE stated Resident 3 was, normally independent, but required one-person assistance with toileting. Unlicensed Staff EE stated Resident 3 exhibited, verbal aggression. Unlicensed Staff EE stated Resident 3 was, mentally abusive to Resident 34. Unlicensed Staff EE also stated Resident 3 threatened to, hit other residents and staff, and actually did, hit his wife (Resident 34) on an earlier occasion. Unlicensed Staff EE stated, (Resident 3's) brother, was available to, come in and help (Resident 3) participate in care, if Resident 3 behaved unreasonably toward staff. In regard to the facility's plan to monitor Resident 3's behavior, Unlicensed Staff EE stated Resident 3, can do what he wants, and go where he wants. Unlicensed Staff EE stated the facility did not impose a, one-to-one, staff assignment for Resident 3. Unlicensed Staff EE stated the facility, cannot provide 24-hour observations, of Resident 3. Unlicensed Staff EE stated the facility kept other residents safe from Resident 3 by, guid(ing) other residents, past Resident 3 upon encountering him in a common area. Unlicensed Staff EE stated the facility used, stop signs, too, to prevent Resident 3 from entering other resident rooms. Unlicensed Staff EE stated, additionally, facility staff, keep an eye on, Resident 3. When asked how frequently staff kept an eye on Resident 3, Unlicensed Staff EE stated, as best as we can. During an observation on 1/6/20, at 1:05 p.m., Resident 3 was seated in his wheelchair near the front lobby door to the facility. Resident 3 faced Resident 34, who was also seated in a wheelchair. At most, one-to-two-feet of space separated Residents 3 and 34. Resident 3 and Resident 34 were engaged in conversation and appeared to be arguing. Then, Resident 3 lifted his leg from the wheelchair's foot rest and a made a kicking motion toward Resident 34. Resident 3 did not make contact with Resident 34. Two staff observed the interaction between Resident 3 and Resident 34. Neither staff placed themselves between Residents 3 and 34, or vocalized the clinical inappropriateness of Resident 3's action. A female staff stated, I think (Resident 34) has to use the restroom, and wheeled Resident 34 way from Resident 3. During an interview on 1/6/20, at 1:45 p.m., Licensed Staff H stated she was Resident 3's nurse and familiar with the interactions between Residents 3 and 34. Licensed Staff H stated, between Thanksgiving and Christmas of 2019, Resident 3, cornered (Resident 34), while both resided in the same room. Licensed Staff H stated, we are all trying, to keep Resident 34, at a safe distance, from Resident 3. Licensed Staff H described the safe distance as using a, different hallway, than Resident 3, to assist Resident 34 through the facility. Licensed Staff H stated Resident 3 exhibited, seeking behavior, toward Resident 34, and, staff have to keep an eye on him. Licensed Staff H stated Residents 3 and 34, need to be in separate locations, of the facility. During a concurrent observation and interview on 1/7/20, at 10:08 a.m., Resident 3 was lying down in his room. Resident 3 stated he, feels safe, at the facility, but, I do not feel safe now. Resident 3 stated another man, stole his wife, (Resident 34), and some way or another he's had help from the city and it worked. Resident 3 stated he woke up and his, wife's gone. Resident 3 stated he did not know the name of the man who stole his wife. Resident 3 stated he would use a, pistol on (the man who stole his wife) . but I don't want to go to jail. During an interview on 1/7/20, at 11:18 a.m., Administrative Staff FF stated she was the facility's receptionist. Administrative Staff FF stated she was present when Residents 3 and 34 interacted in the facility lobby area after lunch on 1/6/20. Administrative Staff FF stated she did not remember what the residents said to each other. Administrative Staff FF stated Resident 34 said something, but Resident 3, misheard it. Administrative Staff FF stated she saw Resident 3 try to kick Resident 34, out of the corner of her eye. Administrative Staff FF stated she did not step-in before Resident 3's kick, because they were just talking. Administrative Staff FF stated she was in the lobby that day due to her role as facility receptionist. Administrative Staff FF stated the facility did not task her with resident supervision in the reception area. Yet, Administrative Staff FF stated she, keeps an eye out for all residents, generally. During an interview on 1/7/20, at 11:38 a.m., Unlicensed Staff T stated he was present in the lobby area when Residents 3 and 34 interacted after lunch on 1/6/20. Unlicensed Staff T stated he, saw (Resident 3) kick at (Resident 34). Unlicensed Staff T stated he and the receptionist were present at the time. Unlicensed Staff T stated, no nurses were in the area. Unlicensed Staff T stated, I've been told to step-in for (Resident 3) if (Resident 3) gets physical. Unlicensed Staff T stated he would step-in, when I'm in the hallways and if nursing is not around. Unlicensed Staff T stated he was not formally trained on how to manage Resident 3's or Resident 34's behaviors. During an interview on 1/7/20, at 1:40 p.m., the Director of Staff Development (DSD) stated she trained staff on abuse and dementia, annually, on orientation, and, as needed. The DSD stated she trained staff on the duties of a, one-to-one assignment on 12/20/19, for about, 20 minutes. The DSD stated she trained staff individually, face-to-face, because staff prefer(red), that method of training. The DSD stated, all staff were trained on, potential abusive situations. During an interview on 1/7/20, at 2 p.m., Unlicensed Staff T verified he received face-to-face training on identifying abuse. Unlicensed Staff T stated the training was, general, and not specific to any one resident. During an interview on 1/7/20, at 2:10 p.m., the Director of Nursing (DON) stated licensed nurses, nursing administration, therapy, and the activities or Social Services Director, may initiate a resident care plan, or modify an existing resident care plan. The DON stated a care plan, applicable to nursing, would indicate, nursing staff on the care plan. The DON stated if a care plan indicated, all staff, then it applied to all staff in the facility. The DON stated the facility used a, template to create its resident care plans. The DON stated, staff are meant to modify the template, in order to make an individualized care plan. Regarding Resident 3's plan of care, the DON stated Resident 3 exhibited, paranoid behavior and had, held (Resident 34) hostage, when the two were admitted to the same room, and did not let staff in. The DON stated Resident 3 had a history of [REDACTED]. During a concurrent interview and record review on 1/7/20, at 3:40 p.m., the DON reviewed all open care plans for Resident 34, and stated the facility currently had, no care plan, to protect Resident 34 from Resident 3's pursuits and abusive behaviors. During a review of Resident 3's clinical record, the Care Plan, revised 10/24/19, at 11:14 a.m., indicated the facility planned to care for Resident 3's psychosocial needs and well-being related to, depression, mental illness, and other, care needs, which required placement at the facility. According to this care plan, the facility did not plan to manage Resident 3's psychosocial needs and well-being arising from Resident 3's relationship with Resident 34. During a review of Resident 3's clinical record, the Care Plan for Activities, revised 1/7/20, at 9:58 a.m., indicated Resident 3, spends most of his day worried about his wife and what she is doing and where she is located. (Resident 3) at times confuses other residents for his wife and can become upset when redirected and reassured . and believes we are lying to him. During a review of Resident 3's clinical record, the Care Plan, revised 1/8/20, at 12:03 p.m., indicated the facility planned to care for Resident 3's, combative behaviors. The care plan indicated Resident 3, aggressively seeks (Resident 34) out, mistakes other women for being (Resident 34) . and will follow them . The care plan indicated Resident 3's combative behaviors increased if unable to locate his wife (Resident 34). The care plan indicated Resident 3 had attempted, to hold (Resident 34) hostage in rooms. During a review of Resident 3's clinical record, the Behavior Monitoring Administration History, dated 1/2020, indicated, every shift staff must, monitor (Resident 3's) episodes of dementia (with [MEDICAL CONDITION], as evidenced by) striking out (with) delusions. The monitoring record indicated the facility did not record the episode of behavior observed in the lobby between Residents 3 and 34, and observed by Administrative Staff FF and Unlicensed Staff T on 1/6/20, during the, AM shift. During a review of Resident 3's clinical record, the Resident Progress Notes, dated 12/9/19, at 4:51 a.m., indicated Resident 3's wife (Resident 34) was his, roommate. The note indicated the two had, no issues noted. During a review of Resident 3's clinical record, the Resident Progress Notes, dated 12/13/19, at 6:28 a.m., indicated the facility spoke with Resident 3's, (responsible party), who stated the facility should not admit Residents 3 and 34 to, the same room for (Resident 34's) safety. During a review of Resident 3's clinical record, the Resident Progress Notes, dated 12/17/19, at 9:52 a.m., indicated Resident 3's abusive vocalizations and actions toward staff, and his pursuits of Resident 34: Resident responded: 'Don't you worry about my hand. I'll slap you with it. Get out of the road ya hear(?),' as he raised his (hand) up in a motion(,) like he was going to strike me with the back of his hand . 