Every finding on record at San Mateo Medical Center D/P SNF

Based on interview, and record review, the facility failed to submit Payroll Based Journal Staffing (PBJ) Data for Federal Fiscal Quarter One for year 2026 (October 1 to December 31) to Center for Medicare and Medicaid Services (CMS). This failure prevented CMS from confirming whether the facility maintained adequate nursing coverage. When staffing levels cannot be verified, residents may be directly affected because inadequate staffing is associated with delays in care, unmet ADL needs, missed medications, and lack of supervision. Residents may also be exposed to risks such as delayed call light response, infrequent toileting or hygiene care, missed treatments or therapy sessions, and unsafe monitoring for residents with higher acuity needs. In addition, insufficient staffing places residents at risk for medication errors and missed care that may result in psychosocial distress.During a review of the Payroll Based Journal (PJB) Staffing Data Report for the facility, dated Federal Fiscal Quarter One for year 2026 (October 1 to December 31), the PBJ Staffing Data Report indicated that no data had been submitted for Federal Fiscal Quarter One for year 2026 (October 1 to December 31) and the star staffing rating was equal to one. During an interview on 08/13/2026 at 2:26 PM with the Payroll Coordinator (PC), the PC stated the facility's hourly employees clock in four times per day at the start of the day, before meal, after meal, and at the end of the day. The PC stated the facility has five time clocks throughout the facility that all employees use. The PC stated exempt employees clock in once per day. The PC stated the time clocks have been in place since the time they started working at the facility in 2023. The PC stated the facility contracts with an agency for temporary nursing staff. The PC explained that temporary employees clock in and out through the agency and the facility receives verification of those hours from the agency. The PC stated the Nursing Staffing Assignment sheets are used as an additional verification method to confirm that temporary workers were present and that their hours match. The PC stated temporary employee hours are verified using 530 Nursing Staffing Assignment and Sign In Sheets, invoices, and timecards. The PC stated the facility collects assignment sheets and schedule sheets from each unit to verify names of nurses, nursing assignments, morning, afternoon, and night shift schedules, attendance, and any assignment changes. The PC reported that 530 Nursing Staffing Assignment and Sign In Sheets are completed for agency nursing staff. The PC stated that the 612 form, titled Census and Direct Care Service Hours per Patient Day (DHPPD), is also completed. The PC stated the payroll team uses multiple forms to verify direct care hours, including DHPPD reports from the time clock system, 530 Nursing Staffing Assignment and Sign In Sheets, nursing schedules for all shifts, assignment sheets for all shifts, and the 612 DHPPD form. The PC stated these forms are collected daily and uploaded electronically to the corporate office. The PC stated the corporate office submits Payroll Based Journal (PBJ) data to the Center for Medicare and Medicaid Services (CMS) because the facility does not submit directly. The PC stated the facility ensures PBJ accuracy by using timeclock correction forms when needed. The PC stated the corporate office reminds the facility of upcoming PBJ deadlines. The PC stated the corporate office notifies the facility when PBJ submissions are complete via email. The PC stated that they have not received any emails from the corporate office indicating inaccurate or incomplete PBJ data. During an interview on 08/13/2026 at 4:01 PM with the Nursing Home Administrator (NHA), the NHA stated the facility contracts with a management company, and the management company uses a vendor to submitt Payroll Based Journal (PBJ) data to Center for Medicare and Medicaid Services (CMS). The NHA further stated that the management company provides the oversight and auditing for PBJ data submissions to CMS. The NHA stated that they were aware the wrong information had been submitted for one of the quarters in 2025.

Based on observation, interview, and record review, the facility failed to:1. Discard over ripe oranges with molds found in the walk-in refrigerator.2. Discard a bottle of expired Tube Feeding (TF) Nepro (a specialized nutrition shake prescribed as a meal replacement for patients with kidney disease who cannot eat by mouth).3. Ensure multiple opened containers of dry goods have open-date labels.This deficient practice had the potential to result in food contamination and negatively impact resident health. 1. During an initial tour of the kitchen on 8/10/26 at around 11:00 AM with the kitchen supervisor (KS) and the Food Service Supervisor (FSS) in the walk-in refrigerator-1, observed a large flat plastic container on the lower shelf with different stages of overripe oranges next to another large flat plastic container of apples. Some oranges were soft, some with darkened discoloration, some with dents, and 4-5 oranges with white, chalky substance. The FSS stated this should not be here. I will take this out of here. Observed the FSS pick up the whole flat plastic container and brought it outside the walk-in refrigerator. The KS stated the person who stocks the refrigerator is not here today. Observed the flat plastic container with the overripe oranges was placed on the lower shelf of the cart outside the walk-in refrigerator. The five oranges with molds were gone. During an interview on 8/13/26 at 9:30 AM, with the Registered Dietitian (RD), Director of Food and Nutrition Services, RD stated, those oranges will not be given to the patients. 2. During an observation and interview on 8/10/26 at 1:08 PM in the dry storage room with the KS and FSS, observed a plastic bottle of Nepro1.8 supplemental tube feeding in front of the box of Jevity 1.2 (another type of specialized shake given through a tube in the stomach for those who cannot eat by mouth). The Nepro supplemental tube feeding was marked use before August 1, 2026. No other Nepro supplemental tube feeding on the shelf. The KS stated that is what we are giving to diabetic patients. I don't know why it is there. Observed the FSS picked up the bottle of Nepro supplemental tube feeding (TF) and stated will bring this outside. During a review online from [NAME] Nutrition (manufacturer) indicated, do not use expired Nepro. Expired medical nutrition can lose key vitamins and protein quality, and the liquid may separate, spoil or grow harmful bacteria. 3. During initial kitchen tour on 8/10/2026 at 10:11 AM, a multiple layer metal rack was observed near the food preparation area. Spices, dry condiments, cooking oil, vinegar were on the rack. Upon checking, the following items were found opened without open-date labels: Imperial Gravy Mix, TRIO Country Gravy Mix, Classic Garlic powder, Reliance Chicken Flavored Base, Ground Black Pepper, Marukan [NAME] Vinegar, and Classic Vegetable Oil. During this time, a Dietary Aide (DA) 3 was standing near the rack and when asked, DA 3 stated, he was not the one who opened it but believed those items were newly opened. During a follow-up visit of the Dry Storage Room inside the facility kitchen on 08/10/2026 at 12:57 PM, clear plastic bins containing multiple bags of pastas and cereals were observed on the racks. Further checking revealed previously opened bags of pastas and breakfast cereals have no open-date labels. Dietary Aide (DA) 4, was in the dry storage room taking out newly delivered fresh bananas out from the box. When asked if he's the person in-charge with labeling, DA 4 stated, he only takes care of new deliveries that come in but not doing labels for opened items. During an interview on 08/13/2026 at 10:36 AM with Kitchen Assistant Supervisor ([NAME]), [NAME] stated, the staff who opens new bags/containers of dry goods should be the one to open-date it. [NAME] further stated, if she sees opened bags without open-date labels, she would throw it away. [NAME] was shown pictures of opened bags of pastas and cereals without open-date labels and [NAME] agreed that it should have been labeled. During a review of the facility's Operational Manual - Dietary Services P-DS52 Food Storage and Handling dated 06/04/2024, the Operational Manual - Dietary Services P-DS52 Food Storage and Handling indicated, Policy - Food items will be stored, thawed, and prepared in accordance with standard sanitary practices. All items will be correctly labeled and dated. It also indicated, 13. h. Label and date all storage products.

This requirement is NOT MET as evidenced by:Based on observation, interview and record review, the facility failed to ensure dietary aides are trained to check and verify the concentration of the sanitizing solution in the green and red buckets which is required to maintain proper sanitation of food-contact surfaces.This failure had the potential to result in the transfer of harmful microorganisms to residents' food and put residents at risk for contamination when dirty wipe cloths used to wipe kitchen surfaces and food carts are not properly sanitized. During a follow-up kitchen visit on 8/11/2026 at 12: 36 PM, Dietary Aide (DA) 1 was observed cleaning in the dishwasher area. A green and red bucket containing liquid were observed on the surface near the metal sink. A visibly dirty wipe cloth was observed soaked in the red bucket. When asked about the usage of the green and red bucket, DA 1 stated the green bucket contains soap while red bucket is used for sanitizing. DA 1 further stated the solution is premixed, pointing 2 big buckets under the sink with hose connected on it where the solution for the buckets come from. When DA 1 was asked when to discard the solution in the red bucket, DA 1 stated, it gets discarded or replaced when there are no more bubbles. When DA 1 was asked if he tests the red bucket solution using test strip, DA 1 stated, No. DA 1 further stated, only the Kitchen Manager or the Kitchen Supervisor does it. During this time, the Kitchen Manager (KM) and the Regional Registered Dietician (RRD) 1 joined us. The Kitchen Manager performed the test strip, dipped the test strip in the red bucket, counting 1-10. The test strip came out dark orange in color. KM stated, No and then instructed DA 1 to replace the solution. DA 1 then proceeded to open the 2 hoses and filled the green and red buckets but after dipping the test strip it came out dark orange again. KM held the 2 hoses (1 green and white color and the other red and white color). KM asked DA1 if the green and white hose went to fill the green bucket and the red and white hose to the red bucket. DA 1 confirmed he interchanged the hoses. This time KM filled up both buckets by himself and did the test strip. The strip came out green which matched the 400 ppm (parts per million) color code which marks the maximum level on a standard 0-400 ppm test scale, indicating a strong concentration of quaternary ammonium sanitizer. During a follow-up kitchen visit on 9/13/2026 at 10:18 AM, Dietary Aide (DA) 2 was observed sanitizing multiple food carts using a wipe cloth. A red bucket containing a liquid solution was observed placed on top of the food cart where DA 2 was working on. DA 2 stated he is wiping the food carts using the red bucket solution. When asked if the solution in the red bucket is still okay, DA 2 stated the solution was newly put in the bucket that same morning. Surveyor asked DA 2 to do a test strip to check whether the solution needs replacement. DA 2 agreed and went to get the test strip, dipped it to the solution for 10 seconds. The color of the strip was dark orange. DA 2 has been wiping the food carts using a solution that did not have the right concentration for sanitizing. During a review of training and in-service records with Kitchen Assistant Supervisor, an in-service training for all kitchen staff titled, Sanitation Buckets/Test Strips was only done on 8/11/2026 at 2:00 PM after the first observation with Dietary Aide 1 on 8/11/2026 at 12:36 PM.

Based on observation, interview, and record review the facility failed to provide the necessary respiratory care and services for four out of seven sampled residents (Residents 6,55,188, 255) when;Resident 255's oxygen humidifier (a medical device that adds moisture to supplemental oxygen before it reaches a patient's nose and lungs) solution was empty while receiving oxygen therapy via nasal cannula (a medical device that provides supplemental oxygen to a resident through the nose) connected to an oxygen concentrator (an electric medical device that pulls in room air, and delivers purified, high-purity oxygen to a person who needs breathing support).Resident 55 and 188's nasal cannula which administered oxygen therapy was not properly placed in nostrils.Resident 6 was experiencing respiratory distress when her oxygen tubing and nasal cannula were found on her chest while oxygen therapy was being administered. This failure had the likelihood to result in negative outcomes for Residents 6,55,188,255 that include, but are not limited to shortness of breath, nasal dryness, fatigue and confusion. Findings:DEFINITIONS: Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxia.1.During a review of Resident 255's Face sheet (document containing a resident's essential demographic, medical, and personal information), (undated), the Face sheet indicated, Resident 255 was initially admitted to the facility on [DATE] with multiple diagnosis including: Chronic Respiratory Failure with Hypoxia (a medical condition where your body's tissues and organs do not get enough oxygen to work the right way), Chronic Respiratory Failure with Hypercapnia (a medical condition where too much carbon dioxide builds up in your blood), Centrilobular emphysema (a chronic lung disease where the tiny air sacs in the upper parts of the lungs are damaged and destroyed), Pulmonary hypertension due to lung disease, and dependance on supplemental oxygen.A review of Resident 255's Minimum Data Set (MDS: a standardized resident assessment tool), dated 8/3/2026, the Minimum Data Set indicated, a Brief Interview of Mental Status assessment (BIMS, a brief memory test to help determine memory, thinking, learning, and decision making ability: a score of 15-13 = intact memory/reasoning; a score of 12-8 = moderate impairment in memory/reasoning; a score of 7-0= severe impairment in memory/reasoning) was completed. Resident 255 scored 13 out of 15, this indicated Resident 255 had intact memory/reasoning.During a concurrent observation and interview on 8/10/26 at 1:21 PM with Resident 255 at her bedside, Resident 255 had a wired black oxygen concentrator that was plugged into the wall and produced oxygen therapy to Resident 255 via a nasal cannula. In the middle of the oxygen concentrator was a clear empty plastic squared shaped bottle that was attached to the concentrator via an attachment port. The clear bottle had black writing on the white affixed label that read, Distilled Solution. When asked if she knew what the clear bottle was used for, Resident 255 stated, It's my humidifier water. During a concurrent observation and interview on 8/10/26 at 1:25 PM with a Licensed Vocational Nurse (LVN 50) at Resident 255's bedside, LVN 50 verified the plastic square bottle attached to Resident 255's oxygen concentrator was Resident 255's humidifier solution and it should always be at least halfway full. LVN 50 stated that she the last monitoring of the solution was earlier that morning, she was not aware how long the solution was empty, and she would replace the solution immediately. When asked what the possible adverse effects of non- humidified oxygen therapy are, LVN 50 stated, Irritation to nostrils and nasal dryness.During an interview on 8/10/26 at 1:38PM with Resident 255, when asked if she was experiencing any nasal irritation or discomfort, Resident 255 stated, her nostrils were a little dry. 2. During a review of Resident 55's Face sheet (undated), the Face sheet indicated, Resident 55 was initially admitted to the facility on [DATE] with multiple diagnosis including: Acute and Chronic Respiratory failure with hypoxia, dependence on supplemental oxygen, and aphasia following cerebrovascular disease.A review of Resident 55's Minimum Data Set dated 6/5/2026, the Minimum Data Set indicated, Resident 55 was rarely/never understood, her cognitive skills for daily decision making was severely impaired (never/rarely made decisions), with limited range of motion (how far and in what direction a joint can move) in both upper extremities (shoulder, elbow, wrist, hand) and was dependent of staff for all care needs.During a review of Resident 55's Order Summary Report dated 8/14/2026, the report indicated, .Oxygen @ 2L/min via NC (nasal canula) to keep O2 Sat (saturation) at/above 90% every shift for SOB (shortness of breath) with a start date of 6/18/2025. During an observation on 8/14/26 at 2:18PM in Resident 55 room, Resident 55 was lying in bed with the head of the bed slightly elevated and a clear plastic nasal cannula hanging out of her left nostril. During a concurrent observation and interview on 8/14/26 at 2:22 PM with a Vendor Certified Nursing Assistant (Vendor 1 CNA) at Resident 55's bedside, Vendor 1 CNA stated, Resident 55 was completely dependent on the staff for all care needs and could not use both of her arms or hands. When asked if Vendor 1 CNA job duties included monitoring oxygen tubing placement, Vendor 1 CNA stated, Yes. When asked if Resident 55's oxygen tubing was placed correctly, Vendor 1 CNA stated, the resident's nasal cannula was not in the correct place.She is not getting full oxygen. Vendor 1 CNA also reported the last visual monitoring provided to Resident 55 was an hour or a little more than that.During a concurrent observation and interview on 8/14/26 at 2:55 PM with a Resident Care Coordinator (RCC 2) at Resident 55's bedside, RCC 2 verified placement of Resident 55's nasal canula and stated it was not properly placed in left nostril. When asked for the potential adverse effects of incorrectly placed nasal canula used to provide oxygen therapy, RCC 2 stated, a potential adverse effect would include not receiving adequate oxygen therapy and/or oxygen supply. During a review of Resident 188's Face sheet (undated), the Face sheet indicated, Resident 188 was initially admitted to the facility on [DATE] with multiple diagnosis including: Acute and Chronic Respiratory failure with hypoxia, Acute Pulmonary edema, Bronchiectasis, and Acute on Chronic Diastolic (Congestive) Heart Failure.During a review of Resident 188's Care Plan Report dated 6/20/2025, the report indicated, .The resident has oxygen therapy r/t (related to) shortness of breath. During an observation on 8/14/26 at 2:46PM in Resident 188's room, Resident 188 was lying in bed with the head of the bed elevated and a clear plastic nasal cannula hanging below both nostrils above her top lip. The nasal cannula tubbing was connected to a wired black oxygen concentrator that was plugged into the wall and produced oxygen therapy to Resident 188 via a nasal cannula.During a concurrent observation and interview on 8/14/26 at 2:48PM with the Director of Nursing (DON) and a Registered Nurse (RN2) at Resident 188's bedside, the DON and RN2 verified placement of Resident 188's nasal canula and stated it was not properly placed in both nostrils. Resident 188's nasal canula was removed and placed in both nostrils by RN2, prior to exiting resident's bedside. 3.During a review of Resident 6's Face sheet (undated), the Face sheet indicated, Resident 6 was initially admitted to the facility on [DATE] with multiple diagnosis including: Cervical Disc Disorder at C4-C5 level with Myelopathy, Quadriplegia, Chronic Obstructive Pulmonary Disease, Unspecified Asthma, and Heart Failure. During a review of Resident 6's Order Summary Report dated 8/14/2026, the report indicated, .Oxygen @ (at) 1L/min via NC (nasal canula) to keep O2 Sat (saturation) at/above 92% every shift d/t (due to) COPD (Chronic Obstructive Pulmonary Disease) with a start date of 3/27/2026. During an observation on 8/14/26 at 2:54PM in Resident 6's room, Resident 6 was lying in bed with the head of the bed slightly elevated and a clear plastic nasal cannula laying around her neck. Resident 6 was observed to have labored breathing (when breathing requires a noticeable, hard physical effort) and speaking out in her primary language (Chinese). The nasal cannula tubbing was connected to a wired black oxygen concentrator that was plugged into the wall and produced oxygen therapy to Resident 6 via a nasal cannula.During a concurrent observation and interview on 8/14/26 at 3:01PM with the Director of Nursing (DON) and a Resident Care Coordinator (RCC3) at Resident 6's bedside, the DON and RCC3 verified placement of Resident 6's nasal canula stated it was not properly placed and should be placed in the resident's nostrils. RCC3 assessed Resident 6's oxygen saturation level with a pulse oximetry (a quick test that uses a small light-based device to check the amount of oxygen in your blood) device placed on Resident's 6 left index finger. Resident 6's oxygen saturation (the percentage of red blood cells carrying oxygen through your body compared to their total capacity) was 58% out of 100%, RCC3 stated Resident 6 appeared to be in distress due to low oxygen level and labored breathing. RCC3 placed Resident 6's oxygen therapy via a nasal cannula and the DON instructed RCC3 to elevate Resident 6's head of bed and continue with the pulse oximetry monitoring. Resident 6's oxygen saturation level increased from 58% to 85% with oxygen therapy in place and head of bed elevated to 70-90% angle. During a review of the facility's policy and procedure titled, NP94 Oxygen Therapy, dated 10/10/2025, indicated, 1. Oxygen is administered under safe and sanitary conditions to meet resident needs.

Based on observation, interview, and record review, the facility failed to ensure that food served to 5 out of 35 residents (Residents 5, 9, 13, 15, and 85) was flavorful, appealing, and at an appetizing temperature . This failure had the likelihood to result in poor nutrition and hinder recovery from illness or injury. During an interview on 08/10/2026 at 11:11 AM with Resident 13, Resident 13 stated, the food does not taste good but still eats the food. Resident 13 added they are not on a special diet. Resident 13 believes that lunch and dinner are questionable. During an interview on 08/10/2026 at 1:44 PM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated, Resident 9 as well as other residents have not received their lunch and that lunch was a little late today. During an observation on 08/10/2026 at 1:48 PM outside of Resident 9's room, Resident 9's food tray had a roast beef sandwich and gravy, along with fries, two waters, and three containers that could not be identified by the surveyor. During an observation on 08/10/2026 at 1:51 PM at the entrance Resident 9's room, Resident 9 refused their lunch tray that was brought in by CNA 1 and informed CNA 1 that they were feeling nauseous. Resident 9 also refused the alternatives CNA 1 offered Resident 9 and requested chocolate pudding and a diabetic shake instead. During an interview on 08/10/2026 at 1:51 PM with CNA 1, CNA 1 stated, Resident 9 refused their lunch and Resident 9 informed CNA 1 they were feeling nauseous. CNA 1 stated they offered Resident 9 alternatives like chicken quesadillas and Resident 9 refused. CNA 1 states Resident 9 normally likes fruits and after the interview will attempt to look for fruits for Resident 9. During a Resident Council Meeting on 08/10/2026 at 2:09 PM with Residents 13, 47, 76, 132, 249, 272, and 277, the residents expressed concerns regarding the quality of the food served at the facility. The residents reported that the food is often overcooked and prepared in a manner they felt was not suitable for a human being. They stated that the preparation appeared careless, noting that items such as butter and syrup were sometimes missing from the trays when pancakes were served. The residents described frequent inconsistencies with the food trays and said the food was often cold. They further stated that the kitchen staff would not take responsibility for the poor food quality, instead telling residents that the menu was mandated by the State and not created by the facility. The residents noted that concerns about the food are raised at every Resident Council Meeting. They also reported that lunch is typically delivered between 1:00 PM and 2:00 PM, which they felt was inappropriate and something they did not like.During an interview on 08/11/2026 at 10:30 am with Resident 9, Resident 9 stated, the food at the facility was trash and was unable to stomach it anymore. Resident 9 added that the sausage is like dog food and that daily lunches are a variation of some overcooked, flavorless meat. Resident 9 states that the nutritionist has only been able to visit them one time about 6 months ago, and after that one visit the food did not change. Resident 9 states they have been losing weight because the food here is not palatable. Resident 9 states that they have tried the alternatives the facility offers like the vegetarian menu, but discovered that the veggie sausage gets steamed and it comes out mushy and gross. Resident 9 also finds the meat sausage gross. During an interview on 08/11/2026 at 11:31 AM with Resident 85, Resident 85 stated that there are several days when food is not palatable and has to get food delivered to the facility. Resident 85 orders food from outside the facility about two times per week. Resident 85 further added that the drinks offered by the facility have a heavy sugar content, which Resident 85 does not like. Resident 85 eats some of the food offered by the facility. Resident 85 adds that sometimes the facility does not provide a complete meal. Resident 85 reports that the temperature of the food tends to be luke warm to cold, and it takes a while for the facility to provide the meals. During an interview on 08/11/2026 at 1:04 PM with Resident 15, Resident 15 stated, the food is low quality and that the facility seems to be using low budget foods. Resident 15 added that the food is either undercooked or overcooked. Resident 15 thinks the facility should taste the food before the residents eat the food. Resident 15 added that the food is always luke warm and on the colder side, and the food is always late. During a follow-up interview on 08/13/2026 at 10:45 AM with Resident 15, Resident 15 stated, the food is really bad and that sometimes the food might be good, but most of the time it's really bad. Resident 15 added that the food tastes bland. Resident 15 added that the food is always luke warm and that one time he received hot food and that was a rare moment of celebration. Resident 15 does not find the food appealing to him and has sent food back to the kitchen, but they don't do anything about it. Resident 15 shared seven photos with the surveyor of food served by the facility from 01/16/2026 to 08/08/2026 that they did not find appealing, and took the photos because it was just so unbelievable to them. During an interview on 08/13/2026 at 11:34 AM with Resident 5, Resident 5 stated the food is not good at the facility and finds the food bland and everything comes in cold. Resident 5 added that the chicken is not cooked all the way through, and as a result, he would not any of the meat provided by the facility. Resident 5 added that they get sick after eating the food at the facility and their family member brings them meals to get through. Resident 5 added that on Fridays the residents get one piece of pizza and it's ice cold and Resident 5 has never gotten one that is warm. Resident 5 added that nursing staff offer to microwave their pizza, but Resident 5 feels bad asking nursing staff since he believes they work so hard. Resident 5 states they came into the facility with a lot of hope that the facility would provide Resident 5 nourishment, but instead Resident 5 feels the facility is trying to starve them. Resident 5 added that they take photos of the food provided by the facility to share the photos with their family member, to encourage them to send Resident 5 food from outside of the facility. Resident 15 shared five photos with the surveyor of food served by the facility from 12/14/2024 to 02/17/2026 that they did not find appealing.During a review of Recipe for Seasoned Fresh Zucchini for 08/12/2026 lunch, the Recipe for Seasoned Fresh Zucchini indicated the ingredients for the recipe include: fresh zucchini, margarine, basil, garlic powder, dill or Italian seasoning and provides a recommendation for cooks to taste the zucchini and add herbs as desired.During a review of the Resident Council Meeting Minutes dated 01/29/2026 at 3:06 PM, the minutes indicated that residents had expressed a desire for additional snack options, including a wider variety of sandwiches. The residents also noted that the food temperature had been improving, suggesting it had previously been a concern. The residents stated during the meeting that they would like to continue following up with the dietary department when available. Additionally, the residents requested that the dietary department review their individual tray cards to ensure they accurately reflected each resident's personal likes and dislikes, indicating that the tray cards at the time were not accurately capturing this information. Ultimately, the residents decided to establish a Food Committee that would meet monthly with the dietary director or designee to review resident food recommendations, discuss food-related concerns, and improve communication. The facility did not provide a resident council grievance response for Resident Council Meeting Minutes dated 01/29/2026.During a review of the Resident Council Meeting Minutes dated 02/04/2026 at 3:06 PM, the minutes showed that residents expressed the same concerns documented in the 01/29/2026 meeting. These included a desire for additional snack options, such as a wider variety of sandwiches; acknowledgement that food temperature had been improving; interest in continuing follow-up with the dietary department when available; and a request for the dietary department to review individual tray cards to ensure they accurately reflected each resident's personal likes and dislikes. The 02/04/2026 Resident Council Meeting Minutes appeared to have been largely copied and pasted from the 01/29/2026 minutes.The minutes also included new business noting that the Food Committee had been established and would meet on the last Tuesday of each month to meet with the dietary director, review resident food recommendations, and discuss food related concerns. The facility did not provide a resident council grievance response for Resident Council Meeting Minutes dated 02/04/2026.During a review of the Resident Council Meeting Minutes dated 03/04/2026 at 3:05 PM, the minutes showed that residents expressed the same concerns documented in the 01/29/2026 meeting. These included a desire for additional snack options, such as a wider variety of sandwiches; acknowledgement that food temperature had been improving; interest in continuing follow-up with the dietary department when available; and a request for the dietary department to review individual tray cards to ensure they accurately reflected each resident's personal likes and dislikes. The 03/04/2026 Resident Council Meeting Minutes appeared to have been largely copied and pasted from the 01/29/2026 minutes. The facility did not provide a resident council grievance response for Resident Council Meeting Minutes dated 03/04/2026.During a review of the Resident Council Meeting Minutes dated 04/01/2026 at 3:06 PM, the minutes indicated that residents again expressed the same concerns documented in the 01/29/2026 meeting. These concerns included a desire for additional snack options, such as a wider variety of sandwiches; acknowledgment that food temperature had been improving; interest in continuing follow-up with the dietary department when available; and a request for the dietary department to review individual tray cards to ensure they accurately reflected each resident's personal likes and dislikes. The 03/04/2026 Resident Council Meeting Minutes also appeared to have been largely copied and pasted from the 01/29/2026 minutes. The minutes further included new business in which residents voiced additional concerns and suggestions. These included requests for alternative food choices and a larger variety of food options; the use of food carts capable of maintaining heat; specific snack suggestions; availability of snacks after lunch and dinner; provision of items such as butter and sugar when oatmeal is served; and a desire to have tea packets and cocoa available on the coffee carts.During a review of the Resident Council Departmental Response Form dated 04/16/2026, the form showed that the Dietary Department had provided responses to issues identified by the Resident Council. In response to residents' requests for alternative meal choices, the department stated that we are given choice by corporate and have to adhere to their rules, and noted they would follow up. Regarding concerns about diet cards or tray cards, the department reported that these are constantly checked, adding that some food items requested by residents are not available every day. The Dietary Department also addressed resident requests for snacks by stating that they were currently implementing a new snack program. In response to requests for tea and cocoa, the department explained that due to budget, we have not provided cocoa or tea but will look into maybe having them available behind nursing stations. Additionally, the department stated that we are always addressing residents' requests and questions, emphasized that we are a corporate entity and follow the rules given, and added that they look into making changes to accommodate each resident as well. The Dietary Department's responses in the Resident Council Departmental Response Form dated 04/16/2026 show a pattern of limited flexibility due to corporate guidelines and budget constraints. During a review of the Resident Council Meeting Minutes dated 05/06/2026 at 3:01 PM, the minutes showed that residents again expressed the same concerns documented in the 01/29/2026 meeting. These included a desire for additional snack options, such as a wider variety of sandwiches; acknowledgment that food temperature had been improving; interest in continuing follow up with the dietary department when available; and a request for the dietary department to review individual tray cards to ensure they accurately reflected each resident's personal likes and dislikes. The 05/06/2026 minutes also appeared to have been largely copied and pasted from the 01/29/2026 minutes. The minutes further reflected residents expressed interest in discussing a fine dining program. Additional concerns and suggestions were also documented, some of which had been documented in previous meetings, including requests for alternative food choices and a greater variety of meal options; specific snack ideas; availability of snacks after lunch and dinner; reports of snack shortages; requests for items such as butter and sugar when oatmeal is served; a desire for tea packets and cocoa on the coffee carts; requests for more fruit, particularly bananas; and reports that lunch and dinner meat entrees were difficult to cut.During a review of the Resident Council Departmental Response Form dated 05/14/2026, the form indicated that the Dietary Department had provided responses to concerns raised by the Resident Council. In response to residents' requests for snacks, the department stated, we will be implementing a new snack program on 05/18/2026 to consist of five snacks, and sandwiches will be substituted out. This response did not appear to align with the residents' prior requests in earlier Resident Council meetings, where they had asked for additional snack options, including a wider variety of sandwiches. In response to requests for butter and sugar to be served with oatmeal, the department replied that they were looking into sugar and substitutions. The form also included incomplete or unclear responses from the Dietary Department, such as created and implementing a new program, which was not linked to a specific issue. Additionally, the department noted that they were looking at implementation of sugar, i.e., substitutes and butter or margarine.During a review of the Resident Council Departmental Response Form dated 06/10/2026, the form indicated that the Dietary Department had provided responses to concerns raised by the Resident Council. The Resident Council Departmental Response Form identified five issues including: coffee carts, sandwich selection, available fruits, sugar or butter with oatmeal, and alternative choices. Resident Council Departmental Response Form provided five explanations for each of the five issues listed. The Dietary Department responded to the coffee cart issue by noting, we follow a schedule to provide coffee; will look into bulking up coffee, but adhere to schedule. The Dietary Department responded to the sandwich selection issue by noting, we have spoken and this is .an ongoing topic. The Dietary Department responded to the available fruits issue by noting, we can provide bananas for snack program. The Dietary Department responded to the sugar or butter with oatmeal issue by noting, am looking at implementation of butter or sugar with. The Dietary Department responded to the alternative choices issue by noting, all alternate food choices are of corporate choice. The Resident Council Departmental Response Form completed by the Dietary Department, shows that resident concerns about food quality, meal variety, and appropriate food items were not adequately addressed and the facility's responses did not demonstrate corrective action or a plan to meet resident food preferences. In addition, corporate restrictions were used as justification, rather than addressing the facility's obligations to meet residents' nutritional needs and preferences.During a review of the Resident Council Meeting Minutes dated 06/30/2026 at 3:45 PM, the minutes showed that residents again expressed the same concerns documented in the 01/29/2026 meeting. These concerns included a desire for additional snack options, such as a wider variety of sandwiches, and a request for the dietary department to review individual tray cards to ensure they accurately reflected each resident's personal likes and dislikes. The minutes also reflected additional concerns and suggestions-many of which had been raised in previous meetings-including requests for alternative food choices and a greater variety of meal options; availability of snacks after lunch and dinner; requests for items such as butter and sugar when oatmeal is served; requests for more fruit, particularly bananas; and reports that residents experienced difficulty cutting pork and ham served in certain entrees.During a review of the Resident Council Departmental Response Form dated 07/10/2026, the form indicated that the Food Service Department had provided responses to concerns raised by the Resident Council. The Resident Council Departmental Response Form identified three issues including: updating tray tickets, coffee carts, and food requests. The Food Service Department responded to the 'updating tray tickets' issue by noting, tray cards or dietary profiles renewed or updated quarterly. The Food Service Department responded to the 'coffee carts' issue by noting, coffee carts continue to be delivered to floors at meals. The Food Service Department responded to the 'food requests' issue by noting, menus are posted, alternatives are available, fruit is available, NHA or the food service department continue to follow-up on any resident concerns related to food. The Food Service Department failed to provided generalized responses that did not adequately respond to or resolve residents' ongoing concerns about food quality, choice, and preferences, and the Food Service Department's responses are generic, non specific, and lack meaningful corrective actions.During a test tray observation conducted on 08/12/2026 at 2:01 PM, temperatures were taken using both the facility's thermometer and the surveyor's thermometer for the regular and pureed versions of the lunch meal, which consisted of taco casserole and zucchini. For the regular meal, the taco casserole measured 135.6 F (Fahrenheit) with the facility's thermometer and 136.4 F with the surveyor's thermometer. The regular zucchini measured 121.9 F with the facility's thermometer and 123.8 F with the surveyor's thermometer. For the pureed meal, the taco casserole measured 118.9 F with the facility's thermometer and 120.0 F with the surveyor's thermometer. The pureed zucchini measured 118.4 F with the facility's thermometer and 112.6 F with the surveyor's thermometer. The pureed zucchini was bland. The facility did not ensure that all hot food items-particularly pureed food and vegetables-were served at temperatures that meet safe and palatable standards, resulting in residents being served food that was not maintained at appetizing temperatures.During a review of Federal Drug Administration (FDA) Food Code, dated 2022, the FDA Food Code indicated hot food that is served must be held at 135 F (57 C) or above. If food falls below 135 F (57 C) for hot holding, it may become unsafe and must be handled according to the Food Code's corrective actions (such as rapid reheating or discarding).During a review of the facility's policy and procedure titled Dietary Profile and Resident Preference Interview, dated 11/11/2025, the policy indicated that its purpose is to ensure residents are consistently evaluated for their dietary needs. The policy states that the Dietary Manager will complete a Dietary Profile for each resident to reflect current nutritional needs and food preferences. If a resident's nutritional needs or food preferences change after the profile has been completed, those updates must be documented in the progress notes.

Based on observation, interview, and record review, the facility failed to ensure that one of 35 sampled residents (Resident 147) received the necessary care and services to maintain good grooming and personal hygiene. This failure resulted in Resident 147 being observed wearing only an adult brief, with no other clothing during two observations.1. During a review of Resident 147's Diagnosis Information, dated 7/17/2026, the Diagnosis Information indicated, Resident 147 include, muscle weakness generalized, contracture (when a muscle or joint becomes stiff and can't move normally) right hand, contracture left hand, Dementia (condition that affects the brain and makes it harder for a person to remember things, think clearly, or make decisions), neurocognitive disorder with Lewy body (is a condition that affects the brain and can cause problems with memory, thinking, and experience stiffness or trouble moving their muscles), cognitive communication deficit ( having trouble thinking clearly or communicating effectively due to problems with memory, attention, or understanding language).During the initial pool screening on 08/10/2026 at 10:20 AM in Resident 147's room, Resident 147 was observed lying in the second bed, wearing only an adult brief and no other clothing. During the second round of the initial pool on 08/10/2026 at 1:03 PM, Resident 147 was observed lying flat in bed, still wearing only an adult brief, which was noted to be wet.During an interview on 8/14/2026 at 1:10 PM with Certified Nursing Assistant (CNA) 4, CNA 4 stated, Resident 147 is a full assist. CNA 4 further stated that she does rounding every 10 minutes for Resident 147 and is assigned to nine residents during her shift. CNA 4 also stated, Resident 147 wears clothes when in a wheelchair and a gown while in bed.A review of Resident 147's Care Plan, dated 6/20/2026, the care plan indicated Resident 147 has an ADL self-care performance deficit.Dressing: the resident requires extensive assist by 1 staff to dress, Personal Hygiene/oral care: the resident is totally dependent on 1 staff for personal hygiene and oral care.A review of Resident 147's Minimum Data Set (MDS, standardized clinical assessment tool required for nursing home and skilled facility) Section GG-Functional Abilities, dated 7/8/2026, MDS indicated GG0130 Self Care.01 - Dependent - Helper does all of the effort, Resident does none of the effort to complete the activity, or assistance of 2 or more helpers is required for the resident to complete the activity. Shower/bathe self - 01, upper body dressing - 01, lower body dressing - 01, personal hygiene 01.

Based on observation, interview, and record review, the facility failed to ensure the safe administration of medication when nursing staff crushed a ferrous sulfate tablet that should not be crushed. This failure has the likelihood to result in complications for residents when medications are administered inappropriately. During a medication administration observation on 8/12/26 at 9:31 AM, Licensed Vocational Nurse (LVN) 4 was observed preparing medications for Resident 24. LVN 4 crushed a ferrous sulfate tablet (used to prevent and treat anemia [lacking healthy red blood/oxygen carrying cells]), placed the crushed medication into a cup, added applesauce, and brought it into Resident 24. LVN 4 stated that ferrous sulfate can be crushed. During an interview on 8/12/26, the Charge Nurse / LVN 3 reviewed Resident 24's physician order and stated there was no order permitting the ferrous sulfate to be crushed. LVN 3 further stated that ferrous sulfate should not be crushed.During an interview on 8/12/26, at 10:31 AM, the Pharmacist confirmed that ferrous sulfate cannot be crushed. During a review of the Policy and Procedure titled, Medication Administration dated 8/19/25, indicated, .All medications shall be administered by licensed nursing staff according to physician orders, current best practices, and federal and state regulations. The facility shall ensure residents receive the correct medications in a timely, safe and documented manner. Purpose. To establish standardized procedures for the safe, effective, and accurate administration of medications in compliance with state and federal regulations and bed practice standards.If the resident has difficulty swallowing pills, the Licensed Nurse will notify the physician to discuss the possibility of a different form of medication i.e. crushed, liquid or suspension. If the medication is to be crushed, a physician order is required.

Based on observation, interview, and record review, the facility failed to ensure proper storage of respiratory equipment for two residents (Resident 41 and Resident 208) when their aerosol masks were not stored in a resident equipment bag.This failure to follow infection prevention practices had the potential to expose residents to cross-contamination and increased risk of infection. During a concurrent observation and interview on 8/10/26 at 10:50 AM, in Resident 41's room, two respiratory devices with attached aerosol masks were observed on the bedside table. Resident 41 identified the two devices as a BiPAP (bilevel positive airway pressure - machine is a noninvasive medical device that helps people breathe) machine and BiWaze Cough device (an advanced cough assist system that helps clear mucus from your lungs when your body can't do it on its own). The aerosol masks attached to both devices were observed to be uncovered and exposed on the bedside table. During interview, Resident 41 stated that nursing staff assist with the use and aftercare of the respiratory equipment. During an observation on 8/11/26 at 2:25 PM, in Resident 208's room, an aerosol mask attached to a nebulizer machine (a medical device that turns liquid medicine into a fine mist) was observed uncovered and exposed on the bedside table. During an interview on 8/13/26 at 2:44 PM, the Infection Preventionist (IP) stated that the respiratory equipment such as masks and cannulas should be stored in an IP pouch, a black colored pouch for infection control purposes. Review of the facility's policy and procedures titled P-RE01 Noninvasive Ventilation (CPAP/BiPAP), revised 10/10/25, indicated, .5. CPAP/BiPAP cleaning and maintenance requirements . f. CPAP/BiPAP resident interface and unit tubing should be kept in a resident equipment bag labeled with the resident's name and room number when not in use . Review of the facility's policy and procedures titled Nebulizer (small volume), revised 10/15/20, indicated, .XV. Place the nebulizer back into the Resident's set-up bag and leave the equipment at the bedside for further treatments .

Based on observation, interview, and record review, the facility failed to ensure comprehensive care plan was developed and physician ordered services were implemented for three (Resident 14, Resident 11 and Resident 49) for the following practices: 1. Resident 14's care plan and physicians order were not accurately implemented on maintaining oxygen level via nasal cannula.2. Resident 11's blood pressure check was not implemented in accordance with the physician order and care plan for resident's dialysis needs. 3. Resident 49's comprehensive care plan did not address the three linear fissures on the sole near the ball on the left foot. These failures had the likelihood of resulting in unmet care needs and placing the residents at risk for adverse outcomes, including compromised oxygenation for Resident 14, complications related to inadequate blood pressure monitoring for Resident 11 and delayed identification, assessment and treatment of the skin for Resident 49 left foot. Findings: 1. During a review of Resident 14 Diagnosis Information dated 3/20/2026, the Diagnosis Information indicated, Resident 14 included Metabolic Encephalopathy (heart disease caused by clogged arteries), Acute Respiratory Failure with Hypoxia (serious breathing trouble where the body wasn't getting enough oxygen). During an observation on 8/10/2026 at 12:53 PM in Resident 14's room, Resident 14, who was lying down in bed, had the oxygen concentrator set at 2.5 L/min via a nasal cannula. (small plastic tube with two prongs that gently fit into the nostrils to deliver oxygen). During a concurrent interview and record review on 08/12/2026 at 10:06 AM with Licensed Vocational Nurse (LVN)2, Resident 14's Physician order dated 8/6/2026 was reviewed. The Physician order indicated, Oxygen at 3L/min VIA NC to keep O2 sat (blood oxygen) at or above 93%, LVN2 stated, Resident 14 was sent out on August 3 and returned on August 6. There is an order to administer oxygen to Resident 14 and monitor the Oxygen level every shift. This has been entered in the Medication Administration Record (MAR). The physician's order indicated oxygen at 3 L/min via nasal cannula to keep O2 saturation (blood oxygen) at or above 93%. LVN2 stated that Resident 14 was sent out on August 3 and returned on August 6. There is an order to administer oxygen to Resident 14. It is important to monitor the oxygen level to prevent episodes of hypoxia (body wasn't getting enough oxygen). A review of Resident 14's Care Plan dated 8/7/2026, the care plan indicated, the resident is on oxygen therapy r/t acute respiratory failure with hypoxia. Interventions, administer 3L oxygen therapy per MD order and monitor response. A review of Resident 14's Medication Administration Record (MAR) on 8/13/2026. The MAR indicated, on 8/9/2026 for Day Shift monitoring, the Liters per minute (LPM) was at 2, there were no O2 sat noted. Review of the facility's policy and procedures titled Oxygen Therapy, revised 11/2017, indicated, Oxygen is administered under safe and sanitary conditions to meet resident needs. 2. During an observation on 8/13/2026 at 11:05 AM, Resident #11 was observed lying in bed with an AV shunt (is a way to connect an artery and a vein in your arm, creating a pathway for blood to flow out of your body to the dialysis machine and then back in) noted in the left upper arm. A review on Resident 11's Physician order dated 6/1/2026, the Physician order indicated, No blood pressure checks to AV shunt in left upper arm every shift. During a concurrent interview and record review on 08/13/2026 at 11:32 AM with Licensed Vocational Nurse (LVN)3, Resident 11's weights and vitals summary on blood pressure dated 8/6/2026 to 8/13/2026 were reviewed. Weight and vital signs on blood pressure indicated, On 8/6/2026 at 5:49 PM and 9:36 PM; 8/7/2026 at 5:13 PM, 6:43 PM, and 8:56 PM; 8/8/2026 at 6:03 AM, 9:32 AM, 6:22 PM, and 8:17 PM; 8/9/2026 at 11:08 AM and 11:11 AM; 8/10/2026 at 9:58 AM, 12:54 PM, 2:21 PM, and 10:50 PM; 8/11/2026 at 1:56 AM, 10:19 AM, 2:28 PM, and 8:08 PM; 8/12/2026 at 4:57 AM, 9:54 AM, and 12:19 PM; and 8/13/2026 at 3:52 AM and 9:38 AM. It was noted that nurses used the left arm to check blood pressure to Resident 11. LVN3 stated, We need to do an in-service on this, after seeing the mistakes. A review on Resident 11's Care plan dated 6/2/2026, the care plan indicated, Monitor AV shunt (location left arm) for bruit and thrill every shift. No blood pressure checks to AV shunt in left arm. 3. During a review of the physician (doctor) visit notes dated 8/5/26, the physician visit notes indicated Resident 49 had diagnoses including hyperlipidemia (abnormally high presence of fats in the blood), and anemia (abnormally low red blood cells). During the observation on 8/10/26 at 10:15 AM, Resident 49 was alert, coherent, calm, and pleasant. Resident 49 was able to relate the need to reside in a nursing facility. Resident 49 was independent with mobility, transfer, and ambulation. Resident 49 stated he has a cut under the left foot causing pain and discomfort when walking. Resident 49 stated self- treating by using miracle foot repair cream, pointing at the cream on the overbed table. Resident 49 lifted his left foot to show the cut. On the sole near the ball of the left foot were three linear fissures with raw, pinkish red tissue visible beneath. During a concurrent interview and record review on 8/12/26 with Licensed Vocational Nurse (LVN) 5, the physician orders for August 2026 were reviewed. The physician orders did not indicate any treatment for the three linear fissures on the sole near the Resident 49's left foot. LVN 5 acknowledged and stated that she was not aware of the three linear fissures on the sole near the ball of the left foot, which were causing Resident 49 pain when stepping on the left foot. During a review of the facility Policy and Procedure titled, Skin Integrity Management dated 7/31/24, indicated, . A Licensed Nurse will complete a skin evaluation then there is a change in kin integrity. Interdisciplinary (IDT) /Skin Committee will document discussion and recommendations for skin integrity issues. Review the resident's care plan and update as necessary. During a review of the progress note on 8/13/26, at 10:50 AM, the progress notes did not indicate discussion and recommendations by the IDT / Skin Committee to address the linear fissures on the near the ball of left foot for Resident 49.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program free of fruit flies for one of three sampled residents (Resident 25) when;1. The facility did not routinely inspect raw fruit and vegetables stored within a resident room (room [ROOM NUMBER]). 2. The facility did not address persistent fruit fly activity in a timely manner. These failures led to Resident 25 being exposed to potential food contaminants that could cause food-borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins), infection, or death. Findings:1.During a review of Resident 25's Face sheet (document containing a resident's essential demographic, medical, and personal information), (undated), the Face sheet indicated, Resident 25 was initially admitted to the facility on [DATE] with multiple diagnosis including: Metabolic Encephalopathy, Severe Septic Shock (hx), Quadriplegia, weakness, Dysphagia, Fistula of stomach and duodenum, and Cognitive communication deficit.A review of Resident 25's Minimum Data Set (MDS: a standardized resident assessment tool), dated 8/1/26, the Minimum Data Set indicated, a Brief Interview of Mental Status assessment (BIMS, a brief memory test to help determine memory, thinking, learning, and decision making ability: a score of 15-13 = intact memory/reasoning; a score of 12-8 = moderate impairment in memory/reasoning; a score of 7-0= severe impairment in memory/reasoning) was completed. Resident 25 scored 14 out of 15, this indicated Resident 25 had intact memory/reasoning.During a concurrent observation and interview on 8/10/26 at 11:00AM with a Certified Nursing Assistant (CNA5), in room [ROOM NUMBER], Resident 25 had a large brown cardboard box with one raw pineapple, one red bag of Nature's Pride potatoes, and an opened bag of peanut butter filled pretzels. When CNA5 removed the red bag of potatoes a large amount of fruit flies was observed flying out of the box and around the shared resident room. CNA5 stated, the fruit flies were from the pineapple, and it was stored to make Resident 25's smoothies. When asked what the bag of potatoes were used for, CNA5 stated the raw vegetable stored at Resident 25's bedside was used to prepare meals based on Resident 25's preference. CNA25 stated food items stored at the bedside and cooked for Resident 25 included potatoes, noodles, broccoli, bell peppers, corn, or tortillas. When asked if fresh fruit that was stored in room Resident 25's room (room [ROOM NUMBER]) were dated, CNA5 stated, No. we know when they go bad.During a concurrent observation and interview on 8/11/26 at 10:36AM with a Certified Nursing Assistant (CNA6), in room [ROOM NUMBER], a large brown cardboard box with one raw pineapple, one red bag of Nature's Pride potatoes was observed. When asked what the raw fruit and vegetables were used for, CNA6 stated, It's his (Resident 25) food. We make it for him when he wants it. Large amounts of fruit flies were observed lying on top of the pineapple and flying around the room when cardboard box was moved. During an interview on 8/13/26 at 3:00PM with the Housekeeping Supervisor (HS), HS stated, housekeeping staff are responsible for cleanliness and sanitation of the entire facility. Housekeeping staff are responsible for letting the HS know if there is excessive clutter, pests observed in any resident rooms and/or common areas. When asked what steps has the facility taken so far to address the fruit fly issue in this resident's room, and how do you determine whether those interventions are effective, HS stated, when fruit flies are observed in a resident room, the housekeeping staff places insect traps as first defense and until pest control vendor complete a full assessment for the origin and/or source. HS also stated that the facility determines interventions are effective if there is a visible decrease in insects.During an interview on 8/14/26 at 12:00PM with a Registered Dietician (RD2), RD2 stated, the presence of fruit flies on food products can contribute to foodborne illnesses and food contamination.Review of the 2022 Federal Drug Administration Food Code, Insects and rodents are vectors (DEF) of disease-causing microorganisms which may be transmitted to humans by contamination of food and food-contact surfaces. (FDA 2022 Annex 3 - Public Health Reasons/Administrative Guidelines, 6-202.15 Outer Openings, Protected.)During a review of the facility's policy and procedure titled P-DS52 Food Storage and Handling, last revised on 2/29/2024, policy indicated, .Fresh Fruits Storage.a. Fresh fruit should be checked and stored for ripeness.e. Label and date all food items.Rotate fruit so that the oldest produce is used first.Fresh Vegetable Storage.a. Fresh vegetables should be checked and stored for ripeness.c. Potatoes and onions, should be stored in a cool and dry place.Label and date all food items. 2.During a concurrent interview and record review on 8/13/26 at 3:22PM with HS, a list of room that housekeeping staff reported to HS for further inspection dated 8/10/26. HS stated room [ROOM NUMBER] was included on the list that was provided by housekeeping staff due to clutter. When asked if he inspected room [ROOM NUMBER], HS stated he inspected room [ROOM NUMBER], but Resident 25 often refused to have his room cleaned. During a review of Care Plan Report dated 3/29/26, the Care plan indicated Resident will maintain a safe and clutter free environment and reduce.reduce risks for falls, infections, and fire hazards will be minimized with interventions that included Set limits on unsafe items (ex: spoiled food, hazardous objects) .encourage gradual declutter with resident participation. No additional documentation found in Resident 25's medical record that indicates interventions were implemented and/or monitored.During a concurrent observation and interview on 8/13/26 at 3:35PM with HS and CNA5, room [ROOM NUMBER] was observed to have large amounts of fruit flies accumulated on an insulated cup with a plastic lid with a clear straw placed on Resident 25's meal tray. Large amounts of fruit flies were observed on the straw and on the rim of the cup. When asked if facility staff was aware of the fruit flies in room [ROOM NUMBER], HS stated, I know that there are fruit flies in here and he (Resident 25) is very particular about what staff can clean and do for him. We have tried but he (Resident 25) does not want us to touch anything When asked if he considers this sanitary, HS stated, I consider this unsanitary and not clean, but we can't do anything about it. When CNA5 was asked to identify what was in the insulated cup, CNA5 stated, it was a Hibiscus mixture that he mixed with water for Resident 25. When asked if Resident 25 would consume the remaining mixture, CNA5 stated, Yes.During a review of the facility's policy and procedure titled Pest Control, last revised on 1/1/2012, policy indicated, Purpose.To ensure the facility is free of insects, rodents, and other pests that could compromise the health, safety, and comfort of residents, facility staff, and visitors.Staff Role.i. The Housekeeping Supervisor takes immediate action to remove the pests from the facility.

Based on observation, interview, and record review, the facility failed to ensure two of 35 sampled residents (Resident 34 and Resident 87) were treated with dignity and respect, and maintain privacy when staff left the privacy curtains open during care.This failure resulted in the unnecessary exposure of Resident 34 and Resident 87's bodies and compromised the resident's dignity and right to personal privacy. During a review of Resident 34, Diagnosis Information dated 5/28/2026, the Diagnosis Information indicated, Resident 34 included Dementia (condition that affects the brain and makes it harder for a person to remember things, think clearly, or make decisions), Major depressive disorder (feeling very sad, hopeless, or uninterested in things for a long time), Cognitive communication deficit (having trouble thinking clearly or communicating effectively due to problems with memory, attention, or understanding language). During an observation on 08/10/2026 at 1:06 PM in a two-bed room, Resident 34 was in the second bed. Resident 34 was observed with her lower back or buttock area exposed while lying on her right side. The privacy curtain was only partially closed, leaving Resident 34 visible to others in the room. During an interview on 08/12/2026 at 2:44 PM with Certified Nurse Assistant (CNA) 3, CNA3 stated, that there should always be privacy, such as keeping the curtain closed and the door closed, even when care is not being provided, and in accordance with resident preferences. During an observation on 8/10/26 at 10:06 AM in Resident 87's room, the privacy curtain was left open while a Certified Nursing Assistant (CNA) 2 provided care, exposing Resident 87's buttocks to the roommate. During concurrent observation and interview on 8/10/26 at 10:07 AM, in Resident 87's room, CNA 2 pulled the privacy curtain closed and stated that curtains should always be closed when providing care.