'Don't think I won't either.' . Resident continued to sit in front of the fire door thinking that every woman at the end of the hall is (Resident 34). During a review of Resident 3's clinical record, the Resident Progress Notes, dated 12/17/19, at 10:10 a.m., indicated Resident 3 ambulated with a front-wheeled walker into a room occupied by two female residents. The note indicated its author, ran down to the room to intervene. The note indicated Resident 3 was, yelling and slamming, his walker on the ground. The note indicated Resident 3 yelled: Wake up (Resident 34's name), Wake up! The note indicated Resident 34 did not occupy the room. The note indicated Resident 3, attempted to slam his (walker) down on (a) resident and I was able to grab it before, it reached the resident. The noted indicated Resident 3, then grabbed his (walker) and attempted to hit me with it. I reported this incident to Administrator, DON, and SSD. During a review of Resident 3's clinical record, the Resident Progress Notes, dated 12/28/19, at 8:58 a.m., indicated Resident 3 yelled, at (Resident 34) to get her, 'g**d*** a** over here, you don't need a smoke and (you're) a stupid b**** if you go outside.' (Resident 3) then came to the dining room and ate (breakfast). During a review of Resident 3's clinical record, the Resident Progress Notes, dated 1/9/20, at 3:48 p.m., indicated the facility's Interdisciplinary Team (IDT) reviewed Resident 3's recent history of behaviors. The note indicated, as of 12/29/19, Resident 3's, verbal and physical behaviors toward staff and (Resident 34) continue. An altercation with (Resident 34) occurred with a resulting skin tear to (Resident 34's) arm. During a review of Resident 3's clinical record, the Resident Progress Notes, dated 12/22/19, at 2 a.m., indicated the facility, removed Resident 34 from Resident 3's room, for safety reasons. The note indicated Resident 3 received a psychiatric evaluation two days prior and the facility now had the medication in house for administration. The noted indicated Resident 3, has been combative with staff and resistant to care. During a review of Resident 34's clinical record, the Resident Progress Notes, dated 12/15/19, indicated the facility initiated a, room change. The note did not indicate the reason for changing rooms. During a review of Resident 34's clinical record, the SOAP Note from Resident 34's physician, dated 12/19/19, indicated the facility had, separated Resident 34, from her husband (Resident 3) because Resident 3 exhibited, behaviors toward Resident 34. During a review of Resident 34's clinical record, the Resident Progress Notes, dated 12/20/19, indicated Resident 34 was inside Resident 3's room. The note indicated Resident 3 was Resident 34's, abusive spouse. The note indicated the two were, arguing and using foul language. The note indicated Resident 3, punched the nurse who tried to separate the two residents. During a review of Resident 34's clinical record, the Resident Progress Notes, dated 12/29/19, indicated Resident 34 received a physical injury, a skin tear on her left hand. The note indicated Resident 34 had been, a victim of a (resident-to-resident) incident with Resident 3. The noted indicated the injury occurred when Resident 3 followed Resident 34 down a hallway and, attempted to restrain Resident 34's movement. The note indicated facility staff cleaned Resident 34's wound, at which time Resident 34, grimace(d) in pain. During a review of Resident 34's clinical record, the Care Plan, revised 10/30/19, indicated facility planned to care for Resident 34's psychosocial needs and well-being related to dementia, mental illness, and other, care needs, which required placement at the facility. The facility did not plan to manage Resident 3's psychosocial needs and well-being arising from Resident 34's relationship with Resident 3. During a review of Resident 34's clinical record on 1/7/20, at 3:40 p.m., the facility maintained no care plan to protect Resident 34 from Resident 3's pursuits and abusive behaviors. During a review of the facility business record, the SOC 341 form for, Report of Suspected Dependent Adult/Elder Abuse, completed 12/29/19, indicated Resident 34 had been the, victim of Resident 3's abuse. The form indicated Resident 3, was seen striking victim with hand (on) her left arm. (Resident 3) proceeded to hit staff with closed fists after that. The form indicated Resident 34 suffered, no physical injury, from the abuse. The facility policy and procedure titled, Abuse Prevention Program, dated 8/2006, indicated the facility's residents, have the right to be free from abuse . and involuntary seclusion. The facility policy and procedure titled, Preventing Resident Abuse, dated 12/2006, indicated the facility's abuse prevention/intervention program included, but was not necessarily limited to, the following: . j. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect(.) The facility policy and procedure titled, Abuse and Neglect - Clinical Protocol, dated 10/2010, indicated the facility's, Treatment/Management, portion of the protocol tasked, facility management and staff, as responsible to, institute measures to address the needs of residents and minimize the possibility of abuse . The facility document titled, Final Investigation Report, dated 1/3/20, indicated Resident 3 and Resident 34 had exhibited behaviors, requiring staff redirection, since the incident on 12/29/19. The report indicated the facility plan included, monitoring both (Resident 3 and Resident 34) closely, involving all staff in efforts to redirect when needed. The report did not indicate any reason why the incident occurred, or whether (and why) it could have been prevented. 2) Resident 32's Minimum Data Set (MDS, an assessment tool), dated 11/5/19, indicated Resident 32 was admitted to the facility from, another nursing home or swing bed on 1/18/13. The MDS indicated Resident 32 received a, summary score of 01(/15), during a cognitive assessment, indicating a severely impaired cognition. The MDS indicated Resident 32 exhibited infrequent, physical behavior symptoms directed toward others, which occurred between, one and three days, during the assessment look-back window. The MDS indicated Resident 32 did not exhibit rejection of care or wandering and exhibited no moods affecting psychosocial well-being. The MDS indicated Resident 32 had no, neurological or psychiatric/mood disorder, diagnoses. The MDS indicated Resident 32 suffered from, Non-Alzheimer's Dementia, and also had, additional active diagnoses, including Dementia with Lewy bodies, [MEDICAL CONDITION] with late onset, and other symptoms and signs involving cognitive functions following cerebral infarction, (e.g., stroke). During an interview on 12/18/19, at 11:16 a.m., Unlicensed Staff X stated Resident 32 had unpredictable behavior and a propensity for being combative. Unlicensed Staff X stated Resident 32 had a tendency to squeeze arms very tight, and tried to strike staff members who assisted him with his Activities of Daily Living. During an interview on 12/18/19 at 12:05 p.m., Unlicensed Staff Z stated Resident 32 would flip someone off or swear at them, usually male residents, for no apparent reason while ambulating the hallway. During an observation and interview on 12/20/19, at 10:48 a.m., Resident 32 was lying down on his bed. Resident 32's head of bed was elevated. A new brief rested on Resident 32's feet. A device was wrapped around his ankle, like an anklet. When asked whether he felt safe, Resident 32 was quick to dismiss the question by replying loudly and aggressively, stating, It's ***t! It's just ***t! It doesn't matter! When re-educated that safety did matter, Resident 32 replied: Yea--everything's fine. During an observation on 12/20/19, at 11:30 a.m., Resident 32 remained lying down in bed. Resident 32's head of bed was reclined to flat. During an interview on 12/20/19, at 11:40 a.m., Unlicensed Staff X stated she was Resident 32's Certified Nurse Aide (CNA). Unlicensed Staff X stated she switched to Resident 32's hallway about one month prior. Unlicensed Staff X stated she encouraged Resident 32 to get out of bed. Unlicensed Staff X stated Resident 32 did get up and socialized in the dining room and group activities. Unlicensed Staff X stated she did not know Resident 32's preferred activities and did not recall learning anything about his preferred activities from the licensed nurses or activity staff. Unlicensed Staff X stated, I'm not sure what (Resident 32's) care plan says for activities. Unlicensed Staff X stated Resident 32 used vulgar language in the facility around men and when, male staff provided care. Unlicensed Staff X stated the facility trained her to manage Resident 32's verbal outburst by, redirect(ing the) situation, and informing him, We can't talk like that. Unlicensed Staff X stated, other times, she just moved (the) person (he was) yelling at. Unlicensed Staff X stated she had not witnessed Resident 32 having a physical outburst. Unlicensed Staff X stated she heard, only stories, of physical outbursts. During an observation on 12/20/19, at 12 p.m., Resident 32 was lying down in bed. Upon entering the doorway to inquire about his condition, he yelled, Get out! and showed the middle finger of his hand, stated A**h***! Resident 32's aggression, language and posturing precluded the opportunity for an interview. During a concurrent interview and record review on 1/6/20, at 10:45 a.m., Administrator A stated she was the Abuse Coordinator at the facility, and stated she was accountable for investigating allegations of abuse in the facility, and she, the Social Services Director (SSD), and Director of Nursing (DON) contributed to the facility's abuse investigations. Administrator A stated the facility's care process and medical record system, for victims of abuse, did not require an Interdisciplinary Team (IDT) review: The way the system is setup, an aggressor and the victim require different forms, and the victim form does not have an IDT section to complete. Administrator A stated the facility conducted an IDT meeting every morning after, stand-up. Administrator A stated the IDT decided whether a resident's behavioral health needs required, one-to-one, to more closely supervise the resident. Administrator A stated she was familiar with Resident 32's behaviors: I was just in (Resident 32's room) because he was not happy with the CNA. He didn't take a like to the CNA. Administrator A stated, (Resident 32) takes a dislike to certain people, at certain times, and Resident 32's mood and behaviors were, not predictable. Administrator A added the facility used, telepsych, from a psychiatric nurse practitioner and an, LCSW, or licensed clinical social worker, to manage Resident 32's behavioral health needs. Administrator A also stated the facility used a, third psychologist, if needed. There's not much out there, referencing the behavioral health services available in the facility's county and greater region. During an observation on 1/6/20, at 11:25 a.m., Resident 32 was lying in bed. The head of Resident 32's bed was elevated about 15 degrees, and his eyes were closed. During an interview on 1/6/20, at 11:27 a.m., Unlicensed Staff DD stated she was a CNA and familiar with Resident 32's behaviors. Unlicensed Staff DD stated Resident 32's behaviors showed, no improvement, over the last eight months. Unlicensed Staff DD stated Resident 32 had hit her before, and stated she observed Resident 32 hit other staff. Unlicensed Staff DD stated Resident 32, throws weight, around and used his, elbow and fists to hit staff on their backs, near the kidneys. Unlicensed Staff DD stated she experienced this physical abuse at least once every shift. Unlicensed Staff DD stated Resident 32 refused care and services: Sometimes he won't let us change him and that makes me sad. During an interview on 1/6/20, at 11:40 a.m., Responsible Party 22 stated she began her role as, Conservator, for Resident 32 eight months prior, in 5/2019. Responsible Party 22 stated the facility informed her of Resident 32's incidents with other residents. Responsible Party 22 stated facility staff, haven't made them sound too bad. Responsible Party 22 stated she attended a care conference each, quarter, and most of the time, in person. Responsible Party 22 stated she knew Resident 32 was, still combative, and did not recall having discussed talk therapy or telepsychiatry as a means to manage Resident 32's thoughts and behaviors while in the facility. During an interview on 1/7/20 at 12;12 p.m., Licensed Staff H stated Resident 32 exhibited very aggressive and unpredictable behaviors. Licensed Staff H stated Resident 32's behaviors made it difficult to watch out for him and for the safety of other residents who gather in the hallway to sit and pass time. During an interview on 3/10/20, at 8:50 a.m., Administrator A stated Residents 32 and 18 had a past history of resident-to-resident incidents. Administrator A stated Resident 18 had reported an unwitnessed incident, in 11/2019, when Resident 32 instigated physical contact. Administrator A stated Residents 32 and 18 engaged in another incident, one month later in 12/2019, and witnessed when Resident 18 swore and kicked at Resident 32. Administrator A stated the facility's investigation into the 12/9/19, incident between Residents 32 and 18, indicated the incident was, a chance encounter even though they had a prior history. Administrator A stated the facility's investigation into the 12/9/19, incident indicated the facility could not have prevented the residents' altercation, because facility staff were not expecting anything to happen between Residents 32 and 18, in the dining room. During a review of Resident 32's clinical record, the Resident Progress Notes, between 10/17/19 and 1/9/20, indicated 14 incidents involving Resident 32, arising out of physical or verbal aggression toward staff and other residents. On 10/17/19, at 2:45 p.m., the record indicated Resident 32 attempted to throw hot coffee on a Certified Nursing Assistant (CNA). On 10/21/19, at 4:33 a.m., the record indicated Resident 32 attempted to strike and kick staff while receiving personal care. On 10/25/19, at 2 p.m., the record indicated Resident 32 was observed hitting Resident 7, with his hand. On 10/27/19, at 7:30 p.m., the record indicated Resident 32 and Resident 13, collided in their wheelchairs, causing Resident 13 to strike Resident 32, and Resident 32 to strike Resident 13, thereafter. On 10/29/19, at 3 p.m., the record indicated Resident 32 squeezed Resident 28's arm, which caused bruising. On 11/2/19, at 4 p.m., the record indicated Resident 32 made contact with another resident's wrist. On 11/6/19, at 2:47 p.m., the record indicated Resident 32 was combative with staff while receiving routine personal care. On 11/11/19, at 3:45 p.m., the record indicated Residents 28 and 18, alleged Resident 32 hit each of them while Resident 32 ambulated in a wheelchair through the hallway. On 11/20/19 at 3:52 p.m., staff documented Resident 32 was combative while receiving care. On 11/22/19 at 5:55 a.m., the record indicated Resident 32 was agitated and combative when receiving care to clean his incontinence. On 12/6/19, at 4:58 a.m., the record indicated Resident 32 was yelling and attempting to strike staff. On 12/9/19, at 12 p.m., the record indicated Resident 32 was the victim of an incident in which Resident 18 yelled profanities at Resident 32 and then kicked Resident 32 in the leg with staff nearby. On 12/16/19, at 10:30 a.m., the record indicated Resident 32 shouted profanities at, and attempted to punch, a staff member. On 1/1/20, at 6:37 a.m., the record indicated Resident 32 attempted to punch staff while receiving incontinence care. During a review of Resident 32's clinical record, the Resident Progress Notes, dated 10/27/19, at 7:30 p.m., indicated Residents 32 and Resident 13, collided in their wheelchairs. The record indicated the collision caused Resident 13 to strike Resident 32, which caused Resident 32 to strike Resident 13, in response. During the review of Resident 32's clinical record, the Resident Progress Notes, dated 11/11/19, at 5:45 p.m., indicated Resident 18 verbalized unwanted physical contact by Resident 32, while Resident 18 sat in the hallway. The record indicated Resident 32, passed by (Resident 18) . gave him the middle finger and then, with a closed hand, struck (Resident 18) in the abdomen. The record indicated Resident 18 verbalized no complaint of pain or discomfort. During a review o(TRUNCATED)

Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice to one resident (Resident 1) when the facility: 1) failed to develop and implement a care plan for risk of [MEDICAL CONDITION] for Resident 1 when Resident 1 was receiving a medication with a black box warning (a government warning of serious side effects) for [MEDICAL CONDITION] ([MEDICATION NAME]) along with a blood thinner ([MEDICATION NAME]); 2) failed to properly monitor Resident 1 for signs and symptoms of [MEDICAL CONDITION]; 3) failed to follow a physician's orders [REDACTED]. 4) failed to notify Resident 1's physician, after Resident 1 had tested positive for blood in her stool, that Resident 1 continued to display signs and symptoms of [MEDICAL CONDITION] such as black stools, fatigue, tiredness and paleness; 5) failed to advocate for Resident 1 by not requesting the discontinuation of a medication with a black box warning for [MEDICAL CONDITION] ([MEDICATION NAME]) after Resident 1 had black stools and tested positive for blood in her stool and not requesting a CBC (complete blood count) blood exam; and 6) failed to transfer Resident 1 to a hospital when Resident 1 developed signs and symptoms of [MEDICAL CONDITION] (blood in the stool, black/tarry stools, paleness, fatigue, and tiredness). The facility discharged Resident 1 to her home after she completed her physical therapy at the facility. Less than four hours after being discharged home from the facility, Resident 1 was taken by ambulance to the Hospital's Emergency Department because she was vomiting blood and had black stools. At the Hospital Resident 1 was diagnosed with [REDACTED]. Resident 1 was admitted to the Intensive Care Unit (where patients with severe and life-threatening illness and injuries are treated) and received four blood [MEDICAL CONDITION]. Findings: A review of Resident 1's Face Sheet indicated Resident 1 was [AGE] years old and was admitted from the Hospital to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. A review of the Hospital's Discharge Summary, dated 