Based on interview and record review, the facility failed to notify the responsible party of Resident 1 regarding changes in his clinical condition for one of four sample residents. This failure had the likelihood to prevent Resident 1's responsible party from being informed in a timely manner and from participating in care decisions related to Resident 1's change in clinical condition.Findings:Review of Resident 1's medical record titled Minimum Data Set (MDS= a standardized resident assessment tool), dated [DATE], indicated his BIMS (Brief Interview for Mental Status: a resident assessment tool for memory and reasoning) score was 6 out of 15. A score of 6 out of 15 indicated Resident 1 was severely impaired in his memory and reasoning skills.Review of Resident 1's medical record titled Face Sheet, printed on [DATE], indicated .Responsible Party Emergency contact #1 was .(Conservator 1).During an interview on [DATE] at 12:03 PM, Resident 1's Case Manager (CM) from a non-profit agency stated Resident 1 was unable to make medical and financial decisions for himself due to a decline in his mental status. The CM stated around December of 2025 was when there were discussions of public guardianship for Resident 1 with the facility. Around [DATE] was when the courts granted public guardianship. During an interview on [DATE] at 1:10 PM, a Public Guardian Supervisor (PGS) stated there was a social worker from the facility who helped Resident 1 arranged his virtual court hearing for guardianship. The PGS stated at the conclusion of the hearing, the court granted his agency authority to be a public guardian for Resident 1. The PGS stated the next day, when they received paperwork from the court granting this authorization, the PGS stated he immediately emailed and attached the court document to the social worker who assisted Resident 1 in attending the hearing. The PGS stated the facility was informed Resident 1 had a public guardian around March of 2026. The PGS was asked to provide evidence of these communications with the facility. The PGS sent documents regarding these communications. Review of the documents sent by the PGS indicated on [DATE], the facility's Social Worker (SW1) assisted Resident 1 and was present during the remote court guardianship hearing. Resident 1 and SW 1 was made aware of the court's decision. The documents sent also indicated the PGS send court documents identifying them as being granted guardianship by the courts and on [DATE] the guardianship agency requested Resident 1's medical records and the facility provided Resident 1's medical records.During a concurrent interview and record review on [DATE] at 11:43 AM, the Director of Medical Records (DMR) was asked to find change in clinical condition (COC) for Resident 1. The DMR searched and stated there were nine instances of COC for Resident 1 from [DATE] to [DATE]. The DMR was asked to search if the responsible party for Resident 1 was informed of these COC. Review of all nine COC under the section titled Resident Representative Notification, indicate staff documented they notified Resident 1 and/or staff documented Resident 1 was his own responsible party. There was no documented evidence in Resident 1's record staff contacted his Responsible Party (Conservator 1) for these COCs. Review of most Resident 1's most serious COCs indicated:On [DATE] at 12:14 PM , Resident 1's blood sugar .before lunch was at 416. (mg/dL= milligram per deciliter, a unit of measurement for blood sugar). Normal blood sugar range is 70-99 mg/dL.On [DATE] at 4:00 PM , Resident 1 .was shivering and calling the doctor, verbalized that he is in pain and feels cold. Immediately checked his .(vital signs and vital signs were normal). No fever noted. As needed pain medication was given . (for) pain on his right big toe.On [DATE] at 1:00 AM, Resident 1's . tip/top portion of the right great toe appears necrotic .(as manifested by) presence of eschar (necrotic = body tissue that has died and is no longer alive, usually because of injury, infection, or a loss of blood supply. Eschar = a dry dark scab of dead skin/tissue) .Resident verbalizes a lot of pain to the right foot and nursing staff noted that since his fall earlier today, he has remained in bed the whole day. orders were obtained to transfer resident to acute care hospital for evaluation and possible treatment of right great toe .with foul odor and pain.On [DATE] at 9:49 PM, Resident 1 .verbalized discomfort on his chest and .(shortness of breath, vital signs) was taken and .(oxygen level) was 84% (normal oxygen level is 95-100%). Elevate the.(head of bed) but .(breathing difficulty) still noted.(doctor) ordered to transfer resident to hospital for further evaluation.Review of the facility's policy titled Change in Condition, effective date [DATE], indicated, .A Licensed Nurse will notify the resident's Physician. and legal representative or an appropriate family member when there is an: .A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status, life-threatening conditions or clinical complications . A need to alter treatment significantly.A decision to transfer or discharge the resident from the Facility.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of three sampled residents (Resident 1) when Phenobarbital (a prescription medication primarily used to control certain types of seizures), Olmesartan Medoxomil (a prescription medication used alone or with other drugs to treat high blood pressure), Metoprolol (a prescription medication primarily used to treat high blood pressure, prevent chest pain, and manage heart failure), and Hydroxyzine (a prescription medication primarily used to treat itching, anxiety, and allergic reactions) were not given according to the doctor's orders from February to April 2026. This failure was likely to result in Resident 1 being put at risk for not attaining or maintaining his highest practicable level of physical, mental, functional, and psychosocial well-being.Review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated, Resident 1 was admitted to the facility with diagnoses including epilepsy (a long-term brain condition where a person has repeated seizures), hypertension (high blood pressure), and malignant neoplasm of brain (brain cancer). Review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 2/17/26 indicated, Resident 1 was cognitively intact. During an interview on 5/27/26 at 11:16 AM with Resident 1, Resident 1 stated that he occasionally did not take Phenobarbital, Olmesartan Medoxomil, Metoprolol, and Hydroxyzine on time from February to April in 2026 because he ran out of these four medications. Resident 1 was worried that missing his medication might affect his health. During a concurrent observation and interview on 5/28/26 at 12:50 PM with Registered Nurse (RN) 1 in the Director of Nursing (DON)'s office, RN 1 stated that each medication packet has blue indicator lines, and when the packets reach the blue line, nurses should request a refill. Resident 1's medication packets including Phenobarbital, Olmesartan Medoxomil, Metoprolol, and Hydroxyzine had all blue indicator lines and had enough medications. During a concurrent interview and record review on 5/28/26 at 1:29 PM with DON, Resident 1's doctor's orders titled, Order Details (OD) were reviewed. Resident 1's OD dated 9/5/23 indicated, Order Summary: PHENobarbital Oral Tablet 100 MG (Milligram, used for medication dosages) . Give 1 tablet by mouth two times a day for epilepsy . Resident 1's OD dated 2/23/25 indicated, Order Summary: Metoprolol . Oral Tablet 25 MG . Give 1 tablet by mouth two times a day for hypertension. Hold if SBP (systolic blood pressure, the maximum pressure in your arteries when your heart beats and pumps blood into your circulatory system) < 105 and HR (heart rate, the number of heart beats per minute) < 60 . Resident 1's OD dated 10/12/25 indicated, Order Summary: Olmesartan Medoxomil Oral Tablet 20 MG . Give 0.5 tablet by mouth one time a day for high blood pressure . Resident 1's two OD dated 3/22/26 and 3/23/26 indicated, Order Summary: hydrOXYzine . Oral Tablet 10 MG . Give 1 tablet by mouth three times a day for itchiness . During a concurrent interview and record review on 5/28/26 at 1:39 PM with Licensed Vocational Nurse (LVN) 1, Resident 1's MEDICATION ADMINISTRATION RECORD (MAR) dated from 3/1/26 to 3/31/26 and from 4/1/26 to 4/30/26, Weights and Vitals Summary dated 3/4/26, and Orders-Administration Note dated 4/9/26 were reviewed. LVN 1 verified that the initials XXXX (LVN 1's initial) on the MAR were hers. The MAR of March 2026 indicated, regarding the administration of Metoprolol, the blood pressure (BP) and pulse entries were marked with an X at 5 PM on 3/4/26. LVN 1 verified that Metoprolol was not given to Resident 1 at 5 PM on 3/4/26, and that the reason it was not given was chart code number 4, indicating Vitals (Known as vital signs, measurements of the body's most basic functions such as BP and pulse) Outside of Parameters for Administration. But Resident 1's Weights and Vitals Summary dated 3/4/26 indicated, there was no BP and pulse at 5 PM. LVN 1 stated she might have missed entering the BP and pulse on 3/4/26 at 5 PM on the MAR for Metoprolol. Resident 1's MAR indicated, regarding the administration of Olmesartan Medoxomil on 4/9/26 at 9 AM, it was recorded with chart code number 9, indicating Other / See Progress Notes. Resident 1's Orders-Administration Note dated 4/9/26 at 11:06 AM indicated, . Olmesartan Medoxomil . on order . LVN 1 stated that Olmesartan Medoxomil was not available from the pharmacy at that time, even though it had been ordered for refill earlier. LVN 1 stated that the pharmacy did not deliver the medication on time. During a concurrent interview and record review on 5/28/26 at 2:16 PM with LVN 2, Resident 1's MAR dated from 2/1/26 to 2/28/26 was reviewed. LVN 2 verified that the initials OOOO (LVN 2's initial) on the MAR were his. The MAR indicated, regarding the administration of Phenobarbital at 9 AM on 2/28/26, it was recorded with chart code number 9, indicating Other / See Progress Notes. LVN 2 acknowledged that there was no nursing progress notes or Orders-Administration Note to explain the situation for the chart code number 9 when asked. But LVN 2 stated that he could not give Phenobarbital to Resident 1 because it was not available from the pharmacy on 2/28/26. LVN 2 stated that since the resident takes phenobarbital to prevent seizures, a seizure could occur if the medication is not taken on time when asked about the possible risks of not taking Phenobarbital on time. LVN 2 stated that delays in medication delivery from the pharmacy to the nursing unit are not an ongoing issue but rarely occur, probably about once every 3 to 4 months. During a concurrent interview and record review on 5/28/26 at 3:03 PM with LVN 3, Resident 1's MAR dated from 3/1/26 to 3/31/26 was reviewed. LVN 3 verified that the initials **** (LVN 3's initial) on the MAR were his. The MAR indicated, regarding the administration of Hydroxyzine on 3/23/26, it was given to Resident 1 at 9 AM and 1 PM by initial @@@@ (LVN 5's initial), then it was given to Resident 1 by LVN 3 at 5 PM and 9 PM. LVN 3 acknowledged that Hydroxyzine was given 4 times on 3/23/26 even though the doctor's orders indicated it should be given three times a day when asked. LVN 3 stated he did not know there were duplicate orders and he just followed the order on the MAR when asked why Hydroxyzine was given 4 times on 3/23/26. LVN 3 stated that Hydroxyzine was given for itchiness when asked. LVN 3 stated it could cause an overdose when asked about the possible risks associated with taking one more dose of Hydroxyzine without doctor's order. During a concurrent interview and record review on 5/28/26 at 3:19 PM with LVN 4, Resident 1's MAR dated from 3/1/26 to 3/31/26 and Orders-Administration Note dated 3/7/26 were reviewed. LVN 4 verified that the initials #### (LVN 4's initial) on the MAR were hers. The MAR indicated, regarding the administration of Olmesartan Medoxomil at 9 AM on 3/7/26, it was recorded with chart code number 9, indicating Other / See Progress Notes. Resident 1's Orders-Administration Note dated 3/7/26 indicated, Olmesartan Medoxomil . on order . LVN 4 stated that the medicine was not available from the pharmacy at that time, even though it had been ordered for refill earlier when asked. LVN 4 stated that medications could not be administered on time because delays occurred about once every 3-4 months during the process of delivering drugs from the pharmacy to the nursing unit. During an interview on 5/28/26 at 3:36 PM with LVN 5 via phone, regarding Resident 1, LVN 5 verified that the initials @@@@ (LVN 5's initial) on the MAR were hers. LVN 5 stated that she did not remember the incident about Hydroxyzine on 3/23/26. But LVN 5 verified that medications should be administered in accordance with the doctor's orders when asked. LVN 5 stated that Hydroxyzine should have been administered 3 times, not 4 times on 3/23/26 per doctor's order when asked. LVN 5 stated that there could be resistance to the medication when asked about the risks associated with taking one more dose without doctor's order. During a concurrent interview and record review on 5/28/26 at 4:13 PM with DON, Resident 1's MAR dated from 2/1/26 to 2/28/26 was reviewed. The MAR indicated, regarding the administration of Olmesartan Medoxomil at 9AM on 2/12/26, she verified that LVN 1 did not administer the medication and that no nursing notes explained why it was not given. During an interview on 5/28/26 at 4:20 PM with LVN 1 via phone, LVN 1 stated that she could not give Olmesartan Medoxomil to Resident 1 at 9 AM on 2/12/26 because the medication was not available from the pharmacy, and she forgot to document it on the nursing notes when asked. During a concurrent interview and record review on 5/28/26 at 4:28 PM with DON, Resident 1's MAR dated from 3/1/26 to 3/31/26 was reviewed. The MAR indicated, regarding the administration of Hydroxyzine at 1 PM on 3/22/26, it was recorded with chart code number 9, indicating Other / See Progress Notes. Resident 1's Order-Administration Note dated 3/22/26 indicated, . hydrOXYzine . medication not available . DON verified that Hydroxyzine was not administered at 1 PM on 3/22/26 by LVN 5 because the medication was not available from the pharmacy. DON acknowledged that the facility shared a pharmacy with ******* (hospital name), and that the pharmacy tends to be late in delivering medications to the facility, even when nurses had requested refills ahead of time. The facility's policy and procedure (P&P) titled, NP76 Medication - Administration dated 6/26/25 indicated, . All medications shall be administered by licensed nursing staff according to physician orders, current best practices, and federal and state regulations. The facility shall ensure residents receive the correct medications in a timely, safe, and documented manner .

Based on interview and record review the facility failed to provide adequate supervision to Resident 1 to prevent his elopement. This failure did not ensure Resident 1 was residing in a safe and supervised environment.Findings:Review of Resident 1's medical records titled MDS (Minimum Data Set assessment: a standardized resident assessment tool), dated 3/12/26, indicated his BIMS (Brief interview for Mental Status: an assessment tool for evaluating memory and reasoning abilities) score was 8 out of 15. A BIMS score of 8 indicated Resident 1 was moderately impaired in his memory and reasoning abilities.Review of Resident 1's medical records titled Care Plan, initiated on 5/1/26, indicated .The resident is an elopement risk/wanderer.(related to) impaired safety awareness as .(manifested by) attempt to leave the facility at 06:50am on 05/01/2026.Review of Resident 1's medical records titled IDT Note (interdisciplinary team note: a healthcare team from various disciplines such as nursing, social services, rehab, dietary etc.), dated 5/13/26, indicated .Resident noted with wandering behaviors and exit-seeking attempts, placing resident at risk for elopement.(WanderGuard: a small wearable alarm device that activates an exit area alarm when a resident attempts to leave unsupervised) place on right wrist remains in place and functioning properly. Resident monitored routinely by staff with redirection and supervision provided as needed.Review of Resident 1's medical records titled eMAR (electronic Medication Administration Record), for the month of May 2026, indicated the 5/18/26 night shift charted Resident 1 .refused (his WanderGuard), offered multiple times. Resident verbally stated that, 'he is okay'. Risk and benefits explain to resident.During an interview on 5/21/26 at 12:41 PM, Certified Nursing Assistant (CNA)1 stated she did her morning rounds on May 19th around 10 AM and everything looked fine and Resident 1 was in his room. CNA 1 stated she went for her break around 11:30 AM and when she came back around 12 noon, Resident 1 was not in his room. CNA 1 stated that was when she alerted her nurse that Resident 1 was missing. CNA 1 stated Resident 1 was confused, was an elopement risk and had a WanderGuard. CNA 1 stated she believed Resident 1 had his WanderGuard on when she saw him in the morning of May 19.During an interview on 5/21/26 at 2:21 PM, License Vocational Nurse (LVN) 1 stated there was a recent physician order to apply a WanderGuard device due to Resident 1's increase risk in elopement. LVN 1 stated she had observed Resident 1 playing with his WanderGuard device and had to re-direct him not to play with his WanderGuard device. LVN 1 stated approximately two weeks ago a CNA had told her that Resident 1 tried to take off his WanderGuard. LVN 1 was asked if she received report from night shift that Resident 1 did not want to wear his WanderGuard? LVN 1 stated no, night shift did not report to her Resident 1 was refusing to wear his WanderGuard. LVN 1 was asked if she charted Resident 1's reported previous behavior in trying to remove his WanderGuard? LVN 1 stated no. LVN 1 was asked what more staff could have done to safeguard Resident 1. LVN 1 offered these additional interventions: Assess why Resident 1 did not want to wear his WanderGuard; Try switching the WanderGuard to a different area; More frequent checks on Resident;Timely charting of this behavior to alert other staff.During an interview on 05/21/26 at 1:45 PM, the Director of Nursing (DON) stated a staff found Resident 1's WanderGuard on his bed. The DON stated Resident 1 took off his WanderGuard and that was how he was able to get pass the alarm. The DON was asked what else the facility could have done knowing these behaviors? The DON said more frequent checks.Review of the facility's policy titled Wandering and Elopement, effective date 2/20/23, indicated .The Facility will identify residents at risk for elopement upon admission and when there is a change in condition to minimize the risk of elopement.The Licensed Nurse, in collaboration with the Interdisciplinary Team (IDT), will assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition according to the RAI (Resident Assessment Instrument) guidelines to determine their risk of elopement.

Based on interview and record review, facility staff failed to recognize and report an allegation of neglect for Resident 1, one of three sample residents: when Resident alleged she was in pain for four hours and staff failed to response to her call for assistance. This failure had the potential for residents to be subject to abuse/neglect.Findings: During an interview on 2/12/2026 at 1:25 PM, Resident 1 stated .I believe it was sometime in January. I was sick really sick. I was in pain.I kept ringing for the nurse .nobody came to the room. Someone closed the door to the room .(later, I saw that my) call bell was not connected but.(initially) I didn't see that. I kept ringing and ringing .Nobody came so I was getting worried.I .(called the) hospital emergency room. (When the ambulance staff came to the facility and wheeled me out of my room, I saw) LVN 1 (License Vocational Nurse). sitting at the desk .I told her I was calling for hours for help. It was very scary. Review of Resident 1's medical record titled HOSPITAL DISCHARGE SUMMARY, dated 1/15/2026, indicated she was diagnosed with Recurrent acute diverticulitis (sudden onset of inflammation/infection of a portion of the colon= final section of the digestive tract, may cause sudden intense abdominal pain). During an interview on 2/13/2026 at 10:49 AM, LVN 1 stated she was aware Resident 1 alleged she was in pain and staff did not response to her call for assistance. During an interview on 2/13/2026 at 12:19 PM, the Unit Supervisor stated he was aware Resident 1 alleged she was in pain and staff did not response to her call for assistance. During an interview on 2/19/26, 4:17 PM, the Director of Nursing stated when the Unit Supervisor talked to Resident 1 on the phone regarding her hospitalization on 1/21/2026, the Unit Supervisor did not identify Resident 1's allegation as an incident of neglect. The Unit Supervisor identified the allegation as Resident 1 just venting. Review of the facility's policy titled Abuse-Reporting & Investigations, revised March 2018, indicated .The facility will report all allegations of abuse and criminal activity as required by law and regulations to the appropriate agencies. The Facility promptly reports and thoroughly investigates allegations of resident abuse, mistreatment, neglect, exploitation, abuse facilitated or enabled by the use of technology, misappropriation of resident property, or injuries of an unknown source, and suspicions of crimes.

Based on observation, interview, and record review the facility failed to thoroughly investigate an allegation of neglect for Resident 1, one of three sample residents. Resident 1 alleged she was calling out in pain for 4 hours and her call light was pulled out of the wall and was non-functional. The facility failed to: Interview other residents and/or responsible parties around Resident 1's room regarding call light response.Check to see if Resident 1's call light automatically triggers when pulled out of the wall socket.Ensure the Maintenance Director was knowledgeable regarding how a call light should function when unplugged from the wall. This failure may subject residents to delayed response to their request for assistant and may delay staff response to an emergent situation. Findings: During an interview on 2/12/2026 at 1:25 PM, Resident 1 stated .I believe it was sometime in January. I was sick really sick. I was in pain.I kept ringing for the nurse .nobody came to the room. Someone closed the door to the room .(later, I saw that my) call bell was not connected but.(initially) I didn't see that. I kept ringing and ringing .Nobody came so I was getting worried.I .(called the) hospital emergency room. (When the ambulance staff came to the facility and wheeled me out of my room, I saw) LVN 1 (License Vocational Nurse). sitting at the desk .I told her I was calling for hours for help. It was very scary. Review of Resident 1's medical record titled HOSPITAL DISCHARGE SUMMARY, dated 1/15/2026, indicated she was diagnosed with Recurrent acute diverticulitis (sudden onset of inflammation/infection of a portion of the colon= final section of the digestive tract, may cause sudden intense abdominal pain). During an interview on 2/13/2026 at 10:49 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated .(Resident 1 has a history) of false accusation. (Resident 1 will) use the call light but still yell for help.(Resident 1) will say that people are abusive to her .(because of this behavior,) we initiated a buddy system (when caring for her).(I think the incident happened in) 1/21/2026. She claimed she was in pain for 4 hours and called the ambulance. (but in reality) She never turned on the call light, she never called for help. Every time we checked, she was always asleep. She never screamed and yelled (for help). We were surprised. At 2:00 AM, I was charting and the ambulance came around 3:00 AM to take her to the hospital. LVN 1 stated this incident was investigated by her Unit Supervisor. During an interview on 2/13/2026 at 12:19 PM, the Unit Supervisor stated .she was transferred out on January 21. because of abdominal pain.it was included in my endorsement (shift to shift report). I'm not sure when she called me from the hospital. It wasn't documented. I remember she called. She was just complaining she was just transferred out. I did an investigation, nurses did their rounds and she was asleep. During their shift, nurses said .(Resident 1) never used her call light.(Resident 1) said she was in pain for 4 hours, no one came to help her. She used her call light, but she was unaware her call light was unplugged from the wall. During the interview the Unit supervisor stated:He did not document any of his investigation: he did not document interviews with the nurses, he did not document his interview with Resident 1. Therefore, he was unable to accurately answer details about specific date, time and content of these interviews.He did not interview other residents, roommates, family members and/or responsible parties regarding this allegation. During a concurrent observation and interview with the Unit Supervisor on 2/18/2026 at 12:55 PM, Resident 1's call light in room [ROOM NUMBER] bed 1 was tested for its cord out call light feature. The cord out call light feature is designed to automatically trigger an alert/alarm at the nursing station when the call light is disconnected from the wall plug. When tested, the cord out feature of Resident 1's call light did not trigger an alert/alarm at the nursing station. During the interview, the Unit Supervisor stated he did not check to see if the cord out feature of Resident 1's call light was functioning during his investigation. Inspection of surrounding rooms found the cord out call light feature of rooms 205-1 and 204-2 not working. During an interview on 2/18/2026 at 1:10 PM the Maintenance Director stated he was not aware the facility's call light system had a cord out feature and his routine maintenance schedule does not include checking for/maintaining this feature of the call light system. Review of the facility's policy titled Abuse-Reporting & Investigations, revised March 2018, indicated .The administrator or designated representative conducting the investigation will interview individuals who may have information relevant to the allegation . Individuals who may have information relevant to the allegation or suspected crime are the resident, witnesses to the incident, other residents under the care of the staff member involved, room mates, family, visitors, etc.