11/30/17, indicated Resident 1 had hip surgery the month before, on 10/31/17, and presented to the hospital on [DATE] with complaints of worsening pain in the surgical site. The Discharge Summary indicated Resident 1 was evaluated and no post-hip surgery complications were found and that Resident 1 was to be discharged to the facility for physical therapy. A review of Resident 1's Medication Administration Record [REDACTED]. A review of Resident 1's MAR indicated [REDACTED]. A review of Resident 1's MAR indicated [REDACTED]. According to the facility's medication resource book, Nursing Drug Handbook (YEAR), [MEDICATION NAME] had a Black Box Warning (BBW) indicating it increased the risk of serious [MEDICAL CONDITION] (A BBW is government warning indicating the risk of serious adverse reactions associated with the medication). The Nursing Drug Handbook (YEAR) indicated, under Nursing Considerations, that nursing staff should Monitor patients for signs and symptoms of GI (gastrointestinal) bleeding. A review of the [MEDICATION NAME] medication package insert, a blood thinner being administered daily to Resident 1, indicated that administering [MEDICATION NAME] together with [MEDICATION NAME] increased the risk of internal bleeding and should be discontinued whenever possible. The package insert recommended that If coadministration (giving both drugs) is essential, conduct close clinical and laboratory monitoring A review of Resident 1's care plans (documents guiding the care of residents) and clinical record, with the Director of Nursing on 4/18/18, at 12:50 p.m., revealed that no care plan was developed or implemented by the facility for signs and symptoms of [MEDICAL CONDITION] for Resident 1. A review of Resident 1's physician orders [REDACTED]. According to the National Institutes of Health (NIH), signs and symptoms of [MEDICAL CONDITION] include black or tarry stools, bright red blood in vomit, weakness, feeling tired and paleness. (https://www.niddk.nih.gov/health-information/digestive-diseases/gastrointestinal-bleeding/symptoms-causes). A review of Resident 1's Progress Note dated 12/16/17, 10:43 p.m., signed by Licensed Nurse A, indicated Resident 1 had a bowel movement on 12/16/17 and the stool was very dark. Licensed Nurse A documented in her note that a Guaiac test (a test that detects blood in stool) was conducted and was positive for blood. Licensed Nurse A documented in her note she informed Resident 1's physician who indicated Nursing to continue Guiac (sic) stools (tests) and if this continues to report to MD for an order for [REDACTED]. During an interview and concurrent review of Resident 1's clinical record on 4/18/18, at 11 a.m., with the Director of Nursing (DON), the DON stated that the standard practice is for Guaiac tests to be done on three consecutive bowel movements, not on only one sample, as documented on the 12/16/17 progress note. No documentation was found in the record indicating the facility conducted additional Guaiac tests for Resident 1 after the first Guaiac test returned positive. No documentation was found that a CBC test was ordered or that facility staff contacted Resident 1's physician to request it. No documentation was found that facility staff contacted Resident 1's physician to request the discontinuation of [MEDICATION NAME], which remained an active order in Resident 1's MAR until her discharge from the facility. During the same interview and record review on 4/18/18, at 11 a.m., the DON was asked for records of the monitoringof Resident 1 for dark stools for the period of one week, as indicated in the Progress Note dated 12/16/17. The DON provided copies of monitoring sheets for four days only, from 12/16/17 to 12/19/17. The DON stated the monitoring sheets required documentation of Resident 1's bowel movements and the color of the stool every shift. A review of the monitoring sheets indicated the sheets were incomplete, with no documentation recorded on 12/16/17 night shift and 12/17/17 evening shift. A review of Resident 1's Progress Notes indicated Resident 1 continued to display signs and symptoms of [MEDICAL CONDITION] after the first black/bloody stool documented on 12/16/17, as follows: - Progress Note dated 12/18/17, 3:10 p.m., signed by Licensed Nurse B, documented Resident 1 had a bowel movement with dark stool. - Progress Note dated 12/25/17, 2:48 p.m., signed by Licensed Nurse B, documented Resident 1 feels tired. - Progress Note dated 12/26/17, 12:34 p.m., signed by Licensed Nurse D, documented Resident 1 was feeling weak, pale . - Physical Therapy Note, dated 12/26/17, 3:35 p.m., documented Resident 1 had fatigue and was feeling poorly. - Occupational Therapy Note, dated 12/26/17, 5:18 p.m., documented Resident 1 was pale in color at approach and not feeling well. - Occupational Therapy Note, dated 12/27/17, 4:49 p.m., documented weakness noted and Pt. has not been feeling well. During an interview and concurrent review of Resident 1's clinical record on 4/18/18, at 11 a.m., with the Director of Nursing (DON), no documentation was found that facility staff notified Resident 1's physician of these subsequent signs and symptoms of [MEDICAL CONDITION]. During an interview on 4/18/18, at 1 p.m., Resident 1's physician stated that following the initial notification of black stools and the positive Guaiac test on 12/16/17, he was not notified by facility staff that Resident 1 had further episodes of black stools or other signs and symptoms of [MEDICAL CONDITION], such as paleness or weakness. During an interview on 4/18/18, at 12:40 p.m., the DON was asked what should be done when a resident develops signs and symptoms of internal or [MEDICAL CONDITION]. The DON stated she would take the resident to the hospital. A review of Resident 1's clinical orders indicated an order for [REDACTED]. A review of Resident 1's Progress Note dated 12/28/17, by Licensed Nurse E, indicated Resident 1 had actively participated in therapy and is now ready to discharge home. The note indicated Resident 1 had vomited twice on 12/28/17 prior to discharge. The note indicated Resident 1 was discharged home on[DATE] at 10:15 a.m. A review of Resident 1's Emergency Department Visit Note (ED Note), dated 12/28/17, 2:34 p.m., indicated Resident 1 presented to the Emergency Department of Hospital A by ambulance on 12/28/17 at 1:58 p.m. vomiting blood, (with) abdominal pain, (and) black stools. The ED Note indicated a Complete Blood Count test was done and Resident 1 had a Red Blood Cell count of 1.93 (L) (reference range is 3.90 to 5.40 M/ul), a Hemoglobin of 5.7 (LL) (reference range is 11.7-15.5 g/dl), and a Hematocrit level of 17.7 (L) (reference range is 35-47%). The ED note indicated Resident 1 was given two blood [MEDICAL CONDITION] and was transferred to Hospital B for evaluation by a [MEDICATION NAME] for [MEDICAL CONDITION]. A review of Resident 1's Discharge Summary dated 1/3/18, from Hospital B, indicated Resident 1 was transferred from Hospital A to Hospital B on 12/29/18 for treatment of [REDACTED]. At Hospital B Resident 1 was diagnosed with [REDACTED]. Resident 1 was discharged home from Hospital B on 1/3/18. Facility policy titled Care Planning - Comprehensive, Revised (MONTH) 2010, indicated: An individualized comprehensive care plan that includes measurable objectives and timetable to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's conditions change, Facility policy titled Job Description - Registered Nurse, Revised (MONTH) 2014, indicated: Essential job functions: assess the resident's response to medication regime with prompt notification to the physician of any adverse effects and accurately prepare, administer and document medications, tests upon which the administration of of medications are dependent, and perform treatments according to physician's orders [REDACTED]. Facility policy titled Job Description - Charge Nurse (LVN), Revised (MONTH) 2014, indicated: Essential job functions: Administer medications, treatments and provide direct care to residents on unit according to physician orders [REDACTED].>Facility policy titled Change in a Resident's Condition or Status, Revised (MONTH) 2011, indicated: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. Facility policy titled Charting and Documentation, Revised (MONTH) 2008, indicated: All observations, medications administered, services performed, etc., must be documented in the resident's clinical records,

Based on interview and record review, the facility failed to provide 1 of 15 residents (Resident 10) with necessary treatment to prevent the development and progression of a pressure ulcer. The facility failed to ensure a care plan was developed upon admission for care of the resident's skin under her leg immobilizer brace (splint to prevent movement of the leg); failed to ensure ongoing skin and wound assessments after wound dressing changes in order to determine effectiveness of treatment and in accordance with standards of practice; failed to develop policies and procedures for ongoing wound assessments and prevention of pressure ulcers for residents with a leg brace/immobilizer; failed to ensure a physician assessed and evaluated the resident's wound under her brace before the wound became necrotic (contains dead tissue, which usually results from an inadequate local blood supply) and deteriorated to an unstageable wound with necrotic tissue which required surgical debridement (surgical removal of necrotic tissue in order to promote healing and reduce infection). These failures resulted in Resident 10 developing a pressure ulcer under the leg immobilizer brace which progressed to a Stage 4 pressure ulcer (Full thickness skin loss exposing muscle or bone). Findings: Review of the facility electronic Observation Report dated 10/12/15 indicated Pressure sore classifications included: DTI- (DeepTissue Injury) a pressure related injury to subcutaneous (beneath the skin) under intact skin. Stage 1 Non blanchable (remains red when pressed) [DIAGNOSES REDACTED] (redness) of intact skin Stage 2- Partial thickness skin loss epidermis (outer layer of skin), dermis (second layer of skin), or both. The ulcer is superficial (surface), clinically seen as an abrasion or shallow crater. Stage 3-Full thickness skin loss involving damage to, or necrosis of subcutaneous tissue that may extend down to, but not through fascia (band of tissue beneath the layers of the skin that binds to muscle). The ulcer presents clinically as a deep crater with or without undermining (destruction) of adjacent tissue. Stage 4-Full thickness skin loss with extensive destruction, tissue necrosis damage to muscle, bone or supporting structure (tendon, joint capsule). Undermining and sinus tracts may be present. Unstageable- if ulcer is covered by eschar (dead tissue), it cannot be staged. Review of Resident 10's acute care hospital discharge summary for the 10/8/15 discharge from the acute care hospital, completed by Resident 10's orthopedic surgeon (Physician P), indicated Resident 1 was admitted to the acute care hospital on [DATE] for dislocation of a right hip. On 10/5/15, Resident 1 underwent surgery to repair the dislocation and was to return to the skilled nursing facility with an immobilizer brace. The discharge summary indicated staff were to keep the immobilizer on Resident 10's right knee at all times, particularly with any kind of transfers and ambulation, but the brace could be removed for hygiene purposes. Instructions included Physical Therapy (PT) staff were to look carefully for changes in rotation of her right lower extremity as well as leg length discrepancies, and the knee immobilizer would remain on for six weeks. Resident 10's skilled nursing facility physician's orders, dated 10/8/15 to 10/18/15, completed by Physician B, Resident 10's treating physician in the skilled nursing facility indicated: WBAT (weight bearing as tolerated), leave immobilizer on. There were no orders regarding removal of the brace or for care of the skin as mentioned in the discharge summary. Resident 10's nursing progress notes, dated 10/8/15 at 11 a.m., indicated Resident 10 was admitted to the skilled nursing facility from the acute care hospital at 10:21 a.m., with a surgical site incision on the right hip; an unable to be determined stage (due to presence of necrotic tissue in the wound bed) pressure ulcer on the coccyx. There was no documentation regarding the knee immobilizer on the resident; or assessment of the skin under the immobilizer or care plan related to care of the brace or how skin would be assessed under the brace. On 10/10/15 at 9:49 p.m., nursing progress notes indicated Resident 10's right hip dressing and the brace was on. There was no documentation of a skin assessment under the brace, or clarification of orders related to the brace. On 10/11/15 at 12:25 p.m., Licensed Staff S (wound care nurse) note documented the resident's right foot had increased [MEDICAL CONDITION] (swelling) with bruising noted just above the lateral (side) ankle and on the posterior aspect (back side). Licensed Staff S noted a skin tear on the lateral aspect of the lower leg found under a Kerlix dressing (gauze dressing) which measured 3 cm x 1 cm. The note documented the area was cleansed and a new dressing was applied for protection and foam was placed at the bottom of the immobilizer to protect the skin. Licensed Staff S documented the charge nurse was notified of the pedal (lower extremity) [MEDICAL CONDITION]. There was no documentation of notification to the doctor of the skin tear at this time; clarification of orders related to removal of the brace for skin assessments; assessment as to the cause of the wound or if it was a stageable pressure ulcer. A nursing order, documented by Licensed Staff S, dated 10/12/15 at 1:29 p.m. indicated to monitor under the immobilizer brace and placement of foam protection at proximal and distal ends of the right leg immobilizer every shift. There was no care plan in the record related to monitoring under the immobilizer brace, placement of foam or specific instructions for removal of the brace. Review of Resident 10's physician orders, dated 10/13/15-11/08/15, documented an order from Resident 10's physician (Physician B) to cleanse a skin tear to the right lower leg with normal saline and dry and apply alginate (a gel that helps absorb wound drainage) and cover with dry gauze dressing until resolved once a day . Review of Resident 10's orders, effective 10/18/15 to 11/13/15, from Resident 10's orthopedic surgeon (Physician P) indicated total hip precautions, WBAT, leave immobilizer on, except can remove during PT/OT(Physical Therapy/Occupational Therapy) sessions for ROM (range of motion) and strengthening only. Another order by Physician P, effective 10/19/15 to 11/13/15 documented therapy may remove the immobilizer only to do ROM and strengthening. The orders did not clarify removing of the brace to conduct skin assessments or for protection of the skin under the brace. During an interview, on 2/3/16 at 3:45 p.m., Licensed Staff T stated Resident 10 had the immobilizer brace on when she came back from the hospital on [DATE]. Licensed Staff T stated it depended on the orders if staff removed the brace. Licensed Staff T stated normally nurses opened the brace to assess the skin under the brace. Licensed Staff T stated she did not take the brace off when she initially took care of Resident 10. Review of nursing notes from 10/10/15-10/11/15 indicated there was no skin assessment under the brace. There was no clarification of orders to remove the brace to assess skin under the brace until 10/12/15 when there was a nursing order placed by the wound care nurse (Licensed Staff S) to monitor the skin under the immobilizer and placement of foam protection at the proximal and distal ends of the the right leg every shift. During a telephone interview, on 2/4/16 at 11:30 a.m., and concurrent review of Resident 10's record, Licensed Staff R (a wound care nurse) stated Resident 10 had a brace on her right leg when she was admitted on [DATE]. Licensed Staff R described the brace had metal strips in the fabric that ran down the back of the knee as well as metal strips that were on each side of the knee, Velcro straps held the splint in place. The splint went from the groin (the area from the hip between the stomach and thigh) to the ankle. Licensed Staff R stated the record indicated the other wound care nurse, Licensed Staff S documented the wound care note on 10/11/15 regarding identification of the skin tear which was covered with the Kerlix (gauze wrap) dressing. Licensed Staff R stated there should have been a care plan in place for removal of the brace which she did not see in the admission care plans or a physician order to remove the brace. Licensed Staff R stated usually the ADON (Assistant Director of Nurses) assessed the skin on admission or the DSD (Director of Staff Development). During an interview, on 2/4/16 at 3:30 p.m., Licensed Staff A (the DSD) stated she usually entered admission data in the computer and started the care plans. Licensed Staff A stated she did not physically see Resident 10 when the resident was admitted and stated Licensed Staff R did the skin assessment. Licensed Staff A stated she documented in the admission record what Licensed Staff R told her. Licensed Staff A stated she did not see a care plan for skin integrity started on admission for Resident 10. She stated usually when a resident had a brace, she customized the skin integrity care plan to include checking the skin under the brace. She stated the treatment orders should include this protocol at least every shift. Licensed Staff A stated a treatment order was initiated on 10/12/15 to monitor skin under the brace. Licensed Staff A stated she thought Licensed Staff R started the care plan. Licensed Staff A stated she did not note there was a brace or care plan upon admission for Resident 10 for its removal and assessment of skin underneath the brace. During a telephone interview and record review, on 2/8/16 at 8:25 a.m., Licensed Staff S (2nd wound care nurse) stated she first saw Resident 10 on 10/11/15. She stated Resident 10 had an immobilizer brace on her leg. Licensed Staff S stated she removed the brace and checked Resident 10's skin and saw some bruising on the right lower extremity on the calf and padded the brace with low profile foam. Licensed Staff S stated she saw a Kerlix dressing on the right lower leg and when she removed the dressing, she noted a skin tear under the dressing. Licensed Staff S stated she did not know when the Kerlix dressing was originally placed and stated the admission nurse should have noted it. Licensed Staff S stated she obtained a treatment order from Resident 10's physician (Physician B) to cleanse the skin tear with normal saline, apply calcium alginate (a gel type dressing that assists to