Based on observation, interview, and record review, the facility failed to provide a safe environment free from potentially serious accident hazards for all residents when its policies and procedures were not implemented for the following practices:1. The facility failed to ensure hot water in 6 of 8 residents' bathroom sinks were at a comfortable and safe temperature level.This deficient practice placed the residents (Residents 165, 187, and 259) at increased risk for scalding.An Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was declared at the [NAME] campus on 6/23/25 at 5:27 PM in the presence of the Administrator, Director of Nursing (DON), Regional Quality Management Consultants (RQMC), Assistant Chief Clinical Officer (ACCO), and [NAME] President of Operations (VPO) for the following deficient practice:Hot water temperatures were found to be between 121.6 F to 136.7 F in 6 of 8 sample rooms as evidenced by:a. room [ROOM NUMBER] = 132.2 Fb. room [ROOM NUMBER] = 136.0 Fc. room [ROOM NUMBER] = 136.7 Fd. room [ROOM NUMBER] = 121.6 Fe. room [ROOM NUMBER] = 131.9 Ff. room [ROOM NUMBER] = 130.5 F.On 6/24/25 at 10:38 AM, the facility submitted an unacceptable IJ Removal Plan (action to correct the deficient practices).On 6/24/25 at 2:36 PM, the facility submitted an unacceptable IJ Removal Plan #2.On 6/24/25 at 4:23 PM, the facility submitted an acceptable IJ Removal Plan #3.On 6/25/25 at 2:43 PM, the IJ was removed after the survey team validated onsite the IJ Removal Plan was implemented through observation, interview, and record review.2a. The facility failed to ensure safe smoking practices were followed when Resident 208 ignited her lighter inside the room while roommate (Resident 195) was actively receiving continuous supplemental oxygen.2b. The facility failed to implement their smoking policy and procedures (P&P) when it allowed five (5) of 14 residents (Resident 208, Resident 2, Resident 138, Resident 139, and Resident 81) who smoked in the facility to keep in possession of their own lighters and cigarettes inside the resident care area.These deficient practices posed an increased risk for combustion and/or fire, serious injury and/or death to residents, staff, and visitors.On 6/26/25 at 5:10 PM, an IJ was declared at the [NAME] campus in the presence of the Administrator, DON, RQMC, ACCO, and VPO for the following deficient practices:a. Without being prompted, Resident 208 ignited her lighter in the room while roommate (Resident 195) was actively receiving continuous oxygen at 2L(liters)/minute via nasal cannula. In addition, Resident 208 was in possession of three lighters and one opened pack of cigarettes.b. Resident and Staff interviews indicated, Resident 2, Resident 138, Resident 139, and Resident 81 were in possession of their own lighters and cigarettes.c. The facility failed to implement its smoking policy when it allowed Residents to keep in possession of their own lighters and cigarettes.On 6/27/25 at 11:13 AM, the facility submitted an unacceptable IJ Removal Plan.On 6/27/25 at 2:04 PM, the facility submitted an acceptable IJ Removal Plan #2.On 6/27/25 at 4:10 PM, the IJ was removed after the survey team reviewed and verified onsite the implementation of the IJ Removal Plan through observation, interview, and record review.3. The facility failed to ensure that one out of two sampled residents (Resident 898) receive adequate supervision to prevent elopement. This deficient practice resulted in Resident 898 eloping on 6/17/25 and putting Resident 898 at risk for serious injury or death.4. The facility failed to consistently implement effective interventions to prevent Resident 234 from elopement. This deficient practice resulted in Resident 234 eloping on 06/15/2025 and putting Resident 234 at risk for serious injury or death. Findings: 1. During an initial tour observation on 6/23/25 at 11:43 AM, in Residents' 195 and 208's room, while hand was held under running water in the bathroom sink faucet with hot and cold handles, the hot water was hot to touch. The bathroom was shared with Residents 1 and 214. During an initial tour observation on 6/23/25 at 11:57 AM, in Residents' 165 and 187's room, while hand was held under running water in the bathroom sink faucet with hot and cold handles, the hot water was hot to touch. During an initial tour observation on 6/23/25 at 1:05 PM, in Residents' 271 and 188's room, while hand was held under running water in the bathroom sink faucet with hot and cold handles, the hot water was hot to touch. The bathroom was shared with Resident 151. Resident 165 was admitted on [DATE] with diagnoses that included schizoaffective disorder (a mental health condition characterized by a combination of symptoms like hallucinations and delusions and mood disorder symptoms like depression or mania), cataract (a medical condition in which the lens of the eye becomes progressively opaque resulting in blurred vision), and glaucoma (a condition on increased pressure within the eyeball, causing gradual loss of sight). Resident 165's Minimum Data Set (MDS - an assessment tool), dated 5/14/25 indicated, vision and cognition were severely impaired. Resident 165's care plan for activities of daily living (ADL) indicated, .Date Initiated: 3/30/22 .Toilet Use: The resident is able to: ambulate to the bathroom (BR) on her own familiar to the location of the BR in her room and back . Resident 187 was admitted on [DATE] with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), peripheral vascular disease (PVD - a slow and progressive circulation disorder affecting blood vessels in the arms and legs), and cognitive communication deficit (difficulties in communication arising from impairments in cognitive processes, rather than primary language or speech problems). Resident 187's MDS dated [DATE] indicated, cognition was moderately impaired, and resident can walk independently. Resident 187's ADL care plan indicated, .Toilet Use: The resident is able to transfer self to the BR .Revised on: 8/29/24 . Resident 259 was admitted on [DATE] with diagnoses that included cognitive communication deficit, Alzheimer's disease (a progressive brain disorder that gradually destroys memory and thinking skills, ultimately impacting the ability to carry out even simple tasks), and type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Resident 259's MDS dated [DATE] indicated, impaired vision, moderate cognitive impairment, can walk independently, and independent with ADLs. During an observation on 6/23/25 at 3:40 PM, with the MS, the hot water in the residents' bathroom sink faucet was turned on and ran for 10-15 seconds, then MS tested the hot water using the facility's thermometer. The hot water temperature for each of the following residents' rooms were room [ROOM NUMBER] = 132.2 °F, room [ROOM NUMBER] = 136.0 °F, room [ROOM NUMBER] = 136.7 °F, room [ROOM NUMBER] = 121.6 °F, room [ROOM NUMBER] = 131.9 °F, and room [ROOM NUMBER] = 130.5 °F. During an interview on 6/23/25 at 4:00 PM, the MS said that random bathroom water temperature check was done each day. MS stated, Anything over 120 °F is too hot. Review of facility's undated policy titled Water Temperatures indicated, .The Facility ensures water is maintained at temperatures suitable to meet residents' needs. Tap water in the Facility is maintained within a temperature range to prevent scalding of residents. Procedure: I. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas are set to temperatures of no more than 120 °F (49 °C) . 2a. The list of smokers provided by the facility dated 6/23/25 indicated, there were 14 residents who smoke in the facility (Resident 208, 2, 138, 139, 81, 116, 57, 140, 5, 241, 263, 285, 58, and 182). During an observation on 6/26/25 at 10:27 AM, a “No Smoking Oxygen In Use sign was posted by the door of Resident 208 and Resident 195’s room. Resident 208’s roommate (Resident 195) was observed lying in bed receiving oxygen at two (2) liters per minute via a nasal cannula (NC, thin flexible tube with small prongs inserted into the nostrils). During an interview on 6/26/25 at 10:28 AM, Resident 208 stated the facility allowed her to smoke in the designated smoking area with staff supervision during smoking hours. When asked where she keeps her smoking materials, Resident 208 stated, “15 cigarettes are in the locked box in the utility room. [Staff Name] from Activities keeps them. But I keep [five] 5 cigarettes with me.” Resident 208 added, “I have a collector’s item lighter that I keep.” During concurrent observation and interview on 6/26/25 at 10:32 AM, in Resident 208’s room, without being prompted, Resident 208 opened the left bedside drawer and took out two (2) objects. Resident 208 showed a brown, pen shaped object with a skull design on one end and a silver, square shaped object with engraved letters on one side. Resident 208 identified the two objects as lighters and stated that she keeps these “two collector’s item lighters” in her possession. After showing the two lighters, Resident 208 suddenly removed the skull shaped part and without being prompted, ignited the lighter which sparked and produced a small yellow/orange flame. Furthermore, Resident 208’s roommate (Resident 195) was on the other bed actively receiving oxygen at 2 liters per minute via a nasal cannula. Review of Resident 195’s “Order Review History Report” for 6/1/25 to 6/30/25, indicated an order to administer “Oxygen 2L/min (liters per minute) via NC continuous to keep O2 Sat (oxygen saturation, amount of oxygen that’s circulating the blood) at/above 92 % (percent, a unit of proportion) for low oxygen every shift related to chronic respiratory failure (occurs when the lungs can't adequately oxygenate the blood or remove carbon dioxide, leading to long-term breathing difficulties) with hypoxia (low levels of oxygen in your body tissues). During a follow up interview on 6/26/25 at 10:42 AM, Resident 208 stated that she was informed of the “rules for smoking” six months ago. During an observation on 6/26/25 at 10:46 AM, in resident’s room, Resident 208 showed the brown and silver colored (collector’s item) lighters and without being prompted, Resident 208 ignited again the pen shaped lighter which immediately sparked. Further observation and interview on 6/26/25 at 10:48 AM, in Resident 208’s room, Resident 208 stated that she keeps some cigarettes and a disposable lighter in her possession because staff are not available at times to provide their smoking materials. During concurrent observation, Resident 208 took something out from the side of her wheelchair next to her bed and showed an opened cigarette pack. Resident 208 then opened the cigarette pack and showed the contents which included a few cigarettes sticks and a pink disposable lighter that had the last four letters of Resident 208’s name. Review of Resident 208’s admission record indicated, was admitted on [DATE] with diagnoses including nicotine dependence (an addiction to tobacco products caused by the drug nicotine), mild cognitive impairment (a condition in which people have more memory or thinking problems than other people their age), fracture of unspecified part of neck of right femur (refers to a broken bone in the neck of the right thigh bone, where the exact location of the fracture within the neck is not specified), presence of left artificial hip joint (indicates a hip replacement surgery where the damaged or diseased parts of the left hip joint have been replaced with artificial components, typically made of metal, ceramic, and/or plastic), and muscle weakness. Review of Resident 208's Minimum Data Set (MDS, a federally mandated resident assessment tool) assessment, dated 5/26/25, indicated no cognitive impairment. Under the Active Diagnoses section of the MDS assessment indicated, Resident 208’s active diagnoses included nicotine dependence, psychotic disorder (a group of serious mental illnesses characterized by psychosis, a condition where a person has difficulty distinguishing between what is real and what is not), and mild cognitive impairment. Review of Resident 208’s “Smoking and Safety” assessment dated [DATE], indicated, “Resident is not consistent with following smoking times. Spoke with resident again and reiterated rules and regulations of smoking protocol.” Resident 208’s “Smoking and Safety” assessment did not indicate Resident 208 was safe to have smoking materials in her possession. Furthermore, the assessment did not address the “Smoking Care Planning” section. Review of Resident 208’s smoking care plan revised on 12/2/24 indicated, individualized plan for safe use and storage of smoking materials was not addressed. Further review of Resident 208’s clinical record indicated, Resident 208 acknowledged and signed a copy of the facility’s “Smoking Policy” on 3/5/25. Review of the facility’s policy and procedures titled “Oxygen Therapy”, revised 11/2017, indicated, “Oxygen is administered under safe and sanitary conditions to meet resident needs … II. A. No smoking signs will be prominently displayed wherever oxygen is being stored or administered. B. Smoking is not allowed near where the oxygen is being stored or administered …” 2b. During an observation on 6/26/25 at 11:40 AM, in Resident 548 and Resident 2’s room, CNA 4 was attending to Resident 548 who was sitting on the bed receiving oxygen at 2 L/min via a nasal cannula. Resident 548’s roommate (Resident 2) was not in bed. During further observation, Resident 2 had an oxygen concentrator attached to an oxygen tubing next to her bed. During an interview on 6/26/25 at 11:41 AM, CNA 4 stated Resident 2 was out for an appointment and confirmed that Resident 2 uses the oxygen concentrator next to her bed whenever she’s in bed/room. CNA 4 also confirmed Resident 2 was an active smoker in the facility. CNA 4 stated that Resident 2 usually goes out to smoke with supervision and always keeps her smoking materials in her pocket. Review of Resident 548’s Order Review History Report for 6/1/25 to 6/30/25, indicated an order to administer Oxygen at 2L/min via nasal cannula to keep O2 Sat at/above 92% continuous for COPD (Chronic Obstructive Pulmonary Disease, a group of lung diseases that block airflow and make it difficult to breathe) / CHF (Congestive Heart Failure, a chronic condition in which the heart doesn't pump blood as well as it should). Review of Resident 2’s admission record indicated, was admitted on [DATE] with diagnoses including asthma (a chronic respiratory disease that affects the airways in the lungs, causing them to become inflamed and narrowed, making it difficult to breath), heart failure, and seizure disorder (abnormal electrical activity in your brain). Review of Resident 2’s Order Review History Report for 6/1/25 to 6/30/25, indicated an order to administer Oxygen at 2L/min via nasal cannula for mild SOB (shortness of breath) as needed. During concurrent observation and interview on 6/26/25 at 11:43 AM, Resident 81 was lying in bed, alert and oriented. Resident 81 stated he smokes in front of the building and keeps his cigarettes and lighter with him in the room. Resident 81 further stated, “I don’t give it to the nurse. I want it with me. It’s easier.” During an observation on 6/26/25 at 11:44 AM, Resident 138 was sitting in his wheelchair outside his room watching on a computer tablet. Resident 138 agreed for interview and went inside his room. During concurrent observation and interview at 11:45 AM, in the resident’s room, Resident 138’s bedside (top) drawer was unlocked and slightly opened. Resident 138 stated he keeps the lighter and cigarettes in his possession and was saying, “here, there”, while pointing to his pocket and to the unlocked bedside (top) drawer. Resident 138 refused to open and check the bedside drawer. During an interview on 6/26/25 at 11:47 AM, Certified Nursing Assistant (CNA) 3 stated, Resident 138 had a lighter and cigarettes kept in his pocket and bedside drawer. CNA 3 also stated that residents’ smoking materials were stored in the Activities Department. CNA 3 further stated that residents should not keep smoking materials in the room for safety reasons. During an interview on 6/26/25 at 11:48 AM, CNA 5 stated, residents should not keep cigarettes or lighters in their rooms and that she would report to the nurse immediately when she finds them in a resident’s room. During an interview on 6/26/25 at 11:54 AM, Resident 139 stated she smokes and vapes occasionally, and that she keeps her cigarettes and lighter in her fanny pack at all times. Resident 139 also stated, she is aware of the facility’s smoking policy which includes safe storage of smoking materials. Review of the facility’s undated “Smoking Policy” acknowledgement form indicated, “… 8. All residents that smoke will have their smoking materials (lighter, cigarettes, e-cigs [electronic cigarettes], etc.) kept in a safe place at Nursing Stations . 10. No resident is allowed to keep any smoking materials in their room . 14. Residents whether it is traditional tobacco cigarettes, pipes, cigars, or electronic (e-cigarettes) cigarettes are governed by this policy.” 3. During an interview on 07/02/2025 at 1:13 PM, with the Administrator, stated Resident 898 was found approximately 3 to 4 hours after Resident 898 was found missing from the facility on 06/17/2025 at 5:15 PM. Code Purple alarm was activated at the facility when Resident 898 was discovered to be missing, which involved an announcement of Code Purple through the overhead paging system (a system that allows a person to speak into a microphone and have their voice broadcast through speakers located throughout the facility). The facility defines Code Purple to mean a resident left the facility without the expectation for leaving the facility or supervision.During an interview on 07/02/2025 at 1:31 PM with the Director of Staff Development (DSD), Resident 898 had exit seeking behavior in the past.During an interview on 07/02/2025 at 2:18 PM with the Director of Nursing (DON), Resident 898 had a wander guard (a special bracelet worn by residents at risk for wandering and elopement, that alerts facility staff when resident leaves a safe area defined by the facility) in place prior to the elopement. During concurrent observation and interview on 07/02/2025 at 10:09 AM with Resident 898, Resident 898 was unable to remember the elopement. Resident 898 was also unable to correctly state the day of the week or current city. Resident 898 had difficulty stating names of siblings. Resident 898 was wearing both an identification wrist band on the right wrist and a wander guard wrist band on the left wrist. During a review of Progress Note entitled Communication with Physician and dated 06/17/2025 at 18:26 for Resident 898, the situation described was, Resident eloped from the facility. The background described is, Resident has a history of elopement and wandering. A recommendation that was made was, Send resident to [emergency room] ER if or when he returns to the facility to be evaluated.During an interview on 07/03/25 at 10:54 AM with the DON, Resident 898 was admitted to the facility on [DATE] for dementia and worsening mental status. Resident 898 was evaluated for elopement risk on 06/02/2025 and was determined to be at risk for elopement with a score of 6 out of 10. Resident 898 was evaluated again for elopement risk on 06/17/2025 and was determined to be at risk for elopement with a score of 6 out of 10, with no change in the elopement risk score. The higher the elopement risk score the higher the risk for elopement. The DON stated the facility has cameras in the hallway, but the facility was unable to identify Resident 898 on any of the camera recordings on the day of the elopement 06/17/2025. During a record review of Elopement Evaluations dated 06/02/2025 and 06/17/2025 did not reveal a specific total score for each evaluation. Both documents note, Score value of 1 or higher indicates Risk of Elopement. Elopement Evaluation for 06/02/2025 at 21:26 has 6 marked questions as yes answers from a total of 10 questions. Elopement Evaluation for 06/17/2025 at 17:40 has 3 marked questions yes answers from a total of 10 questions. The questions answered yes for the Elopement Evaluation for 06/02/2025 include the following: Does the Resident have a history of elopement or an attempted elopement while at home; Does the resident have a history of elopement or attempted leaving the facility without informing staff; Has the Resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door; Does the Resident wander?; Is the wandering behavior a pattern, goal-directed (i.e. specific destination in mind, going home etc.; and, Is the Resident's wandering behavior likely to affect the safety or well-being of self/others. The questions answered yes for the Elopement Evaluation for 06/17/2025 include the following: Does the resident have a history of elopement or attempted leaving the facility without informing staff; Does the Resident wander?; and, Is the wandering behavior a pattern, goal-directed (i.e. specific destination in mind, going home etc.). During a record review of the Medication Administration Record (MAR) for June 2025 shows 3 separate orders for, Check placement of wander guard . with different stop and start dates. The order to Check placement of wander guard every shift is it in place, Yes or No? with start date of 06/10/2025 to 06/12/2025 is marked as completed for 2 days in June, 06/10/2025 and 06/11/2025. The order to, Check placement of wander guard on left wrist every shift is it in place, Yes or No? with start date of 06/14/2025 and no stop date is marked as completed for Day, Evening, and Night shifts from 06/15/2025 to 06/30/2025, and marked as completed for Evening and Night shift for 06/14/2025. The order to, Check placement of wander guard every shift for wanderer is it in place, Yes or No? with start date 06/02/2025 and end date of 06/10/2025 is marked completed for Day, Evening, and Night shifts for 06/03/2025 to 06/09/2025 and marked completed for Night shift only for 06/02/2025. During an interview on 07/03/25 at 1:38 PM with ADON 2, Resident 898's reason for admission to the facility was because Resident 898's caregiver was in the hospital. Resident 898 was found wandering around the vicinity of the caregiver's hospital and identified by police. Resident 898 was evaluated by Hospital 1 and later transferred to the facility for care, while Resident 898's caregiver was hospitalized and unable to care for Resident 898. During a record review of Discharge Summary from CPMC Mission [NAME] Campus dated 06/02/2025, Resident 898's principal problem is AMS (altered mental status) with active problems including, wandering behavior due to dementia, schizophrenia. During a record review of Physical History and Physical (H&P) dated 06/02/2025, the main reason Resident 898 had been admitted to Hospital 1 for 8 days, from 05/25/25 to 06/02/25, was because of AMS and family is unable to care for Resident 898.During a record review of Progress Note dated 06/17/2025 at 10:56 PM, Resident 898 was returned to the facility by [NAME] Police Department and there was no mention of injuries or where Resident 898 had been found. Pickup of Resident 898 was requested by Royal Ambulance. Resident 898 was picked up from the facility at 10:50 PM and taken to a Hospital 2 for evaluation. During a record review of Care Plan Report with no date, notes one of Resident 898's care plan focuses is an elopement risk/wanderer r/t [related to] Impaired safety awareness, cognitive impairment, history of elopement initiated on 06/03/2025 by ADON 2.During a record review of facility procedure entitled P-AP17 Wandering and Elopement and with revision date 01/31/2023, defines elopement as a behavior that may lead to the resident leaving the facility unsupervised and/or without permission. The procedure notes that if Facility Staff observes a resident leaving the premises unaccompanied or without having followed proper procedures, he/she may: a. Try to prevent the departure in a courteous manner. b. Get help from other Facility Staff in the immediate vicinity, if necessary. c. If the resident exits the facility despite efforts to stop the resident, a staff member will accompany or follow the resident to ensure the resident's safety until assistance arrives. 4. Review of Resident 234's records, titled RESIDENT INFORMATION, printed on 07/01/2025, indicated she had multiple diagnoses including: alcohol abuse (an impaired ability to stop/control alcohol use despite adverse consequences), .alcohol -induced persisting amnestic disorder (severe memory loss associated with chronic alcohol abuse), abnormal walking pattern, anxiety disorder (a mental disorder associated with excessive worry, fear, or nervousness that interferes with daily life), delusional disorder (a mental disorder when one cannot tell what is real from what is imaginary), and history of falls. During an interview on 07/01/2025 at 11:40 AM, CNA 1 stated she has cared for Resident 234 for 2-3 years. CNA 1 stated Resident 234 was very .forgetful, she is always trying to find her husband, constantly asking staff how to get a hold of her husband. She doesn't remember her husband passed away two years ago. CNA 1 stated Resident 234 has a history of trying to get out (elope). To keep her from elopement, CNA 1 stated she tries to distract (Resident 234) to activity (and Resident 234) wears a wanderguard. Wanderguard: a bracelet type device that activates an audible alarm when a resident is approaching an exit. Review of Resident 234's record titled Elopement, dated 07/10/2024, indicated Resident 234 eloped from the facility At .(1:15 PM, nurses were) alerted by staff that .(Resident 234) was seen exiting the facility .staff did a search of the facility and unable to locate her.[NAME] .(police department was) . contacted and a missing persons report filed. The document indicated Resident 234 was found 2 hours and 35 minutes later approximately 1 mile away from the facility. During a concurrent interview and record review on 06/26/2025 at 10:18 AM with LVN 1, review of the facility's daily log communication between shifts on the facility's computer (not titled), indicated Resident 234 Eloped on 06/15 at around 7:30 pm, went out on the street. LVN 1 was asked to search Resident 234's record for any documentation regarding this elopement. LVN 1 was unable to find any documentation in Resident 234's medical records regarding this elopement. During an interview on 07/02/2025 at 10:09 AM, CNA 2 stated Resident 234 was a high elopement risk because she .wanders around the facility she very active . We really need to keep an eye on her. she always says I need to go home. Things like that. We always keep an eye on her. CNA 2 stated on 06/15/2025, she does not . remember the exact time around break time so I was at the break room eating .(when)one of my co-workers called me that she saw .(Resident 234) outside so I ran out of the break room .ran out of the building .and we saw.(Resident 234) across . the road . On 07/01/2025 at 3:20 PM, the Registered Nurse Supervisor (RNS1) and the Director of Nursing (DON) were interviewed regarding Resident 234's elopement on 06/15/2025. The RNS 1 and the DON searched Resident 234's records and confirmed there was no documentation regarding the elopement. The DON stated her expectations were staff would initiate a change of condition charting, notify the responsible party, physician, ombudsman and CDPH (California Department of Public Health). The DON stated she expected staff to conduct an investigation to identify potential weakness in the facility's so the facility could put interventions in place to prevent Resident 234 from elopement. Review of the facility's policy titled Wandering and Elopement, Revised on 01/31/2023, indicate .Elopement - A behavior that may lead to the resident leaving the facility unsupervised and/or without permission. When the resident who eloped returns to the Facility, the Licensed Nurse should: i. Assess the resident for possible injuries, changes of condition and vital signs. ii. Notify the Attending Physician of the return of the resident and the result of the exam; and iii. Notify the resident's responsible party of the return of the resident and the result of the exam. iv. Upon return the Licensed Nurse will implement immediate interventions to prevent further elopement of the resident and update the plan of care. b. The Interdisciplinary Team as part of the investigation will conduct a post elopement meeting to determine if alternate prevention measures can be put in place (activities, rehab, etc.) and if necessary, determine if the resident can safely remain in the facility. c. If the resident cannot be safely kept in the facility the Interdisciplinary team will discuss with the physician and responsible party/surrogate decision maker, the transfer of the resident to a safe environment.

Based on interview and record review, the facility failed to employ a qualified social worker on a full-time basis that met the qualifications specified in the regulation for 267 of 267 residents residing in the facility. This failure had the potential to result in residents not receiving sufficient and appropriate coordination of medically related social services to meet their needs.Review of the facility's license to operate, it was indicated the facility had a bed capacity of 281, with an effective date of 2/1/25 and expiring date of 1/31/26.Review of the facility's census at the start of the survey, it was indicated 267 residents were admitted , with an additional two (2) residents on bedhold status. During an offsite preparation interview on 6/18/25 at 1:59 PM, Ombudsman 1 stated the facility has no full time Social Worker (SW), just temporary, resulting to no or delay discharge planning.During an interview on 6/23/25 at 11:10 AM, Resident 40 stated having difficulty hearing and was waiting for hearing aid. When asked if Resident 40 had spoken with the SW regarding the concern, Resident 40 stated, I haven't talked to one. It has been a long time.During an interview on 6/23/25 at 11:27 AM, Resident 204 complained of hand pain, stated, having carpal tunnel (condition where the nerve in the wrist gets pinched causing pain and tingling), and expressed the need for a brace. Resident 204 added, Certified Nursing Assistant (CNA) and License Nurse were informed about the concern. When asked if Resident 204 had spoken with the SW regarding the concern, Resident 204 stated wanting to speak with the SW and further stated, I have not met the Social Worker.During an interview on 7/3/25 at 1:25 PM, SW 1 stated she was designated as the Assistant Social Services Director of the facility but does not have a bachelor's degree in social work or human services field. Additionally, SW 1 stated she's only been working with the facility for three (3) months.During an interview on 7/3/25 at 1:44 PM, the Regional Discharge Liaison (RDL) confirmed and stated the three (3) Social Workers including SW 1 had no background in bachelor's degree in social work or human services field. The RDL also stated she's a regional consultant and oversees the discharge planning of the facility.Furthermore, the facility was unable to provide pertinent information regarding employing a qualified social worker on a full-time basis. The facility was unable to provide credentials for the three social workers, including SW 1 who was identified as the Assistant Social Services Director.During an interview on 7/3/25 at 4:04 PM with the [NAME] President of Operations (VPO), the Administrator (ADMIN), and the Director of Nursing (DON), the VPO acknowledged and stated, the facility does not have a full time Social Worker.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program when:1. A live cockroach was observed on the floor in the kitchen.2. A pest control company report dated 5/27/25 indicated, confirmed cockroach activity in the downstairs kitchen and documented that service was performed. The company provided recommendations, made some recommendations; however, the facility has not implemented them.3. A pest control company report dated 6/30/25 indicated that service was performed to help control an ongoing cockroach problem. This indicates that, despite previous treatment on 5/27/25 cockroaches were still present in the kitchen.4.An interview with the pest control technician revealed that there was a small to moderate number of German cockroaches found in the kitchen. The technician also advised checking the bait stations (small containers with insecticide used to attract and kill pests) regularly to track and manage the cockroach activity 5. The recommendations of the pest control company were not followed, including proper sanitation of the kitchen and other areas of the facility, and bait stations were not monitored.6. The facility did not implement frequent and thorough monitoring for pest activity in high risk areas (places where pests are more likely to appear such as kitchen, food storage areas and locations with moisture or clutter), as recommended by the pest control company.7. Licensed Vocational Nurse (LVN) 2, interview stated she saw roaches in the activity room on the 2nd floor and reported the incident to the Maintenance Director on 6/10/25.This failure had the potential to create an unsanitary environment for a universe of 281 residents. The presence of pests can contribute to the spread of infection and food borne Illnesses (food poisoning) . Findings:1.During an observation on 6/30/2025 at 9:43AM in the kitchen food preparation area, a live cockroach around one centimeter long, crawling slowly on the floor under the steam table ( a heated serving table).During an interview on 6/30/2025 at 9:43AM with Dietary Manager (DM) 1, DM 1 stated, I've only been at the facility for three weeks, but I've never seen anything like that since I started. During an Interview on 06/30/25 02:28 PM with Registered Dietitian (RD) 1, RD 1 stated, I've never seen cockroaches in the kitchen until today. During an interview on 6/30/2025 at 2:31PM with [NAME] 1, [NAME] 1 stated, I only saw flies in the kitchen but not cockroach.During an observation on 6/30/2025 at 2:42PM, in the garbage area at the back of the facility, there were a lot of flies buzzing around the trash area. It reflects the facility's failure to maintain an effective pest control program. This condition combined with the sighting of a cockroach in the kitchen creates an environment that attracts and supports pest activity.During an interview on 6/30/2025 at 3:30PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, I saw roaches in 2nd floor activity room on 6/10/2025. I reported the sighting verbally to Maintenance, but I haven't heard anything back from him since.2. During the interview on 7/1/2025 at 8:26AM with Environmental Supervisor (ES), ES stated, the pest control service came on 5/27/2025, to conduct an assessment. ES added, I've been trying to get the pest service back here for the past three weeks. I've been calling everyday and even escalated the issue to someone higher up to consider using a different vendor because I wasn't satisfied with the current pest control company's response and services. They keep re-scheduling or canceling whenever I make an appointment. During a review of the Pest Control Services (PCS) document dated 5/27/2025, PCS technician's comments summary noted, Cockroach activity noted in the downstairs kitchen Cockroach activity confirmed in the downstairs kitchen; treatment focused accordingly.Recommendations included:a. Maintain strict sanitation routine, especially in the downstairs kitchen where activity was found.b. Monitor bait stations regularly and report any increases in pest activity.c. Continue scheduled treatments and consider enhanced monitoring in high-risk areas like the kitchen and trash zones.3. During a review of the Pest Control Services (PCS) document dated 6/30/2025, PCS technician's comments summary indicated, Comprehensive pest control services were provided at a Senior Living Facility (Skilled Nursing Facility) to address cockroach, fly and ant activity. Treatment involved targeted applications of insecticide and insect growth regulator (IGR), along with installation of glue monitors (sticky trap) and bait placements for monitoring and control.Recommendations:a. Continue monitoring glue boards (sticky traps used to catch insects like cockroach by trapping them on a sticky surface) and bait placements (pest bait stations are small containers with food mixed with pesticide to attract and kill pests) regularly for pest activity.b. Maintain sanitation in kitchen and affected units to support control.During an interview on 6/30/2025 at 2:28PM with Registered Dietitian (RD) 1 RD 1 stated, Pest control is done monthly, they were actually here today. To my knowledge the Pest Control Company were here last May 2025 to do treatment and to make rounds. They also came last week I'm not sure of the exact date , to check and assess their previous treatment. To be clear they were here for the flies. We didn't notify them about the cockroach because there was no sightings but when they came in this morning, I told them we had seen a cockroach, so they sprayed.4. During an interview on 6/30/25 at 1:50 PM through telephone, with the Pest Control Technician (PCT) 1, PCT 1 stated, there is a low to mild infestation of German roaches in the kitchen. One of our recommendation was to monitor the roach bait stations so that the Pest Control Company could be alerted if there was a change in roach activity. I installed 15 bait stations in the kitchen the last time I went there on 5/27/2025. During an interview on 7/1/2025at 11:52AM with RD 1, RD 1 stated, we don't do the monitoring, I believe the maintenance supposed to check regarding pests but I haven't seen the maintenance checking the bait stations . To my knowledge we have only nine bait stations in the kitchen.5. During an observation on 6/30/2025 at 11:20AM, in the dishwashing area, stagnant water was seen under the drying rack and table. The floor was messy with food residues found underneath and on top of the metal table.During an observation on 6/30/2025 at 2:42PM, in the garbage area at the back of the facility, there were a lot of flies buzzing around the trash area. It reflects the facility's failure to maintain an effective pest control program. This condition combined with the sighting of a cockroach in the kitchen creates an environment that attracts and supports pest activity.During observation on 6/30/2025 at 2:54PM, In the dry storage area, a dried blackish banana peel was found at the bottom of the storage rack with a white plastic lid resting on top of it.During an observation on 6/30/2025 at 3:05PM under the dish drying rack in the kitchen, observed an opened packets of peppers, non-dairy creamer, sugar, bread plastic clip, and a lid for cup.During an observation on 7/1/2025 at 11:13AM, in the dry storage area, pieces of cereal were seen on the floor behind a container beside an air vent located at the bottom of a the wall. During an interview on 7/1/2025 at 11:23 with Dietary Aide (DA) 1, DA 1 stated, At times kitchen staff shows a lack of discipline when placing trays here on the dishwashing table, often leaving the plates with leftover foods instead of disposing of it in the trash bins.During an interview on 7/1/2025 at 11:52AM with RD 1, RD 1 stated, we don't do the monitoring, I believe the maintenance supposed to check regarding pests but I haven't seen the maintenance checking the bait stations . To my knowledge we have only nine bait stations in the kitchen.Record review titled Pest Control Policy dated 1/1/2012, Pest Control Policy indicated The facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests. I. General Practices. The maintenance department assists, when appropriate and necessary, with pest control services. III. Staff Role: A. Facility Staff will report to the Housekeeping Supervisor any sign of rodents or insects, including ants, in the facility. i. The Housekeeping Supervisor takes immediate action to remove the pests from the facility. ii. If necessary, after informing the administrator, the housekeeping Supervisor will call the extermination company for assistance.During an interview on 7/1/2025 at 1:50PM with Environmental Supervisor (ES) 1, ES 1 stated, that the pest control company did not instruct facility staff to inspect or monitor the traps. ES 1 further explained that the previous administrator had left, and the responsibility for overseeing pest control was only recently assigned to me approximately a month ago. 6. During record review Pest Control Services (PCS) document dated 5/27/2025, PCS technician's comments summary indicated cockroach activity noted in the downstairs kitchen. No activity observed in bait stations .Cockroach activity confirmed in the downstairs kitchen; treatment focused accordingly. Recommendations: 1. Maintain strict sanitation routine, especially in the downstairs kitchen where activity was found. 2. Monitor bait stations regularly and report any increases in pest activity. 3. Continue scheduled treatments and consider enhanced monitoring in high-risk areas like the kitchen and trash zones.During an interview on 7/1/2025 at 1:50PM with ES 1, ES 1 stated, that the pest control company did not instruct facility staff to inspect or monitor the traps.7. During an interview on 6/30/2025 at 3:30PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, I saw cockroaches in the second floor activity room on 6/10/2025. I reported the sighting verbally to Maintenance, but I haven't heard anything back from him since.During an observation on 6/30/2025 at 2:56PM , Resident 75 room, there were multiple opened food items ( Hawaiian bread, opened chips on the top of the fridge) and used containers. In addition, several flies were observed in the room and line of ants going into the bedside drawer.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage in the kitchen when:1. Diced peaches sat in a partially opened container in the refrigerator.2. A large cut of beef was inside a sealed clear plastic package with no expiration date in the freezer.3. Chocolate puddings were prepared in not fully dried small wet bowls.4. There were an expired container of liquid smoked sauce and brisk coffee roasters in a small bin found in the dry storage.5. Food distribution to the residents were delivered in a timely manner.These failures had the potential to result in putting residents at risk for foodborne illness (a disease caused by consuming contaminated food or drink).1. During a concurrent observation and interview on 6/30/25 at 2:24 PM with Dietary Manager (DM) 1 in the kitchen, diced peaches sat in a partially opened container in a refrigerator. DM 1 stated, I don't know when asked why the lid of the container was open. DM 1 stated, It should be closed when asked what to do with the lid of the container. During a concurrent observation and interview on 6/30/25 at 2:45 PM with Registered Dietitian (RD) 1, RD 1 stated, Limited contamination issue when asked about the risk of the diced peaches in the partially opened container in the refrigerator while watching the pictures of them. RD 1 stated, The lid should be closed when asked about the lid of the container. During a concurrent interview and record review on 6/30/25 at 4:08 PM with RD 1, the facility's policy and procedure (P&P) titled, Food Storage and Handling revised on 2/29/24 was reviewed. The P&P indicated, . 13. Dry Storage Area . g. Place opened products in storage containers with tight fitting lids . RD 1 stated, they are following this practice for all food storage including refrigerators in the kitchen when asked. RD 1 stated, the lid of the container did not fit well, and that's why the lid was open. RD 1 stated, she would replace the container with the new container. During an Interview on 7/03/25 at 11:08 AM with Infection Preventionist (IP) 1, IP 1 stated, It should be sealed when asked about the risk of the diced peaches in the partially opened container in the refrigerator. IP 1 stated, Potential exposure to outside elements like pest and dust when asked. IP 1 stated, the diced peaches in the partially opened container could create food born illness when asked. 2. During a concurrent observation and interview on 6/30/25 at 2:26 PM with DM 1 in the kitchen, a large cut of beef was inside a sealed clear plastic package with no expiration date in the freezer. DM 1 stated, I don't know when asked when the expiration date of the beef would be. DM 1 stated, We received it today, but he stated There should be some stamp when asked about the expiration date of the beef. During a concurrent observation and interview on 6/30/25 at 2:48 PM with RD 1, RD 1 stated, It needs to be dated. We don't know how long it was there (in the freezer) when asked about the large cut of beef inside the sealed clear plastic package with no expiration date in the freezer while watching the pictures of it. During an Interview on 7/03/25 at 11:09 AM with IP 1, IP 1 stated, Potential for food born illnesses when asked about the risk of the large cut of beef inside the sealed clear plastic package with no expiration date in the freezer. Review of the facility's P&P titled, Food Storage and Handling revised on 2/29/24 indicated, . All items will be correctly labeled and dated . b. Raw meat, poultry, and seafood should be labeled, dated . 3. During observation on 6/23/2025 at 11:45AM found a stack of partially dried small bowls in a stacking tray. During observation on 6/23/2025 at 11:46AM found a tray of wet small bowls containing chocolate pudding prepared for lunch at the tray line tableDuring an interview on 6/23/2025 at 11:51AM with Regional RD, stated we shouldn't be serving food with wet dinnerwares.4. During observation on 6/23/2025 at 9:35AM, in Dry storage found an expired container of liquid smoked sauce, date received 5/17/2024, prep date 1/23/2025. During observation on 6/23/2025 at 9:35AM, in Dry storage, a large quantity of packets of brisk coffee roasters with no expiry date or best before dates in a bin, found at the bottom shelf. 5. During observation on 7/3/25 at 9:20 AM in the kitchen, two metal dish drying racks are at the entrance and one in front of the handwashing sink. Cooks are busy with food preparation. The floor was wet with yellow cones. Observed staff wearing hair nets and face masks. Staff who just entered the kitchen washed their hands at the sink near the entrance before proceeding inside the kitchen. During an interview with the Regional Registered Dietitian (RD 1) consultant who stated: Our kitchen manager is [name]. The menu for the day is: Fish with dill sauce; seasoned fries; herbs; corn and tomato; wheat roll; and the dessert is ice cream. - The tray line starts from 11:30 AM to 11:45 AM. Mealtimes are Breakfast is 7 to 9 AM; Lunch is 12 to 2 PM; and Dinner is 5-7 PM. During a concurrent observation and interview at the tray line, food temperature checks with the RD 1 indicated only the hamburger patty (an alternative menu) was below the temperature heat range of 140°F and above. It was 126°F. The RD 1 called for the Regional Dietary Manager (RDM) who took the metal container of the hamburger patty for reheating. The hamburger patty came back at 12:10 PM with temperature of (surveyor's thermometer) 146.5°F while RD 1's thermometer read 160°F.During observation at the tray line observed [NAME] 1 was serving, assisted by a Kitchen Aide (KA 2). On the tray service line were three kitchen aides: KA 1; KA 3; and KA 4; the RDC in the center line, and RD 1 at the end of the line who checks the plates for accuracy before it was placed in the meal cart. The meal cart carrier is KA 5. During a concurrent observation and interview at the tray line on 7/3/25 around 1:30 PM the kitchen staff on tray line was still plating. The RD 1 was yelling, “we are late!” There are a total of eleven (11) meal carts for the whole facility. The last meal cart left the kitchen at 2:40 PM. RD 1 stated, I'm very sad, we are late today. Yesterday we were early. There were two call-ins today. During a review of the facility's policy and procedures (P&P) titled: Meal Service Times, Operational Manual – Dietary Services, date revised July 01, 2014. Purpose: To provide the dietary department with guidelines for meal service. Policy: Meals are served at a regular scheduled hour…. Procedure: … II. The Dietary Manager works with the Director of Nursing Services and other staff to determine routine mealtimes for daily service. A. Changes in mealtimes will be coordinated between the Dietary Manager and the Director of Nursing Services. III. The Dietary Manager is responsible for monitoring meal service time daily to ensure the facility meets posted mealtimes…. V. Mealtimes are typically at 7:00 am, 12:00 pm, and 5:00 pm.