absorb wound drainage and debris) and cover with a dry dressing until resolved. Licensed Staff S stated the Wound Care Physician (Physician Q) had been in for treatment for [REDACTED]. Licensed Staff S stated 11/2/15 was the first time Physician Q saw the wound and that was when Physician Q performed the surgical debridement of the wound. Licensed Staff S stated Physician Q did not see the resident on 11/9/15 as scheduled and the resident was transferred to the acute care hospital on [DATE] due to altered mental status, increased pain and low blood pressure. Licensed Staff S stated Resident 10's leg wound should have been assessed every shift. Licensed Staff S stated there was no nursing care plan until 10/23/15 to check the skin under the brace for Resident 10 and stated that should have been done upon admission. Licensed Staff S stated care plans should be updated on an as needed basis. A wound care nurse's (Licensed Staff R) note, dated 10/23/15 at 9:21 a.m., indicated Resident 10's right leg brace caused irritation to the resident's right lower leg. The note documented the use of foam pads on top of the brace and at the bottom to help with the prevention of irritation/ rubbing. The wound care note documented Resident 10 had a rubbed area, which measured approximately 7.5 cm length x 3.5 cm width x approximately .3 cm depth. The note documented will have the wound care physician assess this Monday (10/26/15). The note documented the physician and the responsible party was aware. There was no documentation of an assessment of the stage of the wound, description of the wound bed, an assessment by the physician or evaluation of the immobilizer brace. A treatment order, dated 10/23/15 to 11/2/15, indicated once a day treatment to the irritation / rubbed area related to the leg brace, cleanse with normal saline, dry, apply wound gel, cover with gauze and foam, then wrap with Kerlix every day. Notify MD (medical doctor) of any negative changes. Wound care physician to assess next visit was written under special instructions. The treatment administration record indicated, by placement of initials, that the wound treatment was administered every day through 11/2/15, except for 10/24/15 when the resident was not available. There was no documentation in the treatment records of ongoing assessments of the wound during these treatments to evaluate for changes in the wound or need to alter treatment. Review of Nurses progress notes, dated 10/23/15 through 11/3/15, indicated one note dated 10/31/15, that described the leg wound, from Licensed Nurse R (wound care nurse) that resident continued on treatment for [REDACTED]. Outer edges with red beefy tissue. No s/s (Signs or symptoms) of infection, just a lot of pain being noted, will continue to monitor daily. The note indicated Physician Q, the wound care physician would assess the patient the day after the next day (11/2/15). A physical therapist progress note, also dated 10/31/15, indicated Licensed Nurse R did a treatment to Resident 10's calf wound. The physical therapist note documented the wound was approximately 2.5 x 1.5 inches (approximately 6.35 cm x 3.81 cm) and full thickness with eschar (dead tissue) noted along the lateral border into the midline of the wound. Review of nurse progress note, dated 11/2/15, documented Physician Q (the wound care physician) examined the ulcer on Resident 10's posterior right calf and the area measured 7.5 x 5 x 1 cm after sharp debridement. The immobilizer worn on the leg had been padded since it was first applied and skin checks were being done every shift. Skin was extremely fragile and Physician Q states the wound was unavoidable. Review of the acute care hospital Emergency Department Physician Note, dated 11/13/15, indicated Resident 10 presented to the acute care hospital emergency room from the skilled nursing facility with an altered mental status. Resident 10 had a large ulcer on her right calf. The final [DIAGNOSES REDACTED]. During a telephone interview, on 2/9/16 at 9:28 a.m., Physician B stated the nurses entered the order for skin treatment of [REDACTED]. Physician B stated he understood the wound care doctor (Physician Q) did the wound care on the leg. Physician B stated Resident 10 had the brace on when she was admitted but staff were supposed to check under the brace and the orthopedic physician wrote it could be removed for hygiene purposes. Physician B stated there was always a chance for skin breakdown under the brace. Physician B stated that the nurses should have had a care plan for the brace as the resident was new to the brace. The first note written by Physician Q regarding the right lower extremity wound was on 11/2/15, which indicated it was an unstageable wound due to necrosis (dead tissue). The wound size was 7.5 x 5 cm with moderate serous exudate (wound drainage) and 100% thick necrotic tissue. The note indicated the physician did a surgical debridement, removing necrotic tissue along with muscle. During a telephone call on 2/11/16 at 9:10 a.m., Physician Q stated the pressure sore could be determined unavoidable if you could not remove the brace as it could cause damage to the hip, but stated nurses should follow their protocols for assessing the skin. During an interview, on 8/4/16 at 9:00 a.m., Physician B stated that unavoidable pressure sore would mean everything was done to avoid the pressures sore, and he expected staff should have had a plan of care for brace removal and the policy for pressure sores should be reviewed. Review of documentation of a visit by Physician B, dated 11/13/15 indicated Resident 10 had severe pain in the right leg that was not relieved with pain medication and a wedge rubbing holes in her legs the wound on her shin was clean with fair granulation tissue and resident was referred back to ER for reevaluation for injury/dislocation vs. [MEDICAL CONDITION] ( blood clot in leg). During an interview, on 8/4/16 at 9:15 a.m., Licensed Staff S stated nurses should assess under a leg brace everyday if ordered and record results weekly. Licensed Staff S stated the wound care doctor did not evaluate unless there was a problem with the skin under the brace. The wound care nurse stated they did not have a policy on the removal of the brace and stated she had never reviewed the policy and procedure for pressure sore assessment and interventions for prevention of pressure sores. Licensed Staff S stated the nurse should develop a care plan to ensure other nurses know what to do and do the same care. During an interview, on 8/5/16 at 12 p.m., the Administrator stated the facility could individualize corporate policy and procedures for the facility's needs and agreed Licensed Staff S should have read the policy and procedure. The Administrator stated they went over policies routinely and tell the Medical Director (Physician B) what they are about and the Medical director signs them. On 8/5/16, review of the facility policy and procedure, revised 2013, for Pressure Ulcer Risk Assessment, provided guidelines for the assessment and identification of residents at risk of developing pressure ulcers. The policy noted pressure can come from splints, casts, bandages and wrinkles in bed linen. If pressure ulcers are not treated when discovered, they have the potential to become larger, painful and infected. The policy indicated residents at risk need to be identified and have interventions implemented immediately to attempt to prevent pressure ulcers. The admission evaluation helped to define the initial care approaches and interventions. Care Planning and interventions should be individualized for the resident according to their risk factors. Review of the Pressure ulcers skin breakdown policy, revised September 2013, indicated the nurse and the attending physician assesses and documents an individuals's significant risk factors for developing pressure sores. In addition, the nurse should describe and document / report a full assessment of the pressure sore including location, stage, length, width, and depth and presence of exudates or necrotic tissue. The nurse will examine the skin of a new admission for ulcerations or alterations in the skin. Under monitoring, the physician will help the staff review and modify the care plan as appropriate, especially when the wounds are not healing as anticipated or new wounds develop despite existing interventions. The facility policies and procedures contained no specific nursing interventions for the prevention of pressure sore development under a brace. Review of National Pressure Ulcer Advisory Panel Quick reference Guide, published 2014, indicated to inspect the skin under and around medical devices at least twice daily for the signs of pressure related injury in the surrounding tissue. The guide indicated to conduct more frequent skin assessments grater than 2 X a day at the skin surface if resident is prone to localized or generalized skin [MEDICAL CONDITION]. The guidelines indicated to access the pressure ulcer initially and reassess it at least weekly. The guidelines indicated with each dressing change to observe the pressure ulcer for signs that indicated a change in treatment was required, such as wound improvement, wound deterioration, more or less exudates, signs of infection or other complications and to address signs of deterioration immediately such as increase in wound, tissue quality, increase in exudates or clinical signs of infection.

Based on interviews and record reviews, the facility failed to ensure one of four resident's (Resident 1) right to be free from verbal abuse when a certified nursing assistant (Staff A) used derogatory language toward Resident 1. This subjected Resident 1 to verbal abuse and psychosocial distress. Resident 1 stated the incident made him feel, not very good. Finding: A facility incident report, dated 8/17/14, indicated certified Staff A made derogatory remarks to Resident 1 on 8/16/14. A follow up Incident / Abuse / Neglect Report, dated 8/21/14, documented Staff A admitted to calling Resident 1 an A'Hole and the staff was terminated. During an interview on 9/2/14 at 2:30 p.m., the Director of Nurses (DON), Staff C, stated she conducted an investigation and substantiated the allegation. Staff C stated she interviewed witnesses who reported Resident 1 told them Staff A had called him an, ugly a-hole. Staff C's written notes of the investigation, dated 8/18/14, documented on the evening of 8/16/14, Resident 1 asked Licensed Staff D if he (Resident 1) was ugly. Resident 1 then stated Staff A had called him an[***] earlier that day. Staff C's investigation notes documented certified Staff B reported to licensed Staff F that on 8/16/14, Resident 1 reported to Staff B that Staff A had called him an[***] and told him he was ugly. Resident 1 asked Staff B if he (Resident 1) was ugly. The notes indicated Staff A must have overheard the conversation because Staff B reported Staff A called out from another room, Well if you hadn't of treated me so badly, I wouldn't have called you an[***] . The facility investigation notes documented Staff A was interviewed by Staff C (DON) on 8/18/14. Staff C's investigation notes documented during the interview, Staff A stated, Yes I called him an ugly[***] . after he called me a [***] . The notes documented Staff A stated Resident 1, . called me a [***] ; so I told him, I'm putting you back in bed after this - I don't have to put up with this[***]' So he called me a [***] again and a few other names - so yeah . I called him an ugly[***] . It just slipped outta my mouth. When asked about calling out from another room, Staff A stated, . I was tired already of hearing him tell others about what happened so I hollered over 'yeah, well if you hadn't of treated me so mean, I wouldn't have called you an[***] ' . Resident 1's Care Plan History, dated 7-21-14 to 8-21-14, documented Resident 1's [DIAGNOSES REDACTED]. The resident's Minimum Data Set Assessment (an assessment tool), dated 2/16/14, documented the resident had some memory problems. During an interview on 9/1/14 at 3:30 p.m., Resident 1 stated Staff A told him he was ugly. When inquiry was made as to how that made him feel, Resident 1 stated, not very good. I feel OK now. I asked others if I'm ugly and they said no.

Based on observations, resident, staff, and neighbor interviews, record reviews, and review of facility policies, the facility failed to ensure its residents were provided an environment that was free from accident hazards, when: 1. The resident smoking area was unsupervised; the perimeter of the smoking area contained dry weeds and flammable mulch; the vacant lot (as wide as the facility building) behind the smoking area contained high (up to 2 1/2 feet tall), dry weeds; the commercial sized propane tank (the only source of gas for the 90 bed facility) was surrounded by high, dry weeds, and was next to the unabated, weed-ridden lot; and unsupervised residents did not dispose of their cigarettes in a safe manner which caused the area, containing weeds and mulch, adjacent to the east of the smoking area to catch on fire, with the potential to cause a fire that would spread out of control or the potential for a propane tank explosion, with the potential for injuries to the 74 residents residing in the facility. An IMMEDIATE JEOPARDY was called at 5:01 p.m., on 6/19/13 and was abated at 2:25 p.m., on 6/21/13. 2. Resident 27 sustained a sunburn when preventative measures to prevent sunburn and/or counseling and education were not provided to prevent sunburn, leading to pain; and 3. A medication cart was left unlocked and the contents were accessible to anyone passing the area, with the potential for ingestion of medications and side effects from the medications. Findings: 1. During a concurrent observation and interview on 6/18/13 at 8:42 a.m., three residents, including Resident 31, smoked in the facility's designated smoking area. The smoking area was outside the rear door of the East Hall. There were smoking aprons (protective coverings that shield residents against hot ashes and dropped cigarettes) hanging on the door to the right of the exit to the smoking patio. There was no staff supervision and none of the residents were wearing protective smoking aprons. When interviewed, Resident 31 stated he was able to smoke "24 hours" unsupervised. In response to whether he ever wore a smoking apron, Resident 31 stated that he and other residents had wondered, "What do you use them for?" The designated smoking area included a concrete patio area, enclosed by a chain link fence. The patio area contained an ashtray. There was a free-standing canopy area containing chairs and a large ashtray. A propane tank was observed behind the chain link fence at the back of the smoking area. A field of tall dry grass grew around the tank and up to the edge of the adjoining lot, across from homes, and around the perimeter of the chain link fence line. Flammable wood chips (mulch) encircled three sides of the smoking patio. According to University of California's Fire Research and Outreach Extension article, "Publication on the Combustibility of Landscape Mulches" (July 20, 2011), mulch is combustible (capable of lighting and burning). During concurrent observation and interview, on 6/19/13 at 10 a.m., there were three residents, including Resident 31, outside smoking in the designated smoking area. They were not being supervised. There were no staff present. On 6/19/13 at 11:45 p.m., three smokers, including Resident 6, were observed to be unsupervised and without smoking aprons. Upon interview, Resident 6 stated, "Yes," residents were able to come out and smoke 24 hours a day. On 6/19/13 at 1:06 p.m., six residents, who were randomly observed, were outside smoking. There was no staff supervision and none of the residents wore a smoking apron. During an interview at 1:09 p.m. Licensed Staff C stated that confused smokers, such as Resident 2, needed to be supervised and smoking aprons were used when required by residents' care plans. On 6/19/13 at 3:24 p.m., the fire alarm sounded. Observation revealed there was smoke billowing outside the rear entrance to the smoking area. The grass outside the chain link fence was burning and the fire was following the grass line up the hill. There were three men with rakes and shovels outside the chain link fence, fighting the fire. During interviews, on 6/19/13 between 3:25 p.m. and 3:35 p.m., the following was noted: a. One of the three men, who helped put out the fire, stated that he was a neighbor and he saw the fire and called the fire department. The neighbor stated that he saw a man, on the smoking patio, throw a cigarette into the mulch. He was unable to identify the man. He stated that he was concerned that the fire would continue up the hill, burning all the weedy, dried grass area and reach his home and adjacent homes. b. Management Staff M stated that she pulled the fire alarm after hearing someone yelling, "turn off the gas!" She stated she saw flames in the outside smoking patio, at the fence line. c. Licensed Staff A stated, "One of the kitchen people informed me of the fire outside. I came out with a fire extinguisher from outside by the door to the smoking patio." d. Unlicensed Staff K stated, "was going to bring snack to Room 33C when I smelled smoke. I went outside and saw fire and smoke and went back inside to scream fire!" The staff member stated that Resident 35 also told her there was a fire. e. During concurrent observation and interview, Resident 35 sat in his wheelchair. He stated that he and another non-smoking resident were outside in the smoking area when the fire started. He did not know who else was outside in the smoking area when the fire started. When asked if he knew how the fire started, Resident 35 stated, "Probably, I'm guessing, a cigarette." During concurrent observation and interview, on 6/19/13 at 4:27 p.m., there were four unsupervised residents on the smoking patio, three of them were smoking (Residents 2, 40, and 41). Resident 2 was identified on 6/19/13 at 1:09 p.m., by Licensed Staff C, as needing supervision when smoking. She stated he was at risk for dropping ashes, he was to be observed for dropping ashes, and he was to wear a smoking apron. There were no staff present. At 4:33 p.m., Unlicensed Staff J and R came out with smoking aprons for Residents 2 and 41, who were already smoking. Review of the list of "Supervised Smokers," received 6/20/13, revealed Residents 2 and 41 were "Supervised Smokers." Management B stated, on 