Based on observation, interview, and record review, the facility failed to prevent abuse to one of one sample resident (Resident 35) when another resident threw a bottle of deodorant at her resulting to an injury. The facility's failure resulted to Resident 35 to sustain a bump (swelling) over the right eye, and bruising (when a part of the body is injured and the blood gets trapped under the skin) to the right orbital areas (skin area around the eye). Findings: A review of the medical record face sheet (a document that provides resident information) indicated Resident 35 was admitted with diagnoses including dementia (decline in memory or other thinking skills) and stroke. A review of the Minimum Data Set (MDS, a standard assessment tool) dated 3/4/24, Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive function [includes thinking, learning, and decision-making ability]) a score of 9 indicated Resident 35 had moderate cognitive impairment (decisions poor, supervision required). A review of the Interdisciplinary Team notes dated 3/7/24, indicated, . [Resident 35 named] .was a victim of her roommate [Resident 122 named]. [Resident 122] threw a bottle of deodorant at [Resident 35] face which resulted in a bump to right upper eyebrow. Bump measures approximately 4 centimeters (cm, a unit of measurement) by (x) 2.5. cm . [Resident 35] told police that she does not want to press charges but wants roommate [Resident 122] out of the room .noted bruising around right eye, purplish in color . During an observation on 3/11/24, at 11:55 AM, Resident 35 was asleep lying in bed with dark purplish, bluish skin discoloration around the right eye. During an interview on 3/12/24, at 2:38 PM, Housekeeping staff 1 as translator stated that Resident 35 verbalized having no recollection of the abuse incident. During an interview on 3/13/24, at 9:01 AM, Restorative Nurse Assistant (RNA, assist residents to help maintain functional abilities (includes walking,transferring in and out of bed and exercising) stated Resident 35 calls out ayuda (help) , ayuda because her legs were hurting and needed repositioning. During an interview on 3/13/24, at 9:04 AM, Certified Nurse Assistant (CNA, caregiver) 5 stated, When [Resident 35 named] calls out ayuda, ayuda, 90 percent it means her leg were hurting and needing help. [Resident 35 named) doesn't use the call light, she has dementia. A review of the medication review report for month of 3/2024, indicated application of ice pack for the right eye and treatment to laceration (a deep cut or tear in skin) on the right eyebrow. A review of the face sheet indicated Resident 122 was admitted with diagnoses including stroke and anoxic brain damage (caused by lack of oxygen in the brain). A review of MDS dated [DATE], BIMS score of 15 indicated Resident 122 was cognitively intact. No memory problem. The MDS also indicated that Resident 122 had trouble falling asleep. During an interview on 3/13/24, at 9:08 AM, Resident 122 stated, [Resident 35 named] was my roommate for almost two weeks. [Resident 35] talking nonstop and makes a lot of noise. [Resident 35] taps the cup on the table. I can't sleep. [Resident 35] calls out CNA, CNA, CNA; coffee, coffee, coffee; ayuda, ayuda, ayuda. [Resident 35] does that day and night. More during the night. I reported this to [Social Services Assistant , SSA 3 named]. I have been talking to (SSA 3 named) about (Resident 35 named) and I asked to be out of that room. [SSA 3] told me I have to wait. A review of the Order Review History Report for the month of 3/2024, indicated, Resident 122 received melatonin (supplement used for difficulty sleeping). A review of the medication administration record for the month of 3/2024, indicated Resident 122 was monitored for hours of sleep. During an interview on 3/14/24, at 2:34 PM, SSA 3 stated, [Resident 35 named] always say ayuda, ayuda. I don't know what that means. [Resident 35] speaks in Spanish. When (Resident 35 named) keep talking, I have to do this (the SSA then by gestured putting her right index finger over her closed lips) to tell (Resident 35) to be quiet. [Resident 122 named] had reported that [Resident 35 named] was making a lot of noise day and night, more at night. I talk to [Resident 122 named] almost every day, and says that (Resident 35 named) is noisy. She (Resident 122) asked to move to another room but it's hard to move residents. On 3/6/24, Resident 122 was moved to another room. A review of the facility investigation dated 3/13/24, indicated, .a nurse heard [Resident 35 named] yelling out for help. When she went to the room, [Resident 35] stated that her roommate had thrown a plastic bottle at her and hit her in the head . During an interview on 3/14/24, at 4:15 PM, Licensed Vocational Nurse (LVN) 11 reviewed care plan for Resident 35 and acknowledged there was no care plan with intervention completed and no monitoring to address constant talking and making noises, and stated, I don't see a care plan for that. LVN 11 also stated that there was no care plan and monitoring to address Resident 122's complaint of the roommate [Resident 35] constant talking and making noises. During an interview of Resident 35's current roommate on 3/19/24, at 9:10 AM, Resident 226 stated, I don't want to get to other peoples business, I have my own troubles and she got hers. I think the one causing trouble should move, not me. Resident 226 gestured with the right fingers thumb snapping and then pointed to roommate Resident 35. During an interview on 3/19/24, at 2:46 PM, the Director of Nursing stated that there was no behavior monitoring because there was no documented behavior for Resident 35. A review of the Policy and Procedure titled, Abuse-Prevention, Screening, & Training Program dated 7/2018, indicated, .The facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment and develops policies and procedures, training programs, and screening and prevention systems to promote an environme free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. The administrator is the abuse prevention coordinator is responsible for the coordination and implementation of the facilities abuse prevention, screening, and training program policies . The facility conducts resident pre-admission, admission, and ongoing assessments (screening) and care planning for appropriate intervention and monitoring of residents with needs and behaviors which might lead to conflict or neglect .The facility conducts mandatory staff training programs during orientation, annually and as needed on: Understand resident behavioral symptoms that may increase the risk of abuse, neglect and how to respond . A review of the facility Policy and Procedure, titled, Behavior/Psychoactive Drug Management dated 11/2018, indicated, .Dementia is a descriptive term for a collection of symptoms that can be caused by a number of disorders that affect the brain. People with dementia have significantly impaired intellectual functioning that interferes with normal activities and relationships. They also lose their ability to solve problems and maintain emotional control, and may experience personality changes and behavior problems such as agitation, delusions, and hallucinations .Upon admission, quarterly, annually, and upon change of condition, the interdisciplinary team will collect and assess information about the resident including but not limited to the past life experiences, description of behaviors, preferences such as those for daily routines, food, music, exercise and others; oral health, presence of pain, medical conditions; cognitive status and related abilities and medications. Collected information about the resident's physical, functional, psychosocial, and environmental conditions will be used as a basis to understand how the resident expresses distress, pain, hunger, discomfort, thirst, anger, and frustration . If the resident manifests a change in his/her mood or behavior symptoms, the licensed Nurse will conduct an assessment of the resident's mood and behavior status utilizing change in condition process . A review of the facility Policy and Procedure titled. Comprehensive Person-Centered Care Planning dated 11/2018, indicated, .It is the policy of the facility to provide person-centered comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being .the comprehensive care will also be reviewed and revised at the following times: onset of new problems, change in condition, in preparation for discharge, to address changes in behavior and care, and other times appropriate or necessary .

Based on observation, interview, and record review, the facility failed to prevent the development of a preventable pressure ulcer ( PU) for one of three sampled residents (Residents 111) when staff did not perform an accurate body check that reflected and identified Resident 111's skin condition. This deficient practice resulted in the development of Stage III PU for Resident 111. Definition/Stages for Pressure Ulcer/Pressure Injury (also called a bed sore, is an injury to skin and underlying tissue resulting from prolonged pressure on the skin. Stage I: Intact skin with a localized area of non-blanchable redness (non-blanchable: redness persists and does not fade or turn white after removal of fingertip pressure). Stage II: Partial-thickness loss of skin with exposed upper skin layer. The wound bed is pink. May also present as an intact or ruptured blister. Fat tissue and deeper tissues (muscle, tendons, bone) are not visible. Stage III: Full-thickness tissue loss. Subcutaneous fat (fat under the skin) may be visible, but bone, tendon (connects muscles to bones) or muscle is not exposed. Slough (dead tissue) may be present but does not conceal the depth of tissue loss. Deep Tissue Injury (DTI): Purple or maroon localized area of discolored intact skin or blood-filled blister (bubble on the skin containing fluid) due to damage of underlying soft tissue from pressure and/or shear (a mechanical force that acts on an area of skin in a direction parallel to the body's surface). Findings: Review of Resident 111's clinical record indicated, resident was readmitted on [DATE] with diagnoses including diabetes (abnormally high sugar level in the blood), congestive heart failure (a serious condition where the heart doesn't pump blood as efficiently as it should) and malnutrition. The facility assessed Resident 111 as moderate risk for developing pressure ulcers. Review of Resident 111's Minimum Data Set (MDS - an assessment tool) dated 2/26/24, indicated, Resident 111 was dependent with bed mobility (resident does none of the effort to complete the activity) and was always incontinent with bladder and bowel functions (unable to control the excretion of urine or the contents of the bowels). Resident 111 had no pressure injuries on readmission. Review of Resident 111's Weekly Skin/Wound Assessment (WSWA) dated 2/4/24 indicated, a right lower arm skin tear with an onset date of 2/3/24. The WSWA did not mention other skin impairments. Review of Resident 111's WSWA dated 2/5/24 indicated, scattered discoloration on anterior (front) and posterior (back) of bilateral (both) lower legs, with an onset date of 2/3/24. The WSWA did not mention other skin impairments. Review of Resident 111's WSWA dated 2/7/24 indicated the following skin impairments: 1. Stage III pressure ulcers on the sacrum (a triangle-shaped bone at the base of the lower back) and on the upper back. Both had an onset date of 11/21/23 and were present on admission. 2. An initial wound assessment of a Stage III PU on the left heel, with a measurement of 0.8 centimeter (cm) x (by) 1.8 cm x 0.1 cm. The wound had an onset date of 2/6/24 and was in-house acquired ([NAME]-facility acquired). Review of Resident 111's WSWA dated 2/14/24 indicated, a bruise on the left lower extremity (the part of the body that includes the hip, thigh, knee, leg, ankle, and foot) with an onset date of 2/14/24. There were no new skin impairments identified. Review of Resident 111's WSWA dated 2/19/24 indicated the following new skin impairments: 1. Discoloration on right lower arm with an onset date of 2/3/24. 2. Stage III PU on the sacrum, with an onset date of 2/7/24 and was [NAME]. No wound measurement was indicated. 3. Stage III PU on the upper back, with an onset date of 2/7/24 and was [NAME]. No wound measurement was indicated. Resident 111's WSWA dated 2/23/24 indicated, pressure injuries to left heel, sacrum and upper back have all healed. There were no new skin impairments identified. Review of 111's WSWA dated 3/1/24 indicated, skin tear to right lower arm has healed. There were no new skin impairments identified. Review of 111's WSWA dated 3/11/24 indicated, .no new skin issues noted . During an interview on 3/19/24 at 10:47 AM, Licensed Vocational Nurse (LVN) 1 said, Resident 111 had Stage III pressure ulcers on the left heel with a wound onset date of 2/6/24 and on the left buttock with a wound onset date of 3/6/24. Both pressure ulcers were in-house acquired. During a concurrent interview and record review on 3/19/24 at 2:44 PM with LVN 2, Resident 111's WSWA dated 3/13/24 was reviewed. The WSWA indicated, Resident 111 had the following new skin impairments: 1. An initial assessment of a Stage III PU on the left buttock measuring 1.0 cm x 0.2 cm x 0.1 cm, with an onset date of 3/6/24 and was [NAME]. 2. Stage III PU on the left heel measuring 0.7 cm x 1.0 cm x 0.1 cm, with an onset date of 2/6/24 and was [NAME]. During the same concurrent interview and record review, Resident 111's Progress Notes (PN) was also reviewed. The PN dated 2/3/24 through 3/13/24 did not indicate licensed nurse was notified of a change in skin condition on the left buttock and left heel. LVN 2 said, the Certified Nurse Assistant (CNA) will report unusual skin conditions like redness, rash, skin tear, and wounds. The licensed nurses will then assess and report to the physician. LVN 2 stated, Stage 3 pressure ulcers could have been prevented if the previous pressure ulcer stages (Stages 1 and 2) were reported, or unusual skin conditions were reported by staff (CNA). I don't see anything reported because the initial assessment was at Stage 3 already. The PN did not indicate the physician was notified of the identified skin impairments. During an interview on 3/19/24 at 3:44 PM, CNA 1 said, skin conditions that should be reported to the nurse are rash, redness, and wounds. CNA 1 stated, Something that looks different or unusual in the skin, the nurse must be made aware. If not reported, it may worsen. During a concurrent wound care observation at Resident 111's bedside and interview on 3/20/24 at 10:10 AM, with the Wound Care Physician (WCP) and LVN 1, LVN 1 explained that he will do wound treatment on Resident 111's left heel and left buttock. WCP said, the left heel was a DTI and the left buttock was a Stage 2 PU. LVN 1 said, the left buttock PU was at Stage III when initially reported. Review of Resident 111's Interdisciplinary Team Progress Notes (IDTPN) dated 1/11/24 through 3/14/24 indicated, no IDTPN on 2/6/24 when the Stage III PU on the left heel was identified. There was no IDTPN on 3/6/24 when the Stage III PU on the left buttock was identified. Review of Resident 111's Care Plan (CP) revised on 7/28/23, indicated the following: .The resident has potential impairment to skin integrity (rashes, skin tear, pressure injury development) . Goal: The resident will have intact skin, free of redness, blisters, or discoloration by/through review date .revised on 2/28/24. Interventions: Follow facility policies/protocols for the prevention/treatment of skin breakdown. Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x width x depth), stage .date initiated: 11/16/21. Review of facility policy titled Skin Integrity Management revised on 10/26/23 with an effective date of 11/14/23 indicated, .Policy: The facility will identify, evaluate, and intervene to prevent and/or heal pressure ulcers and any other skin integrity conditions. Purpose: A plan of care will be developed for residents who are at risk for development of skin integrity conditions, and to provide guidelines for the treatment of skin integrity conditions to facilitate healing. The policy did not indicate the process/procedure for risk assessment, skin inspection (monitoring, reporting), interventions (maintenance of skin integrity, wound care, education, and evaluation of plan of care), and documentation (skin integrity, wound assessment, interventions, and progress towards outcome focused goals). Review of facility policy titled Pressure Injury Prevention revised on 3/30/23 with an effective date of 4/10/23 indicated, .Policy: A plan of care will be developed for residents who have risk factors or are at risk for development of a pressure injury. Purpose: To prevent the development of pressure injury in residents identified at risk. The policy did not indicate the process/procedure for risk assessment, skin inspection (monitoring, reporting), interventions (maintenance of skin integrity, wound care, education, and evaluation of plan of care), and documentation (skin integrity, wound assessment, interventions, and progress towards outcome focused goals).

Based on interviews and record review, facility staff failed to provide pressure injury services for one of four sample residents, Resident 1. For Resident 1, the facility failed to: 1. accurately assess Resident 1's pressure injuries (wounds caused by prolonged pressure to a body part, see definition below). 2. turn/reposition Resident 1 to prevent development and/or worsening of Resident 1's pressure injuries. These failures resulted in worsening of Resident 1's right hip pressure injury, development of a new right elbow pressure injury, and development of a new pressure injury to the right side of Resident 1's back. Definition for pressure injuries Stage I: Intact skin with a localized area of non-blanchable redness (non-blanchable: redness persist and does not fade or turn white after removal of fingertip pressure). Stage II: Partial-thickness loss of skin with exposed upper skin layer. The wound bed is pink. May also present as an intact or ruptured blister. Fat tissue and deeper tissues (muscle, tendons, bone) are not visible. Stage III: Full-thickness loss of skin, in which subcutaneous fat may be visible. Slough (Yellow/white dead tissue) and/or eschar (black dead tissue) may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by location. Stage IV: Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone in the wound. Unstageable pressure injury: Full-thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed because the wound bed is obscured by slough or eschar. Deep Tissue Injury (DTI): Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This injury results from intense and/or prolonged pressure at the bone-muscle connection. The wound may evolve rapidly to reveal the actual extent of tissue injury. Reverse staging: The practice of applying a lower stage classification from the pressure injury staging system to describe a wound's appearance as it heals. This practice is discouraged as a healing pressure injury does not fully replace the damaged underlying tissues such as muscle and fat tissues. cm: centimeter (1 centimeter equals approximately 0.394 inches) Findings: Review of Resident 1's record titled Minimum Data Set assessment (MDS: a standardized resident assessment tool), dated 01/05/2024, indicated she was admitted to the facility on [DATE] with multiple diagnoses including: generalized muscle weakness, high blood pressure, difficulty swallowing food or liquids, and urine retention. His MDS indicated he had memory problems and was severely impaired in daily decision making. His MDS indicated he needed extensive assistance with bed mobility and was totally dependent on staff for dressing, eating, toileting and personal hygiene. Review of Resident 1's record titled Skin Only Evaluation, dated 12/28/22, indicated he was admitted with these pressure injuries: 1. Left hip, Stage II, size = 2.5 cm by 2 cm 2. Right hip, Stage I, size = 8 cm by 5 cm 3. Left heel, stage I, irregular size. 4. Right heel, stage I, irregular size Review of Resident 1's record titled Skin Only Evaluation, dated 01/02/2023, indicated reverse staging of Resident 1's left hip pressure injury from stage II to stage I. Review of the same document indicated Resident 1 developed a new pressure injury: a DTI (Deep Tissue Injury) to his left lateral foot. The same document also indicated that Resident 1 had discoloration to his right hip (size = 9 cm by 7 cm) and discoloration to his right mid back (size = 8 cm by 7cm). During a concurrent interview and record review on 01/19/2024 at 2:15 PM, LVN 1 (Licensed Vocational Nurse) stated he had been working as a LVN for three years. LVN 1 stated staff are not allowed to reverse stage pressure injuries. Record review with LVN 1 indicated he was the nurse who assessed and signed off on 1/2/23 that Resident 1's left hip pressure injury was now a stage I (left hip was previously assessed as a stage II on 12/28/22). LVN 1 offered no explanation regarding why he reverse staged Resident 1's left hip injury from a stage II to a stage I. Review of Resident 1's medical record titled Progress Notes, dated 01/03/2023, indicated he was transferred to a hospital emergency room for evaluation because Resident 1's responsible party was concerned about his increase muscle weakness and his decline in mobility since admission. Review of Resident 1's hospital records titled Careplan Notes, encounter date 01/03/2023, indicated upon admission he had these pressure injuries: 1. Right hip, unstageable pressure injury, size = 6 cm by 7 cm 2. Right back, unstageable pressure injury, size = 7 cm by 8cm 3. Right elbow, unstageable pressure injury, size = 1cm by 1 cm During an interview on 01/19/2024 at 2:15 PM, LVN 1 was shown the assessment discrepancies between his assessments dated 01/02/2023 and the hospital admission skin assessments dated 01/03/2023. Facility assessment 01/02/2023 1. right hip, Discoloration, size = 9 cm by 7 cm 2. right mid back, Discoloration, size =8cm by 7 cm 3. right elbow (no data) Hospital admission assessment, 01/03/2023 1. right hip, unstageable pressure injury, size = 8 cm by 7cm 2. Right back, unstageable pressure injury, size = 7 cm by 8cm 3. Right elbow, unstageable pressure injury, size = 1 cm by 1 cm During an interview on 01/22/2024 at 3:35 PM, Nursing Supervisor (NS) 1 was asked about turning/repositioning dependent residents. NS1 stated Definitely some of these residents are not turned every two hours. NS 1 stated she know these residents were not being turned because I watch the CNA (Certified Nursing Assistant). We don't have regular staff. Most of them are agency. So, it's very hard to supervise them. NS1 stated the facility does not have a turning/reposition system in place nor does the facility have a way for supervisors to audit to verify if dependent residents were turned/repositioned according to their needs. During an interview with the Administrator and the Director of Nursing (DON) on 01/23/2024 at 1:50 PM, the DON stated the facility does not document repositioning/turning of residents. The DON stated her expectation of staff was for staff to follow standard practice and she stated standard practice was to turn/reposition dependent residents every two hours. On 02/15/2024, the facility was asked to provide a list of Certified Nursing Assistants (CNA)who cared for Resident 1. The following interviews were with the CNAs who cared for Resident 1. During an interview on 02/16/2024 at 9:23 AM, CNA 1 was asked about her workload from December 2022 to January 2024. CNA 1 stated they were Short staff all the time that's why a lot of people left.There were a lot of .(residents) to take care of. The .(resident) ratio to staff was just ridiculous. You would have people on the schedule and people won't show up. 80% of the time you come in and they were short. They would tell you you got this whole hallway of 25 .(residents). A list of showers and take care of .(residents) and feed .(residents). It was hard to do all they want you to do. With the workload, it was hard to reposition dependent .(residents) on top of that you would have to find help to reposition some of these .(residents). During an interview on 02/16/2024 at 9:49 AM, CNA 2 was asked about her workload from December 2022 to January 2024. CNA 2 stated Staffing is always bad. 80% 95% of the time the staffing is bad. Sometimes we have 14 .(residents) to take care of in the morning.We can't give the right care. CNA 2 was asked to specify what she meant by the right care and CNA 2 stated ADL. CNA 2 was asked if this included turning and repositioning dependent residents and CNA 1 stated Yes sir. During an interview on 02/19/2024 at 8:25 AM, CNA 3 was asked if the unit was short staff from December 2022 to January 2023. CNA stated Yes. we only have 4 CNA on day shift. That's about 15-16 .(residents) per CNA in the morning. We should only have 7-8 (residents) in the morning. CNA 3 was asked if she was able to reposition dependent residents during her shift. CNA 3 stated We cannot, not with the workload we have. The facility was asked to provide facility policies regarding: 1. Turning and repositioning of dependent resident. Specifically, if there was a system in place for turning/repositioning, regarding how these activities are documented, and how direct care givers are supervised/audited to ensure compliance. 2. Staging of pressure injuries. Specifically, differentiating between stage I versus discoloration versus deep tissue injury, differentiating between stage I and stage II. The facility answered via email on 02/16/2024 that they do not have item 1 (turning and repositioning of dependent residents). Review of item 2 sent by the facility failed to address how staff were expected to differentiate between pressure injuries and other skin issues. Item 2 sent by the facility consisted of : 1. A policy titled SK04 Skin Integrity Management, revised on 10/26/2023 2. A policy titled SK01 Pressure Injury Prevention, revised on 03/30/2023. 3. A policy titled Skin and Wound Management, revised on 01/01/2012