6/20/13 at 4:30 p.m., that "Supervised Smokers" were to be supervised at all times while outside on the patio and were to wear smoking aprons. Review of the "Safe Smoking Evaluations," received 6/19/13, for Residents 2 and 41, revealed there were concerns about Resident 2 and 41's ability to smoke independently. During confidential interview with a family member (who went on the patio with a resident), on 6/19/13 at 4:55 p.m., the family member stated that the residents did not always use the provided ashtray. She stated that one resident put her lit cigarettes on the ground and then would step on them to put them out. IMMEDIATE JEOPARDY was identified, on 6/19/13 at 5:01 p.m., under 483.25(h) Accidents. The Administrator, Director of Nursing Services, and Social Services Director were present. During concurrent observation and interview, on 6/19/13 at 5:08 p.m. Residents 27 and 34 were outside on the patio smoking. They were not supervised. Staff was not present. Both residents stated that they had no knowledge of a fire in the area that day and stated that they did not know of any new facility regulations prohibiting them from smoking unsupervised. During an interview on 6/19/13 at 5:40 p.m., a neighbor stated he witnessed 2 people standing near the east side of the facility's smoking patio fence line. He stated one was smoking and then he saw smoke and flames. "They have lots of people that smoke and no one to supervise...need someone to supervise." The neighbor assisted with putting out the flames before the Fire Department arrived. During interviews with four residents (identified by facility documentation, received 6/17/13, as alert and oriented) who stated that they went outside to the smoking area to socialize and to smoke, the following was noted: a. On 6/19/13 at 5:30 p.m., Resident 27 stated that she frequently sees residents, who smoke, flick lit cigarettes into the mulch area around the smoking area. b. On 6/20/13 at 3:30 p.m., Resident 28 stated that she had seen residents toss cigarettes into the mulched area. c. On 6/21/13 at 1 p.m., Resident 37 stated that he had "seen lots of people flick their butts" out near the grassy, mulched area. d. On 6/21/13 at 1:20 p.m. Resident 38 stated that there were two smokers who "always scrape their cigarettes on the fence there." He pointed to the chain link fence area where the fire started and where there had been mulch and weeds the previous day. "It bothers me because they scrape them and just drop them and they are not all the way out. They (the cigarettes) just smolder. Nobody puts their butts in those ash holders (large standing ash tray)." The facility corrective actions that abated the Immediate Jeopardy included removal of the mulch and replacement with gravel; placing signage in the smoking area that directs smokers to place smoking material in the designated areas; signage placed on the door to the smoking area that says, "Resident Smoking Area Only;" supervised smoking times to be every two hours (and as indicated) between 6:30 a.m. and 10:30 p.m.; and facility to keep resident smoking materials. These actions were validated through observations and interviews on 6/21/13. The IMMEDIATE JEOPARDY was abated, on 6/21/13 at 2:25 p.m. The Administrator, Social Services Director, Maintenance Supervisor, Assistant Social Services, and Director of Staff Development were present. 2. During concurrent observation and interview, on 6/18/13 at 2:30 p.m., Resident 27 sat in her wheelchair. She was wearing shorts. Her thighs were tan, her calves were pink, and her ankles and feet were red. The alert and oriented resident stated that her feet were sunburned. She stated that liked to sit outside in the sun and until lately she had been wearing socks while sitting out in the sun and her feet were protected. Recently, she began to wear sandals and her feet became sunburned. She stated that both feet were painful. Observation, on 6/19/13 at 2:15 p.m., revealed Resident 27 sat in her wheelchair. She was wearing sandals, exposing her feet. Both feet and ankles were visibly red and swollen. The resident stated that her feet were sunburned and her feet and ankles were not usually swollen. She stated that she had been trying to keep her legs elevated to reduce the swelling. She stated that she had not been using sunscreen on her legs in the past, but she had some on "Now." During interview on 6/21/13 at 4:20 p.m., Management Staff Q stated that staff are educated to put sunscreen on residents who spend time outside in the sun and the residents were to be monitored. She stated that there was no facility policy for this and care plans were not developed to address individual residents. During interview, on 6/21/13 at 4:30 p.m., Licensed Staff Y stated that it was the facility practice to put sunscreen on those residents who go outside and ready access to the sunscreen was available at each nursing station. She was unaware of any care plans related to prevention of sunburn. 3. On 6/19/13 at 4:20 p.m., a medication cart was left unattended on the West Hall outside a resident room. The left top drawer, containing the medications for the residents on that hallway, was open three inches and the contents were accessible to anyone passing in the hall. The medication cart was not locked. There were residents, visitors, and staff walking by the open and unlocked medication cart. The door to the resident room where the med cart was parked was partially closed and the privacy curtains were drawn. No staff were visible in the room. Licensed Staff D exited the resident room and pushed the open drawer closed. He acknowledged that the drawer had been open and the cart unlocked. Review of the facility policy "Administering Medications," revised April 2010, revealed that the medication cart is to be kept closed and locked when out of sight of the medication nurse.

The facility failed to ensure that a staff member used a mechanical lift safely, with adequate supervision, when transferring one resident (Resident 1). This failure resulted in Resident 1 falling out of the lift onto the floor and sustaining a head injury. Resident 1, a [AGE] year-old-female, was admitted to the facility 7/10/10, with [DIAGNOSES REDACTED]. Review of Resident 1's medical chart on 1/21/11 at 3 p.m., indicated in the Minimum Data Set (MDS-an assessment tool), that Resident 1 was totally depending on staff for bathing, dressing, and transferring and required transfer by mechanical lift, as Resident 1 was non-ambulatory. The MDS indicated Resident 1 had difficulty speaking but was alert and usually able to make her needs known. Additional review of the Interdisciplinary Notes dated 9/7/10, indicated Resident 1 required the assistance of two persons for all her activities of daily living. Resident 1 was also assessed as a high fall risk. During an interview on 1/20/11 at 2 p.m., Administrative Staff A stated that on 12/21/10, Staff C was transferring Resident 1 back to bed using a mechanical lift, when Resident 1 fell out of the lift onto the floor, hitting the back of her head. Resident 1 was taken immediately to the local emergency room where she received treatment for [REDACTED]. Administrative Staff A stated Staff C was doing the transfer by herself, even though the staff had been trained to use two people for transfers involving a mechanical lift. During an interview on 1/20/11 at 2:20 p.m., Staff C stated on 12/21/10 around 1 p.m., Resident 1 indicated she wanted to go back to bed. Staff C stated she looked around for help but everyone looked busy so while Resident 1 was in her wheelchair, Staff C hooked Resident 1 up in the sling on the lift by herself and put the lift to the height of Resident 1's bed, (approximately 2 1/2 to 3 feet from the floor). Staff C stated she did not know exactly what happened, except the sling did not seem to fit right or that maybe Resident 1 was wiggling around, but Resident 1 fell out with the sling still attached to her. Her feet were still in the lift as she hit the floor, bumping her head. Staff C called out for help, and two nurses responded immediately, 911 was called and Resident 1 was transported to the emergency room per ambulance. During additional interview, Staff C was asked if she usually did mechanical lift transfers by herself. Staff C stated no, two people were required, but she thought she could do it by herself. During an interview on 1/20/11 at 5 p.m., Administrative Staff B stated it was the facility's standard of practice that two persons were required to transfer a resident using the mechanical lift. Administrative Staff B stated the reason for using two people was safety for both the resident and the staff. During an interview on 1/21/11 at 2 p.m., Staff D stated when a resident was transferred using the mechanical lift two staff members were required, one as a, "spotter," and the other to operate the lift. The facility failed to ensure that Resident 1 had adequate supervision to prevent an accident while being transferred by a mechanical lift. This failure had a direct relationship to the health, safety, or security of patients.