Based on observation, interview, and record review, the facility failed to provide process oversight and ensure effective implementation of its abuse policies and procedures to protect three of three sampled residents (Resident 2, Resident 3, and Resident 8) when: 1. Facility did not ensure three allegations of sexual abuse (non-consensual sexual contact of any type with a resident) were reported to the State Survey Agency (SSA) within the required timeframe of two (2) hours for Resident 2 and Resident 3. Additionally, Certified Nursing Assistant (CNA) 2 and Licensed Vocational Nurse (LVN) 1 who witnessed and reported the sexual abuse allegations to the nurse-in-charge were placed on suspension. 2. Facility did not conduct a thorough investigation of the three allegations of sexual abuse for Resident 3 in July 2023 and two incidents for Resident 2 in August 2023. In addition, the facility did not report the results of the investigation for all three allegations of sexual abuse to the SSA within five (5) working days. 3. Facility did not identify triggers of Resident 1 to manifest the sexually abusive behavior which resulted to another incident of inappropriate touching of Resident 8's right breast on 10/12/23. The cumulative effects of these failures resulted in delayed identification of Resident 1's sexually inappropriate behavior towards Resident 2 and Resident 3; did not prevent further sexual abuse towards Resident 2 and Resident 8; and staff including CNA 2 and LVN 1, being afraid to report witnessed abuse incidents. Additionally, these failures placed other vulnerable residents in the facility to experience sexual abuse and the potential to compromise resident's safety from unreported and uninvestigated allegations of abuse. On 10/17/23 at 4:44 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) situation was identified in the presence of the Administrator, Administrator in Training (AIT), Director of Nursing (DON), Assistant Director of Nursing (ADON) 2, and Senior [NAME] President of Operations (SVPO) for facility's failure to provide process oversight and ensure effective implementation of the facility's abuse policies and procedures during the provision of care and services for Resident 2, Resident 3, and Resident 8. Five (5) IJ Removal Plan were not accepted. On 10/20/23 at 11:20 AM, the IJ was removed in the presence of the Administrator after the surveyors verified onsite through observation, interview, and record review the implementation of the facility's submitted and accepted IJ Removal Plan #6 (action to correct the deficient practices). The IJ Removal Plan #6 included the following information: 1. CNA 2 and LVN 1 were both placed on suspension on 9/1/23 for 10 days and were given in-service on 9/1/23 regarding their duty as mandated reporter. 2. In-services were started by the Director of Staff Development (DSD) on 10/18/23 for all staff on abuse prevention and reporting. Any staff who did not receive training by 10/19/23 were not allowed back on the floor until they have received training and completed a Post Test and an Acknowledgement of Abuse and Neglect Training. In-services by the DSD will continue until all staff have been retrained. 3. The DSD/Designee started a weekly audit of all employees' file to ensure they received training on prohibiting and preventing abuse, identifying what constitutes abuse, recognizing signs of abuse, reporting abuse, and understanding resident behavioral symptoms that may increase the risk of abuse and neglect and how to respond. 4. SSAs and Administrator in Training (AIT) conducted interviews on 10/17/23 of all alert female residents to see if they feel safe and if they had been touched inappropriately. All residents stated they felt safe and no inappropriate touching had taken place. 5. Director of Nursing (DON)/Designee reviewed all change of condition and behavior monitoring on 10/18/23 for all nonverbal residents from July of 2023 to present to see if there were any indications of abuse. There was no nonverbal resident identified from those with change of condition and behavior monitoring. 6. The IDT reviewed Resident 1's chart on 10/17/23 to determine root cause of behaviors, possible triggers and interventions that can be used to ensure safety of all residents in the facility. Resident 1's care plan was updated on 10/17/23 to reflect these findings. Cross referenced to F600, F609, and F610. Findings: Review of Resident 1's admission record indicated, was admitted to facility on 8/30/22 with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), dementia (a group of symptoms affecting memory, thinking and social abilities), history of alcohol abuse, mild cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions), and cognitive communication deficit (difficulty thinking and communicating). Review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/1/23, indicated, Resident 1's cognition (thought process) was moderately impaired. The MDS indicated, Resident 1 did not exhibit any mood symptoms and physical behavioral symptoms directed towards others such as scratching, grabbing, and abusing others sexually. Further review of the MDS indicated, Resident 1 required supervision with set up help to one-person physical assist for bed mobility, transfer, walking, locomotion (ability to move from one place to another), eating, and toilet use. The MDS also indicated Resident 1 required extensive assistance with one-person physical assist for dressing and personal hygiene. Review of Resident 2's admission record indicated, was admitted to facility on 5/11/23 with diagnoses including encephalopathy (damage or disease that affects the brain), cognitive communication deficit, and catatonic disorder (a behavioral syndrome marked by an inability to moved normally). Review of Resident 2's MDS dated [DATE], indicated, Resident 2 has memory problem and moderately impaired decision-making skills under the staff assessment for mental status. The MDS indicated, Resident 2 had episodes of feeling or appearing down, depressed, or hopeless for 2 to 6 days under the staff assessment of resident mood. The MDS did not indicate any behavioral symptoms for Resident 2. Further review of the MDS indicated, Resident 2 required supervision with one-physical assist for transfer, walk in room, locomotion, and eating; limited assistance with one-physical assist for bed mobility and walk in corridor; extensive assistance with one-physical assist for dressing, toilet use, and personal hygiene. Review of resident 3's admission record indicated, was admitted to facility on 12/21/22 with diagnoses including hemiplegia (complete paralysis of side of the body), hemiparesis (partial weakness or paralysis of on one side of the body), dementia, and cognitive communication deficit. Review of Resident 3's MDS dated [DATE], indicated, Resident 3's cognition was severely impairment. The MDS indicated, Resident 3 did not exhibit any mood and behavioral symptoms. Further review of the MDS indicated, Resident 3 required extensive assistance with one-person physical assist for bed mobility and total dependence with one-person physical assist for transfer, walking, locomotion, eating, toilet use, and personal hygiene. Review of Resident 8's admission record indicated, was admitted to facility on 3/17/21 with diagnoses including heart disease, stroke, functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Review of Resident 8's MDS dated [DATE] indicated, Resident 8 has a BIMS (Brief Interview of Mental Status, a brief screener that aids in detecting cognitive impairment) score of 15, a score of 15 means no cognitive impairment. The MDS also indicated, Resident 8 was non-ambulatory and required extensive assistance with two-person assist for bed mobility, transfer, and locomotion on and off the unit; and one-person assist for dressing, eating, toilet use, and personal hygiene. 1a. Review of facility's untitled letter document dated 9/7/23, indicated, .On 8/31/2023, our resident [Resident 1] was observed in his room with a female resident who was touching his penis. The nurse separated the two residents. During the course of the investigation, it was found that [Resident 1] was involved in previous incident in July, in which he was seen touching a different resident on the breast . Review of California Department of Public Health (CDPH) document titled, Complaint/Incident Intake Report, known as HS 802 indicated, the incident of Resident 1 touching Resident 3's breast was received on 9/1/23 at 5:20 PM by fax. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 8/31/23, indicated, date and time of the incident Resident 1 touching Resident 3's breast was sometime in July. This alleged incident was reported to the police by phone on 8/31/23, no time indicated; and to CDPH and Ombudsman by fax on 8/31/23, no time indicated. Review of facility document titled, Transmission Result Report, indicated, the facility faxed to CDPH on 8/31/23 at 8:03 PM. 1b. Review of CDPH's document titled, Complaint/Incident Intake Report, known as HS 802 indicated, the incident of Resident 2 touching Resident 1's penis was received on 9/1/23 at 10:39 AM by fax. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 8/31/23, indicated, date and time of the incident of Resident 2 touching Resident 1's penis was 8/31/23 at 2:10 PM. The incident was reported to the police by phone on 8/31/23 at 4:30 PM; the facility reported to CDPH and Ombudsman by fax on 8/31/23, no time indicated. Review of facility document titled, Transmission Result Report, indicated, the facility faxed to CDPH on 8/31/23 at 6:10 PM and to Ombudsman on 8/31/23 at 6:11 PM (4 hours after the incident). 1c. During an interview on 9/14/23, at 3:30 PM, CNA 2 stated, she witnessed the first incident involving Resident 1 and Resident 3 in July 2023 on the second-floor dining room. CNA 2 recalled the incident and stated, [Resident 1] was wheeling himself towards the dining area. I saw [Resident 1] rubbing left breast of [Resident 3] in circular motion. CNA 2 also stated, she reported the incident immediately to Licensed Vocation Nurse (LVN) 1 and took Resident 1 back to his room. During further interview, CNA 2 stated, she was suspended during the investigation of the incident on 8/31/23 (Resident 1 and Resident 2) because she did not report the July 2023 (breast) incident directly to the Administrator. CNA 2 added that she reported the incident immediately to the charge nurse. During an interview on 9/14/23 at 3:34 PM, CNA 2 stated, a month later, she witnessed and reported two incidents that involved Resident 1 and Resident 2. CNA 2 stated, on the same month (August 2023), prior to the reported incident on 8/31/23, [Resident 1] attempted to touch [Resident 2] vagina by the social worker's office. CNA 2 added, she reported the incident to the evening nurse and was told to monitor Resident 1 since it was only an attempt. CNA 2 further stated, she did not document the incident and cannot remember the exact date it happened. During an interview on 9/14/23 at 3:40 PM, CNA 2 stated, she was suspended during the investigation of the incident on 8/31/23 (Resident 1 and Resident 2) because she did not report the July 2023 (breast) incident directly to the Administrator. CNA 2 added that she reported the incident immediately to the charge nurse. CNA 2 then stated, It doesn't make sense to suspend me. Now I'm afraid to report. I might get suspended again. Review of Resident 1 and Resident 2's progress notes for August 2023 indicated, there was no documentation regarding Resident 1's attempt to touch Resident 2's vagina. During an interview on 9/14/23 at 3:46 PM, LVN 1 confirmed and stated, CNA 2 reported to her regarding Resident 1 touching Resident 3's breast but cannot remember the exact date of the incident. LVN 1 stated, I reported it (referring to touching Resident 3's breast) to Resident Care Coordinator (RCC). I don't know what happened after. No investigation after. LVN 1 explained that the witness should report to RCC and Administrator (ADM) and that she doesn't do anything after reporting an allegation of abuse. LVN 1 added, the RCC will then report to the Administrator and complete the documentation and investigation. During further interview on 9/14/23 at 3:48 PM, LVN 1 stated, Everybody are mandated reporters. LVN 1 also stated, I don't report (to the State Agency/Ombudsman). Only (report) to RCC. During an interview on 9/14/23 at 4:23 PM, RCC stated, she received two reports that involved Resident 1. RCC stated, the incident of Resident 1 touching Resident 3's breast was not reported to the Administrator/Abuse Coordinator. RCC stated, the way she understood the report was that Resident 1 tap or grab Resident 3's shoulder, therefore concluded that it was not abuse. Thus, no report and no further investigation was conducted. During further interview on 9/14/23 at 4:28 PM, RCC stated, any alleged incidents should be reported directly to the Administrator and/or designee and reporting should be whoever witness the incident. RCC further stated, a change of condition and staff interview should be conducted after a report of alleged abuse was made. During an interview on 9/14/23 at 4:52 PM, Social Worker (SW) 1 stated, she learned about the incident of Resident 1 touching Resident 3's breast during her interview with CNA 2 regarding the incident between Resident 1 and Resident 2 on 8/31/23. SW 1 further stated, the CNA, LVN, or RCC were expected to report the alleged incident of Resident 1 touching Resident 2's breast immediately or within two hours from the time they knew about the incident. During an interview on 9/14/23 at 4:59 PM, Assistant Director of Nursing (ADON) stated, the Abuse Coordinator was not notified of the touching of the breast. ADON stated, Abuse Coordinator should have been notified immediately which did not happen. During further interview on 9/14/23 at 5:03 PM, SW 1 stated that the alleged incident of Resident 1 touching Resident 3' breast was not investigated after learning about the incident. SW 1 stated, At that time the DON and Administrator said it will be taken care of but did not happen (referring to reporting and investigation of the incident). During an interview on 9/14/23 at 5:19 PM, RCC stated, she did not get a report regarding Resident 1 attempted to touch Resident 2's vagina in August 2023. During a joint interview on 9/14/23 at 5:27 PM, ADM and RQMC stated, the two staff (CNA 2 and LVN 1) were suspended for not reporting immediately to the Administrator. Review of CNA 2's employee file indicated, Corrective Action Memo dated 9/12/23 was given to and signed by CNA 2 on 9/12/23 indicating, .Employer Statement: Staff did not follow policy in properly reporting an alleged sexual abuse case to the abuse coordinator. On 8/31/23, [CNA 2] notified us about the alleged abuse case that happened in July, but the abuse coordinator was not informed . Employee Statement (Optional): I did notify the nurse in-charge and it was [LVN 1] and the nurse reported to the supervisor [RCC] and did mention to [LVN 3]. Review of LVN 1's employee file indicated, Corrective Action Memo dated 9/12/23 was given to and signed by LVN 1 on 9/12/23 indicating, .Employer Statement: [LVN 2] did not follow policy in properly reporting an alleged sexual abuse case to the abuse coordinator on time . Under the Employee Statement (Optional) indicated LVN 1 did not write her statement. Review of CNA 2 and LVN 1's timesheet dated 9/1/23 to 9/15/23 indicated, CNA 2 and LVN 1 were taken off the schedule from 9/1/23 through 9/8/23. During a follow up telephone interview on 9/26/23 at 11:58 AM, CNA 2 stated, she reported the incident of Resident 1 attempted to touch Resident 2's vagina to the evening shift nurse (LVN 3) since the incident happened before dinner. CNA 2 added, [LVN 3] told me to monitor [Resident 1] since it was only an attempt. During a telephone interview on 9/27/23 at 10:35 AM, LVN 3 confirmed and stated, CNA 2 reported Resident 1 attempted to touch Resident 2's vagina during the evening shift and the two residents were separated immediately and monitored. LVN 3 also stated, I didn't document (referring to the incident). It was an attempt. I can't remember if I reported it. During an interview on 9/27/23 at 10:38 AM, DON stated, she was not aware of the attempt of Resident 1 touching Resident 2 that was reported by CNA 2 to LVN 3. DON added, If there's a report attempting to touch, it needs to be reported immediately. We need to do something right away. During an interview on 9/27/23 at 1:08 PM, ADM stated, any allegations of abuse need to be reported by phone right away and faxed SOC 341 to SSA within two hours of the incident. 2. Review of Resident 3's clinical record indicated, there was no progress notes in July 2023 regarding the incident of Resident 1 touching Resident 3's breast. Further review indicated, there was no documented evidence a plan of care was initiated to address the incident. Review of Resident 1's clinical record indicated, there was no progress notes in July 2023 regarding the incident of Resident 1 touching Resident 3's breast. Further review indicated, there was no documented evidence a plan of care was initiated to address Resident 1's sexually inappropriate behavior. Review of Resident 1 and Resident 2's progress notes for August 2023 indicated, there was no documentation regarding Resident 1's attempt to touch Resident 2's vagina. During an interview on 9/14/23 at 3:46 PM, LVN 1 stated, I reported it (referring to touching Resident 3's breast) to Resident Care Coordinator (RCC). I don't know what happened after. No investigation after. LVN 1 explained that the witness should report to RCC and Administrator (ADM) and that she doesn't do anything after reporting an allegation of abuse. LVN 1 added, the RCC will then report to the Administrator and complete the documentation and investigation. During concurrent interview and record review on 9/14/23 at 3:53 PM, LVN 1 was unable to find documentation of the incident in Resident 1 and Resident 3's clinical record. LVN 1 stated, I don't see it here. During an interview on 9/14/23 at 4:23 PM, RCC stated, she received two reports that involved Resident 1. RCC stated, the incident of Resident 1 touching Resident 3's breast was not reported to the Administrator/Abuse Coordinator. RCC stated, the way she understood the report was that Resident 1 tap or grab Resident 3's shoulder, therefore concluded that it was not abuse. Thus, no report and no further investigation was conducted. During further interview on 9/14/23 at 4:28 PM, RCC stated, a change of condition and staff interview should be conducted after a report of alleged abuse was made. During an interview on 9/14/23 at 4:52 PM, SW 1 stated that the alleged incident of Resident 1 touching Resident 3' breast was not investigated after learning about the incident. During a concurrent interview and record review on 9/27/23 at 10:44 AM, DON stated there was no investigation and IDT conducted regarding the two incidents of Resident 1 touching Resident 3's breast and the attempt to touch Resident 2's vagina. Review of facility's untitled letter document dated 9/7/23, indicated, This letter is to inform you of the results of our investigation regarding a resident-to-resident sexual interaction that was reported to you on 8/31/2023. Since the date of that report, there has been a change in two key positions which resulted in this letter not being completed within the five-day time frame . During an interview on 9/27/23 at 1:08 PM, ADM stated, any allegations of abuse need to be reported by phone right away and faxed SOC 341 to SSA within two hours of the incident. ADM also stated, a 5-day follow-up or written result of the investigation should be faxed to the State Agency within five days from the incident or up to seven days including weekends, which did not happen. 3. Review of Resident 1's Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together toward the goals of the residents) Note dated 9/7/23, indicated, Staff reported this resident (Resident 1) was with a female resident (Resident 2) in his room, touching his penis on 8/31/23 . Upon investigation of this incident on 8/31/23, we found that this same resident (Resident 1) was involved with another incident of touching the breast area of a female resident (Resident 3) in the dining hall in the month of July . The IDT Note indicated, Administrator, Abuse Coordinator, DON (Director of Nursing), MD (Medical Doctor), RP (responsible party), police, CDPH and Ombudsman were notified of the incident. Further review of the IDT Note indicated, the alleged perpetrator (Resident 1) was placed on 15-minute monitoring for signs and symptoms of adverse effects from the alleged incident, was transferred to another floor and room, referred for psych evaluation, and olanzapine (medication used to treat mental disorders) was increased to 10 mg (milligrams, a unit of measurement). The IDT Note did not indicate the incident of Resident 1 touching Resident 3's breast was further discussed and investigated. Review of Resident 1's Psych assessment dated [DATE], indicated, Resident 1 was referred for psych evaluation due to the following targeted symptoms: sexually pre-occupied, impulsivity, and poverty of thought. The Psych Assessment indicated a diagnostic impression of schizophrenia with interventions including supportive psychotherapy (a type of therapy that primarily focuses on providing emotional support, encouragement, and validation during difficult life circumstances or psychological challenges), discontinue olanzapine 7.5 mg, start with olanzapine 10 mg 1 tablet per orem (po, per mouth) at hours of sleep (hs), and refer accordingly. Review of Resident 1's care plan for The resident was involved in alleged sexual abuse, initiated on 9/3/23, three days after the incident, indicated, the alleged abuser was sitting on the wheelchair, pants were down while the alleged victim is touching the alleged abuser's penis. The care plan indicated Resident 1 will have no evidence of behavior problems or will not display the same behavior until the next review. The care plan indicated the following interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a clam manner. Divert attention. Remove form situations. Document behavior and potential causes. Observed the behavior and report any abnormal findings. Separate/transfer the room of the abuser to [room number/unit]. SOC-341 was completed and filed. Further review of Resident 1's care plan indicated, there was no documented evidence a care plan was initiated to address Resident 1 touching Resident 3's breast and attempt to touch Resident 2's vagina. During an interview on 9/14/23 at 5:20 PM, ADON 1 stated, a plan of care was put in place after the reported incident on 8/31/23 between Resident 1 and Resident 2 and no other plan of care initiated after the incident in July 2023 between Resident 1 and Resident 3. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 10/12/23, indicated, date and time of the incident was on 10/12/23 at 4:55 PM, Staff heard Resident in room [number] who was in the hallway by her room in her wheelchair crying loudly. Staff asked resident what was wrong she stated a 'male resident down the hall was passing her and touched her on her right breast.' Resident stated that she wasn't in any pain from the incident. Male resident relocated to a different room and hallway. Continue current interventions in place. During an observation on 10/16/23 at 3:04 PM, in Unit 1 hallway, Resident 1's room was located next to the Administrator's office and one room/door away from Resident 8's room, which was located on the same side of the hallway. Resident 8 was inside her room, sitting on a wheelchair next to her bed watching television (TV). Resident 8 was alert, verbally responsive, oriented to time, place, and person. During an interview on 10/12/23 at 3:05 PM, Resident 8 recalled the incident with Resident 1 on 10/12/23 and stated, I was sitting on the chair outside the room and then there's this man [Resident 1's Name was mentioned], wheeling. I thought he's just gonna (going to) wave at me. He squeezed my right breast. I was screaming out loud, crying. I screamed for help, 'maniac'. Resident 8 also stated, the social worker and supervisor came to asked what happened. Resident 8 then asked if Resident 1 can be in jail or moved somewhere. Resident 8 further stated, I was shocked. I was already crying. They (referring to supervisor and social worker) didn't ask me how I feel. During an interview on 10/16/23 at 3:59 PM, RN 1 stated, [Resident 1] likes waving both hands like reaching out to you. Has a habit of reaching out. RN 1 further stated, Resident 1's habit of waving both hands and reaching out were not part of the behavior monitoring. During an interview on 10/16/23 at 4:47 PM, ADM stated that after the incident, new interventions were implemented for Resident 1 including room transfer close to the nurse's station, reminded staff not to leave resident alone, and to continue one-to-one sitter in the morning and evening shift, and Q 15 minutes check at night shift. During concurrent interview and record review on 10/16/23 at 5:06 PM, AIT reviewed and provided copies of Resident 1's Every 15 minutes Resident Monitoring for October 2023 and was unable to find documented evidence of Q 15 minutes monitoring on 10/12/23. Further review of the provided copies of Resident 1's Every 15 minutes Resident Monitoring for October 2023 indicated, monitoring sheets were missing on 10/1/23, 10/3/23, 10/6/23, 10/7/23, 10/8/23, 10/10/23, 10/11/23, 10/12/23, and 10/16/23. AIT stated, That's all of October's monitoring sheet. Review of Resident 1's care plan for A female resident claimed [Resident 1] allegedly touched her on the breast., initiated on 10/12/23, indicated, The resident will not exhibit any sexually inappropriate behavior problems until next review. The care plan indicated the following interventions: Continue with line sight supervision during the day and frequent checks while in room at night. Transfer to a different room . Monitor the resident for nay sexually inappropriate behavior and immediately intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Immediately remove from situation and take to alternate location as needed. Review of the facility's policy and procedure titled, Abuse - Prevention, Screening, & Training Program, revised July 2018, indicated, .Policy - The Facility does not condone any form of resident abuse .The Administrator as abuse prevention coordinator is responsible for the coordination and implementation of the Facility's abuse prevention, screening, and training program policies . Procedure 'Sexual abuse' is defines as non-consensual contact of any type, sexual harassment, sexual coercion, or sexual assault . III. Screening residents - A. The Facility conducts resident pre-admission, admission, and ongoing assessments (screening) and care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect. IV. Training - A. The facility conducts mandatory staff training programs during orientation, annually and as needed on: i. Prohibiting and preventing abuse . ii. Identifying what constitutes abuse . iii. Recognizing signs of abuse . iv. Reporting abuse . v. Understanding resident behavioral symptoms that may increase the risk of abuse and neglect and how to respond . V. Prevention . I. As appropriate, the Facility involves qualified psychiatrists, psychologists and other mental health professionals to help staff manage challenging or aggressive residents. J. The Facility establishes a safe environment that reasonably supports resident to the extent possible including, but not limited to, consensual sexual activity. K. The Facility identifies, corrects, and intervenes in situations in which abuse .is more likely to occur . M. The Facility conducts resident pre-admission, admission and ongoing assessments (screening) and care planning for appropriate interventions and monitoring of residents with needs and behaviors that might lead to conflict or neglect . Review of the facility's policy and procedure titled, Abuse Reporting and Investigations, revised 7/31/23 with effective date of 8/18/23, indicated, .The Facility promptly reports and thorough investigates allegations of resident abuse, mistreatment, neglect, exploitation, abuse facilitated or enabled by the use of technology, misappropriation of resident property, or injuries of unknown source, and suspicions of crimes . 1. Administrator as Abuse Prevention Coordinator . a. Allegations of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime to be reported to the Administrator or designated representative immediately. b. When the Administrator or designated representative receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, abuse facilitated or enabled technology, exploitation, or injuries of unknow source, or suspicion of a crime, the Administrator or designated representative will initiate an investigation immediately . ii. The facility will not inhibit facility staff/covered individuals from their mandated reporting obligations. iii. Facility staff/covered individuals will not be disciplined or retaliated against for good-faith reporting . 2. Immediate Action . b. The administrator or designated representative conducting the investigation will interview individuals who may have information relevant to the allegation or suspected crime . 3. Notification of Outside Agencies of Allegations of Abuse . b. Administrator or designed representative will notify the LTC (Long Term Care) Ombudsman, and CDPH (California Department of Public Health) by telephone and in writing (SOC 341) within two (2) hours of an initial report. 4. Notification of Outside Agencies of Allegations of Abuse Caused by a Resident with Dementia diagnosed by a Physician . i. The Administrator or designated representative will notify within two (2) hours, notify by telephone, CDPH, the Ombudsman and Law Enforcement. ii. The Administrator or designated representative will send a written SOC 341 report to the Ombudsman and Law Enforcement and CDPH Licensing and Certification within 2 hours. 5. Notification of Outside Agencies of Allegation of Abuse With No Serious Bodily Injury - a. The Administrator or designated representative will notify within two (2) hours notify, by telephone, CDPH, the Ombudsman and Law Enforcement. b. The Administrator or designated representative will send a written SOC 341 report to the Ombudsman and Law Enforcement and CDPH Licensing and Certification within two (2) hours . 10. Investigator Consultation with Administrator - a. The individual who is conducting the investigation will consult daily with the Adm [TRUNCATED]

Based on observation, interview, and record review, the facility failed to protect three of 3 sampled residents (Resident 2 and Resident 3, and Resident 8) from sexual abuse (non-consensual sexual contact of any type with a resident) by Resident 1 when: 1. Facility did not identify, report, and initiate an investigation of Resident 1 touching Resident 3's breast in the dining room in July 2023. Additionally, the facility did not develop and implement interventions to address Resident 1's behavior of touching female resident's sensitive area. This resulted in delayed identification and implementation of interventions to address Resident 1's sexually inappropriate behavior towards a female resident. 2. Facility did not report, investigate, develop, and implement interventions when Certified Nursing Assistant (CNA) 2 witnessed Resident 1 attempted to touch the private part of Resident 2 in August 2023. These failures resulted in continued access to Resident 2 and further sexual contact instigated by Resident 1 on 8/31/23. 3. Facility did not conduct a thorough investigation and implement interventions on an incident on 8/31/23 at 2:10 PM where CNA 2 observed Resident 2 standing in front of Resident 1, holding (in a sexual way) his penis while seated on a wheelchair in his room, with disposable brief and pants down. Resident 2 has communication deficit, cognitive (thought process) impairment, and lacked capacity to consent to sexual activity. These failures resulted in Resident 2 being subjected to a nonconsensual (not agreed to by one or more of the people involved) sexual contact instigated by Resident 1 and the potential to affect other vulnerable residents in the facility to experience sexual abuse. 4. Facility failed to protect Resident 8 from sexual abuse when one-to-one supervision was not provided to Resident 1, who briefly touched the right breast of Resident 8 on 10/12/23, at 4:55 PM. There was no documented evidence the facility implemented every 15 minutes monitoring for Resident 1. Additionally, the facility did not thoroughly assess and revise the care plan for Resident 1 to identify the potential risk to other female residents in the facility. These failures resulted to Resident 8 crying, feeling shocked, and upset; and placed other vulnerable residents in the facility at risk for sexual abuse by Resident 1. On 10/17/23 at 4:44 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) situation was identified in the presence of the Administrator, Administrator in Training (AIT), Director of Nursing (DON), Assistant Director of Nursing (ADON) 2, and Senior [NAME] President of Operations (SVPO) for facility's failure to protect Resident 8 and other female residents in the facility from Resident 1's sexually inappropriate behavior. Five (5) IJ Removal Plan were not accepted. On 10/20/23 at 11:20 AM, the IJ was removed in the presence of the Administrator after the surveyors verified onsite through observation, interview, and record review the implementation of the facility's submitted and accepted IJ Removal Plan #6 (action to correct the deficient practices). The IJ Removal Plan #6 included the following information: 1. Resident 1 was sent to the acute hospital for an evaluation due to increase sexual behavior on 10/17/23 and returned to facility with new medication order. 2. Resident 8 was visited by Social Services Assistant (SSA) and Licensed Vocational Nurse (LVN) from the day of the incident and subsequent visits resulted in no reports or evidence of emotional distress or change in daily routines. 3. The Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together toward the goals of the residents) met on 10/17/23 and updated Resident 8's care plan. 4. The IDT reviewed Resident 1's chart on 10/17/23 to determine root cause of behaviors, possible triggers and interventions that can be used to ensure safety of all residents in the facility. Resident 1's care plan was updated on 10/17/23 to reflect these findings. 5. SSAs and Administrator in Training (AIT) conducted interviews on 10/17/23 for all alert females to see if they feel safe and if they had been touched inappropriately. All residents stated they felt safe and no inappropriate touching had taken place. 6. Director of Nursing (DON)/Designee reviewed all change of condition and behavior monitoring on 10/18/23 for all nonverbal residents from July of 2023 to present to see if there were any indications of abuse. There was no nonverbal resident identified from those with change of condition and behavior monitoring. 7. The AIT in-serviced the Health Care Partners (HCP, non-licensed staff providing one-to-one [1:1] supervision to residents) on 10/13/23 regarding procedure for one-to-one monitoring. All HCPs will pass competency evaluation by 10/19/23. After 10/19/23, they will be allowed back on the floor until the competency evaluation is completed by the AIT/Designee. 8. One-to-one sitter was in place from 7:00 AM to 10:00 PM. Every (Q) 15-minute checks from 10:00 PM to 7:00 AM by CNA/Designee while resident is in his room and 1:1 if he wants to come out of his room. 9. Night shift CNAs, LVNs and RNs (Registered Nurse) were in-serviced on monitoring and Q 15-minute checks of Resident 1 by the Administrator on 10/18/23. 10. The Administrator checked the Q 15-minute log on 10/18/23 from the time Resident 1 returned from the acute hospital on 10/17/23. The log was complete, and no gaps or issues were noted. The Administrator/Designee will check the log daily. Cross referenced to F607, F609, and F610. Findings: Review of Resident 1's admission record indicated, was admitted to facility on 8/30/22 with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), dementia (a group of symptoms affecting memory, thinking and social abilities), history of alcohol abuse, mild cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions), and cognitive communication deficit (difficulty thinking and communicating). Further review, indicated, Resident 1 was his own responsible party (decision maker). Review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/1/23, indicated, Resident 1's cognition (thought process) was moderately impaired. The MDS indicated, Resident 1 did not exhibit any mood symptoms and physical behavioral symptoms directed towards others such as scratching, grabbing, and abusing others sexually. Further review of the MDS indicated, Resident 1 required supervision with set up help to one-person physical assist for bed mobility, transfer, walking, locomotion (ability to move from one place to another), eating, and toilet use. The MDS also indicated Resident 1 required extensive assistance with one-person physical assist for dressing and personal hygiene. Review of Resident 3's admission record indicated, was admitted to facility on 12/21/22 with diagnoses including hemiplegia (complete paralysis of side of the body), hemiparesis (partial weakness or paralysis of on one side of the body), dementia, and cognitive communication deficit. Review of Resident 3's MDS dated [DATE], indicated, Resident 3's cognition was severely impairment. The MDS indicated, Resident 3 did not exhibit any mood and behavioral symptoms. Further review of the MDS indicated, Resident 3 required extensive assistance with one-person physical assist for bed mobility and total dependence with one-person physical assist for transfer, walking, locomotion, eating, toilet use, and personal hygiene. Review of Resident 2's admission record indicated, was admitted to facility on 5/11/23 with diagnoses including encephalopathy (damage or disease that affects the brain), cognitive communication deficit, and catatonic disorder (a behavioral syndrome marked by an inability to moved normally). Review of Resident 2's MDS dated [DATE], indicated, Resident 2 has memory problem and moderately impaired decision-making skills under the staff assessment for mental status. The MDS indicated, Resident 2 had episodes of feeling or appearing down, depressed, or hopeless for 2 to 6 days under the staff assessment of resident mood. The MDS did not indicate any behavioral symptoms for Resident 2. Further review of the MDS indicated, Resident 2 required supervision with one-physical assist for transfer, walk in room, locomotion, and eating; limited assistance with one-physical assist for bed mobility and walk in corridor; extensive assistance with one-physical assist for dressing, toilet use, and personal hygiene. 1. Review of facility's untitled letter document dated 9/7/23, indicated, .On 8/31/2023, our resident [Resident 1] was observed in his room with a female resident (referring to Resident 2) who was touching his penis. The nurse separated the two residents. During the course of the investigation, it was found that [Resident 1] was involved in previous incident in July, in which he was seen touching a different resident on the breast . Review of CDPH's document titled, Complaint/Incident Intake Report, known as HS 802 indicated, the incident of Resident 1 touching Resident 3's breast was received on 9/1/23 at 5:20 PM by fax. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, date completed on 8/31/23, indicated, date and time of the incident Resident 1 touching Resident 3's breast was sometime in July. This alleged incident was reported to the police by phone and to CDPH (California Department of Public Health) and Ombudsman by fax on 8/31/23, no time indicated. Review of Resident 3's Change in Condition dated 9/1/23, indicated, Resident was reported to have been touched in the breast area by another resident. Assessment done without issues noted. SOC 341 completed. Ombudsman and [NAME] Police Department notified. Resident unable to verbalize any information. Daughter and MD notified. During an observation on 9/14/23 at 3:07 PM, Resident 1 was wearing a pair of green socks with a hole exposing his right big toe and was pushing his wheelchair while walking by himself towards his room. During an interview on 9/14/23 at 3:11 PM, Resident 1 stated he doesn't remember an incident of touching female residents in the facility. Resident 1 then started asking for the phone to call his sister. Resident 1 was asked once again if he remembers any encounter with female residents in the facility. Resident 1 then stated, Are you criticizing me for liking women? Resident 1 then started wheeling himself towards the front desk. During concurrent observation and interview on 9/14/23 at 3:16 PM, Resident 3 was not in her room. CNA 1 stated, Resident 3 was up on her wheelchair in the dining room. CNA 1 stated she was not present when Resident 1 allegedly touched the breast of Resident 3 in July 2023 but have heard about it. CNA 1 explained, Resident 3 used gestures when communicating her needs and was total dependent with ADLs (activities of daily living). During an observation on 9/14/23 at 3:19 PM on the second-floor dining room, Resident 3 was sitting on a reclining wheelchair and was verbally responsive in Cantonese. During an interview on 9/14/23 at 3:22 PM, Licensed Vocational Nurse (LVN) 1 stated, a CNA said that one resident tried to touch the breast of Resident 3 and that there was no report or documentation of the incident in resident's chart. During an interview on 9/14/23, at 3:30 PM, CNA 2 stated, this was the first incident she witnessed that involved Resident 1 and Resident 3 in July 2023 on the second-floor dining room. CNA 2 recalled the incident and stated, [Resident 1] was wheeling himself towards the dining area. I saw [Resident 1] rubbing left breast of [Resident 3] in circular motion. CNA 2 also stated, she reported the incident immediately to LVN 1 and took Resident 1 back to his room. During an interview on 9/14/23 at 3:46 PM, LVN 1 confirmed and stated, CNA 2 reported to her regarding Resident 1 touching Resident 3's breast but cannot remember the exact date of the incident. LVN 1 stated, I reported it (referring to touching Resident 3's breast) to Resident Care Coordinator (RCC). I don't know what happened after. No investigation after. LVN 1 explained that the witness should report to RCC and Administrator (ADM) and that she doesn't do anything after reporting an allegation of abuse. LVN 1 added, the RCC will then report to the Administrator and complete the documentation and investigation. During further interview on 9/14/23 at 3:48 PM, LVN 1 stated, Everybody are mandated reporters. LVN 1 also stated, I don't report (to the State Agency/Ombudsman). Only (report) to RCC. Review of Resident 3's clinical record indicated, there was no progress notes in July 2023 regarding the incident of Resident 1 touching Resident 3's breast. Further review indicated, there was no documented evidence a plan of care was initiated to address the incident. Review of Resident 1's clinical record indicated, there was no progress notes in July 2023 regarding the incident of Resident 1 touching Resident 3's breast. Further review indicated, there was no documented evidence a plan of care was initiated to address Resident 1's sexually inappropriate behavior. During concurrent interview and record review on 9/14/23 at 3:53 PM, LVN 1 was unable to find documentation of the incident in Resident 1 and Resident 3's clinical record. LVN 1 stated, I don't see it here. During an interview on 9/14/23 at 4:23 PM, RCC stated, she received two reports that involved Resident 1. RCC stated, the incident of Resident 1 touching Resident 3's breast was not reported to the Administrator/Abuse Coordinator. RCC stated, the way she understood the report was that Resident 1 tap or grab Resident 3's shoulder, therefore concluded that it was not abuse. Thus, no report and no further investigation was conducted. During further interview on 9/14/23 at 4:28 PM, RCC stated, any alleged incidents should be reported directly to the Administrator and/or designee and reporting should be whoever witness the incident. RCC further stated, a change of condition and staff interview should be conducted after a report of alleged abuse was made. During an interview on 9/14/23 at 4:57 PM, Social Worker (SW) 1 stated, she learned about the incident of Resident 1 touching Resident 3's breast during her interview with CNA 2 regarding the incident between Resident 1 and Resident 2 on 8/31/23. During an interview on 9/14/23 at 4:59 PM, Assistant Director of Nursing (ADON) 2 stated, the Abuse Coordinator was not notified of the touching of the breast. ADON stated, Abuse Coordinator should have been notified immediately which did not happen. During further interview on 9/14/23 at 5:03 PM, SW 1 stated that the alleged incident of Resident 1 touching Resident 3' breast was not investigated after learning about the incident. SW 1 stated, At that time the DON and Administrator said it will be taken care of but did not happen (referring to reporting and investigation of the incident). During an interview on 9/14/23 at 5:09 PM, DON stated, There was a miscommunication between LVN 1 and RCC. RCC did not understand what LVN explained. No follow-up interview to clarify the reported incident of Resident 1 touching Resident 3's breast. During a follow-up interview on 9/14/23 at 5:14 PM, RCC stated, I should have followed up more. Get more information. RCC also stated that there was no report or documentation regarding the alleged incident (referring to Resident 1 touching Resident 3's breast), I didn't do anything. No action done. 2. During an interview on 9/14/23 at 3:34 PM, CNA 2 stated, a month later, she witnessed and reported two incidents that involved Resident 1 and Resident 2. CNA 2 stated, on the same month (August 2023), prior to the reported incident on 8/31/23, [Resident 1] attempted to touch [Resident 2] vagina by the social worker's office. CNA 2 added, she reported the incident to the evening nurse and was told to monitor Resident 1 since it was only an attempt. CNA 2 further stated, she did not document the incident and cannot remember the exact date it happened. Review of Resident 1 and Resident 2's progress notes for August 2023 indicated, there was no documentation regarding Resident 1's attempt to touch Resident 2's vagina (female's private part). During an interview on 9/14/23 at 4:52 PM, SW 1 stated, she was not aware of Resident 1 attempted to touch Resident 2's vagina. During an interview on 9/14/23 at 5:19 PM, RCC stated, she did not get a report regarding Resident 1 attempted to touch Resident 2's vagina in August 2023. During a follow up telephone interview on 9/26/23 at 11:58 AM, CNA 2 stated, she reported the incident of Resident 1 attempted to touch Resident 2's vagina to the evening shift nurse (LVN 3) since the incident happened before dinner. CNA 2 added, [LVN 3] told me to monitor [Resident 1] since it was only an attempt. During a telephone interview on 9/27/23 at 10:35 AM, LVN 3 confirmed and stated, CNA 2 reported Resident 1 attempted to touch Resident 2's vagina during the evening shift and the two residents were separated immediately and monitored. LVN 3 also stated, I didn't document (referring to the incident). It was an attempt. I can't remember if I reported it. During an interview on 9/27/23 at 10:38 AM, ADON 1 stated, she was not aware of the attempt of Resident 1 touching Resident 2 that was reported by CNA 2 to LVN 3. ADON 1 added, If there's a report attempting to touch, it needs to be reported immediately. We need to do something right away. Review of Resident 2's care plan indicated, there was no documented evidence a care plan was initiated to address Resident 1's attempt to touch Resident's vagina in August 20223. 3. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 8/31/23, indicated, date and time of the incident of Resident 2 touching Resident 1's penis was 8/31/23 at 2:10 PM. The incident was reported to the police by phone on 8/31/23 at 4:30 PM; the facility reported to CDPH and Ombudsman by fax on 8/31/23, no time indicated. Review of Resident 2's Change in Condition dated 9/1/23, indicated, Resident was found in male resident room his [sic] hand in his penis. Resident separated from resident. Head to Toe assessment completed without issues noted. SOC 341 completed. Ombudsman and BPD ([NAME] Police Department) notified. BPD on scene and interviewed resident. Resident unable to verbalize any information. Family-Daughter and Dr [doctor] notified. Review of Resident 1's Change in Condition dated 9/1/23, indicated, At around 1410 (2:10 PM) on 08/31/2023 .the male resident on [room number] was witnessed by CNA inside [room number] with another female resident [room number], the alleged victim. The alleged abuser was sitting on the wheelchair, pants was down while the alleged victim is touching the alleged abuser's penis. Both residents were separated, and the alleged victim was escorted back to her own room for safety while the alleged abuser stayed inside the room . An SOC-341 (known as Report of Suspected Dependent Adult/Elder Abuse) was completed and filed . CDPH and Ombudsman were also notified of the incident . During an interview on 9/14/23 at 3:40 PM, CNA 2 stated that on 8/31/23, she was walking by Resident 1's room towards the nursing station and noticed the door was open and saw Resident 2 standing in front of Resident 1 who was sitting on his wheelchair. CNA 2 stated, [Resident 1] pull-ups (disposable brief) were down. [Resident 2] was touching his penis. CNA 2 further stated, she called Resident Care Coordinator (RCC) and was told to separate the two residents and bring Resident 2 back to her room. During further interview, CNA 2 stated, she was suspended during the investigation of the incident on 8/31/23 (Resident 1 and Resident 2) because she did not report the July 2023 (breast) incident directly to the Administrator. CNA 2 added that she reported the incident immediately to the charge nurse. CNA 2 then stated, It doesn't make sense to suspend me. Now I'm afraid to report. I might get suspended again. During an interview on 9/14/23 at 4:19 PM, RCC stated, CNA 2 called her to go to Resident 1's room whose sitting on a wheelchair with his pants down while Resident 2 was standing in front holding his penis. RCC stated, the two residents were separated immediately and told CNA 2 to assist Resident 2 to her room. RCC also stated that she brought CNA 2 to the ADON to report the incident. During an interview on 9/14/23 at 4:52 PM, SW 1 stated, she interviewed the staff regarding the incident and assisted the ADON in completing form SOC 341. SW 1 then stated, the DON and Administrator did the reporting and investigation of the incident. Review of Resident 2's care plan for At risk for decline in psychosocial well-being due to sexual contact instigated by male resident, initiated on 9/1/23, indicated, Resident 2 will express/demonstrate feeling safe in facility through the review date. The care plan indicated the following interventions: observe resident for occurrence of or changes in sleep pattern, depression, anxiety, anger, confusion, behavior, and appetite changes. Refer the resident to psych evaluation for a psychosocial wellbeing assessment. Report s/s (signs/symptoms) of psychosocial distress to nurse. Review the daily routine of the facility with the resident and accommodate wishes. Review the resident's coping skills and support the use of the coping mechanism as much as possible. Review of Resident 1's Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together toward the goals of the residents) Note dated 9/7/23, indicated, Staff reported this resident (Resident 1) was with a female resident (Resident 2) in his room, touching his penis on 8/31/23 . Upon investigation of this incident on 8/31/23, we found that this same resident (Resident 1) was involved with another incident of touching the breast area of a female resident (Resident 3) in the dining hall in the month of July . The IDT Note indicated, Administrator, Abuse Coordinator, DON (Director of Nursing), MD (Medical Doctor), RP (responsible party), police, CDPH and Ombudsman were notified of the incident. Further review of the IDT Note indicated, the alleged perpetrator (Resident 1) was placed on 15-minute monitoring for signs and symptoms of adverse effects from the alleged incident, was transferred to another floor and room, referred for psych evaluation, and olanzapine (medication used to treat mental disorders) was increased to 10 mg (milligrams, a unit of measurement). The IDT Note did not indicate the incident of Resident 1 touching Resident 3's breast was further discussed and investigated. Review of Resident 1's Psych assessment dated [DATE], indicated, Resident 1 was referred for psych evaluation due to the following targeted symptoms: sexually pre-occupied, impulsivity, and poverty of thought. The Psych Assessment indicated a diagnostic impression of schizophrenia with interventions including supportive psychotherapy (a type of therapy that primarily focuses on providing emotional support, encouragement, and validation during difficult life circumstances or psychological challenges), discontinue olanzapine 7.5 mg, start with olanzapine 10 mg 1 tablet per orem (po, per mouth) at hours of sleep (hs), and refer accordingly. Review of Resident 1's care plan for The resident was involved in alleged sexual abuse, initiated on 9/3/23, three days after the incident, indicated, the alleged abuser was sitting on the wheelchair, pants were down while the alleged victim is touching the alleged abuser's penis. The care plan indicated Resident 1 will have no evidence of behavior problems or will not display the same behavior until the next review. The care plan indicated the following interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove form situations. Document behavior and potential causes. Observed the behavior and report any abnormal findings. Separate/transfer the room of the abuser to [room number/unit]. SOC-341 was completed and filed. Further review of Resident 1's care plan indicated, there was no documented evidence a care plan was initiated to address Resident 1 touching Resident 3's breast and attempt to touch Resident 2's vagina. During an interview on 9/14/23 at 5:20 PM, ADON 1 stated, a plan of care was put in place after the reported incident on 8/31/23 between Resident 1 and Resident 2 and no other plan of care initiated after the incident in July 2023 between Resident 1 and Resident 3. During a joint interview on 9/14/23 at 5:27 PM, ADM and Regional Quality Management Consultant (RQMC) stated, the two staff (CNA 2 and LVN 1) were suspended for not reporting immediately to the Administrator. During an interview on 9/19/23 at 1:54 PM, Activity Assistant (AA) 2 stated, she observed Resident 1 winking at female residents during group activities and when he's out in the hallway. AA 2 also stated Resident 1 was just friendly and did not think of it as sexually inappropriate. During a concurrent interview and record review on 9/27/23 at 10:44 AM, ADON 1 stated there was no investigation and IDT conducted regarding the two incidents of Resident 1 touching Resident 3's breast and the attempt to touch Resident 2's vagina. During an interview on 9/27/23 at 1:08 PM, ADM stated, any allegations of abuse need to be reported by phone right away and faxed SOC 341 to SSA within two hours of the incident. ADM also stated, a 5-day follow-up or written result of the investigation should be faxed to the State Agency within five days from the incident or up to seven days including weekends, which did not happen. Review of facility's untitled letter document dated 9/7/23, indicated, This letter is to inform you the results of our investigation regarding a resident-to-resident sexual interaction that was reported to you on 8/31/23. Since the date of that report, there has been a change in two key positions which resulted in this letter not being completed within the five day time frame. Thank you for your understanding in this matter . During the course of the investigation, it was found that [Resident 1] was involved in previous incident in July, in which he was seen touching a different resident on the breast . [Resident 1] has been placed on increased monitoring to observe for behaviors and for psychosocial well-being. He was also moved to the first floor of the building near the nurse's station, away from the two female residents. he was evaluated by a psychiatrist who ordered a medication change. There have been no further incidents of inappropriate behavior . During further review, the untitled letter document did not indicate the result of the facility's investigation of the incident. 4. Review of Resident 8's admission record indicated, was admitted to facility on 3/17/21 with diagnoses including heart disease, stroke, functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Review of Resident 8's MDS dated [DATE] indicated, Resident 8 has a BIMS (Brief Interview of Mental Status, a brief screener that aids in detecting cognitive impairment) score of 15, a score of 15 means no cognitive impairment. The MDS also indicated, Resident 8 was non-ambulatory and required extensive assistance with two-person assist for bed mobility, transfer, and locomotion on and off the unit; and one-person assist for dressing, eating, toilet use, and personal hygiene. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 10/12/23, indicated, date and time of the incident was on 10/12/23 at 4:55 PM, Staff heard Resident in room [number] who was in the hallway by her room in her wheelchair crying loudly. Staff asked resident what was wrong she stated a 'male resident down the hall was passing her and touched her on her right breast.' Resident stated that she wasn't in any pain from the incident. Male resident relocated to a different room and hallway. Continue current interventions in place. During an interview on 10/16/23 at 2:38 PM, the ADM stated, on 10/12/23 at 4:55 PM, Resident 8 was heard crying loudly in the hallway saying, He touched my boob (breast). Resident 8 was asked who touched and claimed it was Resident 1. The ADM further stated, CNA 5 was going to give a shower to Resident 1 however, CNA 5 left Resident 1 in his room unaccompanied to check if the shower room was available. The ADM stated, CNA walked away from resident. The ADM added, Resident 1 was transferred to another room in the same Unit as Resident 8 but in a different hallway. Resident 1 continued to have a one-to-one sitter in the morning and evening shift while every 15 minutes monitoring during night shift. During an interview on 10/16/23 at 2:56 PM, ADON 1 stated, she went to check on Resident 8 after she heard her yelling in the hallway he touched me on the breast. ADON 1 then stated, she asked and wheeled Resident 8 to Resident 1's room, which was one room away from her, to show and confirm if it was Resident 1 who touched her on the breast. Resident 8 confirmed it was Resident 1 who touched her on the breast. During further interview, ADON 1 explained that CNA 5 brought the shower chair in Resident 1's room and informed him it was his shower time. ADON 1 added, CNA 5 stepped out of the room to check if the shower room was available. ADON 1 further stated, The sitter (a person who looks after or takes care of someone) left resident unfortunately. She thought the CNA was with him. During an observation on 10/16/23 at 3:04 PM, in Unit 1 hallway, Resident 1's room was located next to the Administrator's office and one room/door away from Resident 8's room, which was located on the same side of the hallway. Resident 8 was inside her room, sitting on a wheelchair next to her bed watching television (TV). Resident 8 was alert, verbally responsive, oriented to time, place, and person. During an interview on 10/12/23 at 3:05 PM, Resident 8 recalled the incident with Resident 1 on 10/12/23 and stated, I was sitting on the chair outside the room and then there's this man [Resident 1's Name was mentioned], wheeling. I thought he's just gonna (going to) wave at me. He squeezed my right breast. I was screaming out loud, crying. I screamed for help, 'maniac'. Resident 8 also stated, the social worker and supervisor came to asked what happened. Resident 8 then asked if Resident 1 can be in jail or moved somewhere. Resident 8 further stated, I was shocked. I was already crying. They (referring to supervisor and social worker) didn't ask me how I feel. During an observation on 10/16/23 at 3:12 PM, the shower room where CNA 5 went to check was located in Unit 2 hallway, across room [ROOM NUMBER], and back end of Unit 1 hallway. During an observation on 10/16/23 at 3:17 PM, in the lobby by the front desk, Resident 1 was observed sitting on a wheelchair outside the front door by himself. Resident 1 was behind the front desk and did not have a one-to-one sitter with him. A female staff then came outside to sit with Resident 1. During an interview on 10/16/23 at 3:18 PM, Health Care Partner (HCP) 1 stated, she is one of the sitters assigned to Resident 1 and[TRUNCATED]

Based on observation, interview, and record review, the facility failed to conduct a thorough investigation for six of 7 sampled residents (Resident 1, Resident 2, Resident 3, Resident 5, Resident 6, and Resident 7) when: 1. Three allegations of sexual abuse (non-consensual sexual contact of any type with a resident) were not thoroughly investigated for Resident 1, Resident 2, and Resident 3. In addition, there was no documented evidence Resident 1's sexually inappropriate behavior towards Resident 2 and Resident 3 was addressed and measures were not implemented to prevent further sexual abuse towards Resident 2. Furthermore, the facility failed to report the results of all investigations of three allegations of sexual abuse to the administrator or designee and State Survey Agency (SSA) within 5 working days of the alleged incidents. 1a. Resident 1 was seen in the dining room touching Resident 3's breast in July 2023. 1b. Resident 1 attempted to touch inappropriately Resident 2's vagina in August 2023. 1c. On 8/31/23, CNA 2 witnessed Resident 1 in his room sitting on his wheelchair, with pants down while Resident 2 was touching Resident 1's penis. The cumulative effects of these failures resulted in delayed identification of Resident 1's sexually inappropriate behavior towards Resident 2 and Resident 3; and did not prevent further sexual abuse towards Resident 2. Additionally, these failures had the potential to compromise the safety of all residents in the facility from unreported and uninvestigated allegations of abuse. 2. The facility did not conduct a thorough investigation to determine the probable cause of injury for Resident 5, Resident 6, and Resident 7, who were totally dependent to staff for activities of daily living, were found with fracture (broken bone) of the femur (thigh bone). In addition, the facility did not report the results of the investigation related to Resident 5, Resident 6, and Resident 7's fracture to the administrator or his designee and to the SSA within 5 working days of the incident. These failures resulted in Resident 5, Resident 6, and Resident 7's delayed identification of fracture, diagnosis and treatment. In addition, these failures placed Resident 5, Resident 6, Resident 7, and all other residents with fracture at risk for untreated pain and further injury. 3. The facility failed to report the result of the abuse investigation to the California Department of Public Health (CDPH) within 5 working days in accordance with Federal requirements for one of three sampled abuse incidents (Resident 9). The alleged abuse incident for Resident 9 occurred on 6/26/23 and there was no result of facility investigation upon request on 10/5/23,10/6/23, 10/9/23 and 10/11/23. The facility's failure to report abuse according to the required time frame had the potential to delay the identification and implementation of appropriate corrective action that may place the resident at risk for abuse. Findings: 1. Review of Resident 1's admission record indicated, was admitted to facility on 8/30/22 with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), dementia (a group of symptoms affecting memory, thinking and social abilities), history of alcohol abuse, mild cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions), and cognitive communication deficit (difficulty thinking and communicating). Further review, indicated, Resident 1 was his own responsible party (decision maker). Review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/1/23, indicated, Resident 1's cognition (thought process) was moderately impaired. The MDS indicated, Resident 1 did not exhibit any mood symptoms and physical behavioral symptoms directed towards others such as scratching, grabbing, and abusing others sexually. Further review of the MDS indicated, Resident 1 required supervision with set up help to one-person physical assist for bed mobility, transfer, walking, locomotion (ability to move from one place to another), eating, and toilet use. The MDS also indicated Resident 1 required extensive assistance with one-person physical assist for dressing and personal hygiene. Review of Resident 2's admission record indicated, was admitted to facility on 5/11/23 with diagnoses including encephalopathy (damage or disease that affects the brain), cognitive communication deficit, and catatonic disorder (a behavioral syndrome marked by an inability to moved normally). Review of Resident 2's MDS dated [DATE], indicated, Resident 2 has memory problem and moderately impaired decision-making skills under the staff assessment for mental status. The MDS indicated, Resident 2 had episodes of feeling or appearing down, depressed, or hopeless for 2 to 6 days under the staff assessment of resident mood. The MDS did not indicate any behavioral symptoms for Resident 2. Further review of the MDS indicated, Resident 2 required supervision with one-physical assist for transfer, walk in room, locomotion, and eating; limited assistance with one-physical assist for bed mobility and walk in corridor; extensive assistance with one-physical assist for dressing, toilet use, and personal hygiene. Review of Resident 3's admission record indicated, was admitted to facility on 12/21/22 with diagnoses including hemiplegia (complete paralysis of side of the body), hemiparesis (partial weakness or paralysis of on one side of the body), dementia, and cognitive communication deficit. Review of Resident 3's MDS dated [DATE], indicated, Resident 3's cognition was severely impairment. The MDS indicated, Resident 3 did not exhibit any mood and behavioral symptoms. Further review of the MDS indicated, Resident 3 required extensive assistance with one-person physical assist for bed mobility and total dependence with one-person physical assist for transfer, walking, locomotion, eating, toilet use, and personal hygiene. 1a. Review of CDPH's document titled, Complaint/Incident Intake Report, known as HS 802 indicated, the incident of Resident 1 touching Resident 3's breast was received on 9/1/23 at 5:20 PM by fax. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 8/31/23, indicated, date and time of the incident Resident 1 touching Resident 3's breast was sometime in July. This alleged incident was reported to the police by phone on 8/31/23, no time indicated; and to CDPH and Ombudsman by fax on 8/31/23, no time indicated. Review of facility document titled, Transmission Result Report, indicated, the facility faxed to CDPH on 8/31/23 at 8:03 PM. During an interview on 9/14/23, at 3:30 PM, CNA 2 stated, she witnessed the first incident involving Resident 1 and Resident 3 in July 2023 on the second-floor dining room. CNA 2 recalled the incident and stated, [Resident 1] was wheeling himself towards the dining area. I saw [Resident 1] rubbing left breast of [Resident 3] in circular motion. CNA 2 also stated, she reported the incident immediately to Licensed Vocation Nurse (LVN) 1 and took Resident 1 back to his room. During an interview on 9/14/23 at 3:46 PM, LVN 1 confirmed and stated, CNA 2 reported to her regarding Resident 1 touching Resident 3's breast but cannot remember the exact date of the incident. LVN 1 stated, I reported it (referring to touching Resident 3's breast) to Resident Care Coordinator (RCC). I don't know what happened after. No investigation after. LVN 1 explained that the witness should report to RCC and Administrator (ADM) and that she doesn't do anything after reporting an allegation of abuse. LVN 1 added, the RCC will then report to the Administrator and complete the documentation and investigation. Review of Resident 3's Change in Condition dated 9/1/23, indicated, Resident was reported to have been touched in the breast area by another resident. Assessment done without issues noted. SOC 341 completed. Ombudsman and [NAME] Police Department notified. Resident unable to verbalize any information. Daughter and MD notified. Review of Resident 3's clinical record indicated, there was no progress notes in July 2023 regarding the incident of Resident 1 touching Resident 3's breast. Further review indicated, there was no documented evidence a plan of care was initiated to address the incident. Review of Resident 1's clinical record indicated, there was no progress notes in July 2023 regarding the incident of Resident 1 touching Resident 3's breast. Further review indicated, there was no documented evidence a plan of care was initiated to address Resident 1's sexually inappropriate behavior. During concurrent interview and record review on 9/14/23 at 3:53 PM, LVN 1 was unable to find documentation of the incident in Resident 1 and Resident 3's clinical record. LVN 1 stated, I don't see it here. During an interview on 9/14/23 at 4:23 PM, RCC stated, she received two reports that involved Resident 1. RCC stated, the incident of Resident 1 touching Resident 3's breast was not reported to the Administrator/Abuse Coordinator. RCC stated, the way she understood the report was that Resident 1 tap or grab Resident 3's shoulder, therefore concluded that it was not abuse. Thus, no report and no further investigation was conducted. During further interview on 9/14/23 at 4:28 PM, RCC stated, any alleged incidents should be reported directly to the Administrator and/or designee and reporting should be whoever witness the incident. RCC further stated, a change of condition and staff interview should be conducted after a report of alleged abuse was made. During an interview on 9/14/23 at 4:52 PM, Social Worker (SW) 1 stated, she learned about the incident of Resident 1 touching Resident 3's breast during her interview with CNA 2 regarding the incident between Resident 1 and Resident 2 on 8/31/23. SW 1 further stated, the CNA, LVN, or RCC were expected to report the alleged incident of Resident 1 touching Resident 2's breast immediately or within two hours from the time they knew about the incident. During further interview on 9/14/23 at 5:03 PM, SW 1 stated that the alleged incident of Resident 1 touching Resident 3' breast was not investigated after learning about the incident. SW 1 stated, At that time the DON and Administrator said it will be taken care of but did not happen (referring to reporting and investigation of the incident). During an interview on 9/14/23 at 5:09 PM, DON stated, There was a miscommunication between LVN 1 and RCC. RCC did not understand what LVN explained. No follow-up interview to clarify the reported incident of Resident 1 touching Resident 3's breast. During a follow-up interview on 9/14/23 at 5:14 PM, RCC stated, I should have followed up more. Get more information. RCC also stated that there was no report or documentation regarding the alleged incident (referring to Resident 1 touching Resident 3's breast), I didn't do anything. No action done. 1b. During an interview on 9/14/23 at 3:34 PM, CNA 2 stated, a month later, she witnessed and reported two incidents that involved Resident 1 and Resident 2. CNA 2 stated, on the same month (August 2023), prior to the reported incident on 8/31/23, [Resident 1] attempted to touch [Resident 2] vagina by the social worker's office. CNA 2 added, she reported the incident to the evening nurse and was told to monitor Resident 1 since it was only an attempt. CNA 2 further stated, she did not document the incident and cannot remember the exact date it happened. Review of Resident 1 and Resident 2's progress notes for August 2023 indicated, there was no documentation regarding Resident 1's attempt to touch Resident 2's vagina. During an interview on 9/14/23 at 4:52 PM, SW 1 stated, she was not aware of Resident 1 attempted to touch Resident 2's vagina. During an interview on 9/14/23 at 5:19 PM, RCC stated, she did not get a report regarding Resident 1 attempted to touch Resident 2's vagina in August 2023. During a follow up telephone interview on 9/26/23 at 11:58 AM, CNA 2 stated, she reported the incident of Resident 1 attempted to touch Resident 2's vagina to the evening shift nurse (LVN 3) since the incident happened before dinner. CNA 2 added, [LVN 3] told me to monitor [Resident 1] since it was only an attempt. During a telephone interview on 9/27/23 at 10:35 AM, LVN 3 confirmed and stated, CNA 2 reported Resident 1 attempted to touch Resident 2's vagina during the evening shift and the two residents were separated immediately and monitored. LVN 3 also stated, I didn't document (referring to the incident). It was an attempt. I can't remember if I reported it. During an interview on 9/27/23 at 10:38 AM, DON stated, she was not aware of the attempt of Resident 1 touching Resident 2 that was reported by CNA 2 to LVN 3. DON added, If there's a report attempting to touch, it needs to be reported immediately. We need to do something right away. 1c. Review of CDPH's document titled, Complaint/Incident Intake Report, known as HS 802 indicated, the incident of Resident 2 touching Resident 1's penis was received on 9/1/23 at 10:39 AM by fax. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 8/31/23, indicated, date and time of the incident of Resident 2 touching Resident 1's penis was 8/31/23 at 2:10 PM. The incident was reported to the police by phone on 8/31/23 at 4:30 PM; the facility reported to CDPH and Ombudsman by fax on 8/31/23, no time indicated. During an interview on 9/14/23 at 3:40 PM, CNA 2 stated that on 8/31/23, she was walking by Resident 1's room towards the nursing station and noticed the door was open and saw Resident 2 standing in front of Resident 1 who was sitting on his wheelchair. CNA 2 stated, [Resident 1] pull-ups (disposable brief) were down. [Resident 2] was touching his penis. CNA 2 further stated, she called Resident Care Coordinator (RCC) and was told to separate the two residents and bring Resident 2 back to her room. During further interview, CNA 2 stated, she was suspended during the investigation of the incident on 8/31/23 (Resident 1 and Resident 2) because she did not report the July 2023 (breast) incident directly to the Administrator. CNA 2 added that she reported the incident immediately to the charge nurse. CNA 2 then stated, It doesn't make sense to suspend me. Now I'm afraid to report. I might get suspended again. During an interview on 9/14/23 at 4:19 PM, RCC stated, CNA 2 called her to go to Resident 1's room whose sitting on a wheelchair with his pants down while Resident 2 was standing in front holding his penis. RCC stated, the two residents were separated immediately and told CNA 2 to assist Resident 2 to her room. RCC also stated that she brought CNA 2 to the ADON to report the incident. During an interview on 9/14/23 at 4:52 PM, SW 1 stated, she interviewed the staff regarding the incident and assisted the ADON in completing form SOC 341. SW 1 then stated, the DON and Administrator did the reporting and investigation of the incident. Review of Resident 1's Change in Condition dated 9/1/23, indicated, At around 1410 (2:10 PM) on 08/31/2023 .the male resident on [room number] was witnessed by CNA inside [room number] with another female resident [room number], the alleged victim. The alleged abuser was sitting on the wheelchair, pants was down while the alleged victim is touching the alleged abuser's penis. Both residents were separated, and the alleged victim was escorted back to her own room for safety while the alleged abuser stayed inside the room . An SOC-341 (known as Report of Suspected Dependent Adult/Elder Abuse) was completed and filed . CDPH and Ombudsman were also notified of the incident . Review of Resident 1's care plan for The resident was involved in alleged sexual abuse, initiated on 9/3/23, 3 days after the incident, indicated, the alleged abuser was sitting on the wheelchair, pants were down while the alleged victim is touching the alleged abuser's penis. The care plan indicated Resident 1 will have no evidence of behavior problems or will not display the same behavior until the next review. The care plan indicated the following interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a clam manner. Divert attention. Remove form situations. Document behavior and potential causes. Observed the behavior and report any abnormal findings. Separate/transfer the room of the abuser to [room number/unit]. SOC-341 was completed and filed. Review of Resident 2's Change in Condition dated 9/1/23, indicated, Resident was found in male resident room his hand in his penis. Resident separated from resident. Head to Toe assessment completed without issues noted. SOC 341 completed. Ombudsman and BPD ([NAME] Police Department) notified. BPD on scene and interviewed resident. Resident unable to verbalize any information. Family-Daughter and Dr [doctor] notified. Review of Resident 2's care plan for At risk for decline in psychosocial well-being due to sexual contact instigated by male resident, initiated on 9/1/23, indicated, Resident 2 will express/demonstrate feeling safe in facility through the review date. The care plan indicated the following interventions: observe resident for occurrence of or changes in sleep pattern, depression, anxiety, anger, confusion, behavior, and appetite changes. Refer the resident to psych evaluation for a psychosocial wellbeing assessment. Report s/s (signs/symptoms) of psychosocial distress to nurse. Review the daily routine of the facility with the resident and accommodate wishes. Review the resident's coping skills and support the use of the coping mechanism as much as possible. Review of Resident 1's Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together toward the goals of the residents) Note dated 9/7/23, indicated, Staff reported this resident (Resident 1) was with a female resident (Resident 2) in his room, touching his penis on 8/31/23 . Upon investigation of this incident on 8/31/23, we found that this same resident (Resident 1) was involved with another incident of touching the breast area of a female resident (Resident 3) in the dining hall in the month of July . The IDT Note indicated, Administrator, Abuse Coordinator, DON (Director of Nursing), MD (Medical Doctor), RP (responsible party), police, CDPH and Ombudsman were notified of the incident. Further review of the IDT Note indicated, the alleged perpetrator (Resident 1) was placed on 15-minute monitoring for signs and symptoms of adverse effects from the alleged incident, was transferred to another floor and room, referred for psych evaluation, and olanzapine (medication used to treat mental disorders) was increased to 10 mg (milligrams, a unit of measurement). The IDT Note did not indicate the incident of Resident 1 touching Resident 3's breast and attempt to touch Resident 2's vagina was further discussed and investigated. Review of facility's untitled letter document dated 9/7/23, indicated, This letter is to inform you of the results of our investigation regarding a resident-to-resident sexual interaction that was reported to you on 8/31/2023. Since the date of that report, there has been a change in two key positions which resulted in this letter not being completed within the five-day time frame .On 8/31/2023, our resident [Resident 1] was observed in his room with a female resident who was touching his penis. The nurse separated the two residents. During the course of the investigation, it was found that [Resident 1] was involved in previous incident in July, in which he was seen touching a different resident on the breast . During a concurrent interview and record review on 9/27/23 at 10:44 AM, DON stated there was no investigation and IDT conducted regarding the two incidents of Resident 1 touching Resident 3's breast and the attempt to touch Resident 2's vagina. During an interview on 9/27/23 at 1:08 PM, ADM stated, any allegations of abuse need to be reported by phone right away and faxed SOC 341 to SSA within two hours of the incident. ADM also stated, a 5-day follow-up or written result of the investigation should be faxed to the State Agency within five days from the incident or up to seven days including weekends, which did not happen. Review of the facility's policy and procedure titled, Abuse Reporting and Investigations, revised 7/31/23 with effective date of 8/18/23, indicated, .The Facility promptly reports and thorough investigates allegations of resident abuse, mistreatment, neglect, exploitation, abuse facilitated or enabled by the use of technology, misappropriation of resident property, or injuries of unknown source, and suspicions of crimes . 1. Administrator as Abuse Prevention Coordinator . b. When the Administrator or designated representative receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, abuse facilitated or enabled technology, exploitation, or injuries of unknow source, or suspicion of a crime, the Administrator or designated representative will initiate an investigation immediately . ii. The facility will not inhibit facility staff/covered individuals from their mandated reporting obligations. iii. Facility staff/covered individuals will not be disciplined or retaliated against for good-faith reporting . 2. Immediate Action . b. The administrator or designated representative conducting the investigation will interview individuals who may have information relevant to the allegation or suspected crime . 10. Investigator Consultation with Administrator - a. The individual who is conducting the investigation will consult daily with the Administrator concerning progress/findings of the investigation. 11. Informing Resident of Results of Investigation/Corrective Action - a. The Administrator will inform the resident and his/her representative of the results of the progress of the investigation. b. The Administrator will inform the resident and his/her representative of the results of the investigation and corrective action taken within five (5) working days of the reported incident. 12. Providing State Survey Agency and Other Agencies of the Results - a. The Administrator will provide a written report the results of all abuse investigations and appropriate action taken to CDPH Licensing and Certification and others that may be required state or local laws, within five (5) working days of the reported allegation . 40454 2a. A review of the face sheet indicated Resident 5 was admitted with diagnoses including stroke, seizure disorder (epilepsy) and dementia (decline in memory or other thinking skills). A review of MDS dated [DATE], BIMS indicated Resident 5 has severe cognitive impairment. Under functional status Resident 5 totally dependent ADL's including mobility, transfer, eating, and toileting. A review of the nurses 'notes dated 5/24/23, addressing Resident 5 ' s Change in Condition indicated, .Certified Nurse Assistant (CNA, caregiver) reported to Licensed Nurse (LN) that the resident 's right thigh looked bigger than the left one .LN noted the resident with internal rotation of the right hip and swelling to the right thigh. With slight discomfort when right thigh was touched . A review of the Physician (Medical doctor) notes dated 5/24/23, indicated, .Patient (Resident 5) reported to have a possible fracture of which an x-ray was done on 5/24/23, showing right intertrochanteric fracture, staff reports no fall . During a review of the clinical record for Resident 5 and interview on 9/14/23, at 3:05 PM, ADON 1 stated, There was no IDT notes for the incident. I don ' t see any IDT charting. She ' s conserved. The conservator transferred her to another facility. The conservator has another resident here. Both residents were transferred to another facility after both had a fracture. 2b.A review of the face sheet indicated Resident 6 was admitted with diagnoses including dementia, heart failure, and diabetes. A review of the MDS, dated [DATE], BIMS score of 2 indicated severe cognitive impairment. Under functional status Resident 6 was dependent requiring one-person physical assistance with ADL's including mobility, transfer, dressing, and toilet use. A review of the nurses' notes, dated 5/24/23, indicated, CNA reported that the resident has bruising on her right thigh .notes scattered yellowish, greenish discoloration on the right groin, extending to the right hip to entire posterior (back) thigh .No fall incident reported during the past week . Resident has cognitive impairment related to dementia, and unable to provide description on the origin of bruising . A review of the ER visit notes dated 5/25/23, indicated, Resident 6 had .Diagnosis: closed fracture of the right hip. A review of the facility investigation dated 5/30/23, indicated, .Conclusion: Resident has not experienced any falls or any unusual incidents in the past two weeks. She was found to have a spontaneous fracture which the leading cause is decreased bone mass which has a propensity to affect older female adults . The facility was not able to provide evidence of documentation that indicated Resident 6 had, decreased bone mass. 2c. A review of the face sheet indicated Resident 7 was admitted with diagnoses including dementia, diabetes, and hypertension (abnormally high blood pressure). A review of the MDS dated [DATE], BIMS score of 4 indicated severe cognitive impairment. Under functional status Resident 7 was totally dependent and required one-person physical assistance with activities of daily living including mobility, transfer, eating and toileting. A review of care plan addressing ADLs initiated 3/7/23, indicated, Resident needs assistance with ADL's. At risk for declining self-performance of ADL's r/t weakness, depression, aging, impaired cognitive function, communication, mood, and behavior problem due to dementia . Noted sometimes talking to self-nonsense when awake. Goal: ADL and safely needs will be anticipated and met by staff daily . refer rehab consult as needed. Turn and reposition as ordered. Provide assistance with ADL's care as needed . During an observation on 10/5/23 at 3:48 PM, Resident 7 was asleep in bed on side lying position. During an interview on 10/5/23, at 3:49 PM, LVN 4 stated, Resident (Resident 7) barely speak, does not understand her condition and is totally dependent to staff with all her ADL needs. A review of the Change in Condition Evaluation dated 3/31/23, indicated . CNA reported .new skin issue . New onset of swelling and tenderness 4/10. Pain with touch . A review of change in condition ff up note dated 4/4/23, indicated, .Still noted with large yellowish discoloration to the right knee with swelling. Resident was sent to the ER (emergency room ) . A review of the ER notes dated 4/3/23, indicated .Resident was sent in from the nursing home due to concern of a right-side femur fracture .X-ray resuilts: displaced distal femoral fracture .called nurses at (facility) .States that the patient is immobile . The facility was not able to provide evidence of documentation of a completed investigation of Resident 7's injury. 48894 3. Resident 9 was admitted on [DATE], with diagnoses including Multiple sclerosis (Disabling disease of the brain and spinal cord), Diabetes mellitus (Disease that affect how the body uses blood sugar), Heart Failure (heart can't pump blood well enough to meet body's need). Review of SOC 341 Report of suspected Dependent Adult /Elder Abuse dated 7/17/23, Indicated Resident claims there is one half dose missing of my Ozempic. During an interview on 10/11/2023 at 9:10AM, with Interim director of nursing (ADON) 1, ADON 1 stated The new administration is still looking for the investigation summary but there is nothing we can find, that's why we have new administration. During review of Policy and Procedure, revised 7/31/23, titled ANOZ Abuse - Reporting and Investigations indicated a. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to CDPH Licensing and Certification and others that may be required by state or local laws, within five (5) working days of the reported allegation.

Based on observation, interview and record review, the facility failed to provide supervision and assistance to prevent a fall to Resident 4; and prevent injuries to three residents (Resident 5, Resident 6, and Resident 7) . This facility failure resulted in Resident 4 sustaining fractures (broken) to the 4th, 5th, 6th, 7th, and 8th right ribs (part of the bony framework that protect the chest) and Resident 5, Resident 6, and Resident 7, who were totally dependent on staff with their activities of daily living (ADL, self-care activities) were found with fractures of the femur (thigh bone) of unknown cause. Findings: A. A review of the face sheet indicated, Resident 4 was admitted with diagnoses including heart failure (when the muscles of the heart does not pump as strong as it should), and asthma (a lung disease). A review of the Minimum Data Set (MDS, a standard assessment tool) dated 3/20/23, Brief interview of mental status (BIMS, a brief memory test to help determine cognitive function) score of 2 indicated severe cognitive impairment. Under functional status, Resident 4 required one-person physical assistance in performance of ADL including mobility, transfer, and toilet use. Resident 4 was frequently incontinent (inability to control) bladder function (passing urine) and bowel function . A review of the Fall Risk assessment form dated, 3/20/23, indicated, . If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. A review of the fall risk evaluation dated 3/20/23, indicated Resident 4 had a score of 11, at risk for falls. A review of the Bowel and Bladder Program Screener for Resident 4 dated 3/20/23, indicated: a. Voids appropriately without incontinent: Not always, but at least daily, score of 2. b. Incontinent of stool 1-3 times (x) a week: score of 2. c. Ability to get to the bathroom (BR) /transfer to toilet/commode/urinal, adjust clothing and wipe: Independently, but slowly: score of 2. d. Mental status: Confused, needs prompting, score of 1. e. Mentally aware of need to toilet: Usually aware of need to toilet, score of 2. f. Condition of skin on genital, perineal, buttocks: No redness, score of 3. g. Predisposing factors: Diabetes, MS, Cerebrovascular accident (CVA, stroke, blood supply to the brain is blocked ), bladder or prostate disease, frequent urinary tract infection (UTI), spinal cord injuries, cerebral palsy. Score of 2. Score: 14. Category: Candidate for schedule toileting (timed voiding). A review of the care plan addressing Resident 4 risk for falls and injury, initiated on 11/29/22, indicated, .related to (r/t) confusion, deconditioning, gait balance problems, incontinence, poor communication/comprehension, psychoactive drug use, unaware of safety needs, uses wheelchair for locomotion on and off unit. Resident is noted to transfer self from bed and walk pushing her wheelchair, not redirectable at times, easily gets agitated .Interventions: Anticipate and meet (Resident 4) needs, she frequently goes up to the nurse ' s station for juice, sandwiches, and snacks. Educate resident about safety reminders and what to do if a fall occurs. Follow facility fall protocol. Involve family in explaining to the resident the risk and benefits of following safety protocol in their language. Provide nonskid socks when resident is walking barefoot. Physical therapy (PT) evaluates and treat as ordered or as needed (PRN). The resident needs a safe environment with even floors free from spills and/or clutter, adequate, glare free light, a working and reachable call light, the bed in low position at night, handrails on walls, personal items within reach . During observation on 9/14/23, at 2:56 PM, Resident 4 was sitting up in a wheelchair. She was alert, calm and pleasant. Resident 4 was calling out and waving to staff. Assistant Director of Nursing (ADON) 2 responded to Resident 4 and stated, She said that she doesn't' need anything. A review of the nurses' notes dated 5/18/23, 11:31 AM indicated, Patient (Resident 4) found on floor, next to bed side commode .patient was assisted back to bed and instructed to use the call light when she needs help .moderate pain on her right ribs . A review of the nurses' notes, a late entry, dated 5/18/23, indicated, .Resident (Resident 4) had an unwitnessed fall attempting to self-toilet to commode after breakfast without assist and without using call light . A review of the post fall assessment for Resident 4 dated 5/18/23, indicated, .Date/Time of fall: 5/18/23, 9:45 AM. Fall was not witnessed. Fall occurred in resident ' s room. Resident was attempting to self-toilet at the time of fall .Contributing factors: self-toileting using bedside commode without assistance .Conclusion .Any additional needs identified: Yes. Needs identified: Re-education. Additional needs note: teaching resident to use call light whenever she needs help. A review of the Interdisciplinary Team (IDT, group of healthcare professionals working together to provide care) notes dated 5/19/23, indicated, .Resident (Resident 4) had an unwitnessed fall on 5/18/23, at 9:15 AM when she attempted to use the bedside commode and was found sitting on the floor Resident did report 5/10 pain on her right ribs area.Resident is at high risk for falls related to impaired cognition, impaired safety awareness, impaired balance. In addition to taking medication that can increased the fall risk including diuretic, antidepressant, narcotic analgesic antihypertensive .The resident will benefit from assistance to the bedside commode after breakfast. Care plan reviewed with DON, ADON, SW. A review of nurse's notes for Resident 4 dated 5/19/23, indicated, .X-ray (a procedure to take pictures of the inside of the body) result came back on 9/19/23, with Mildly displaced (when bones come out of alignment) fractures of the lateral 4th, 5th, 6th, 7th, and 8th ribs . A review of the nurses' notes for Resident 4 addressing Change in Condition, dated 5/19/23, indicated, .Plan of care for this fall is to assist with toileting before and after meals and as needed because the resident had a fall when attempting to use the bedside commode without using the call light .call light within reach and educated to use the call light whenever she needs help . During an interview on 9/14/23, at 3:05 PM, Licensed Vocational Nurse (LVN) 2 stated, When she (Resident 4) wanted to go to the toilet, she will say pee (urinate, pass urine) or point to the bathroom. She is usually continent during the day, incontinent at night. She doesn't want to get up at night. We have been telling her to use the call light. She is not using the call light. She can't remember she needs to use the call light. During an interview on 9/14/23, at 3:24 PM, LVN 1 stated, The resident (Resident 4) doesn't use the call light. She doesn't remember the instructions on how to use the call light. And most of the time was not able to follow directions. She has dementia. During an interview on 9/14/23, at 4:28 PM, Certified Nurse Assistant (CNA) 3 stated, We are always short of staff. It's hard. There's not enough help. We have to hurry so everyone is taken cared of. During an interview on 9/14/23, at 4:55 PM, Physical Therapy (PT, used to improve movement and manage pain) Director stated, We do not evaluate a resident unless there is a physician order. We can screen. PT Director further stated that PT screening (used to identify resident's needs and rehabilitation potential) was not done to Resident 4 after the fall episode. During an interview on 9/17/23, at 1:54 PM, CNA 1 stated, I help her (Resident 4)go from bed to wheelchair. She cannot stand up by herself. She does not use the call light. She knocks on the table or knocks the door when she wants to go to the toilet. CNA 1 further stated that Resident 4 tries to transfer out of bed by herself that she had to check her more frequently. During an interview on 9/19/23. at 3:05 PM, ADON 1 stated, She (Resident 4) was not on any toileting program. The care plan for risk for fall and injury was not revised and updated to include that Resident 4 required one person assistance during mobility and transfer. A review of the care plan addressing bowel and bladder function was not revised and updated to include that Resident 4 required one-person physical assistance with toilet use. B1. A review of the face sheet indicated Resident 5 was admitted with diagnoses including stroke, seizure disorder (epilepsy) and dementia (decline in memory or other thinking skills). A review of MDS dated [DATE], BIMS indicated severe cognitive impairment. Under functional status Resident 5 was totally dependent with ADL including mobility, transfer, eating, and toileting. A review of the nurses' notes dated 5/24/23, addressing Resident 5's Change in Condition indicated, . CNA reported to Licensed Nurse (LN) that the resident 's (Resident 6) right thigh looked bigger than the left one .LN noted the resident with internal rotation of the right hip and swelling to the right thigh. With slight discomfort when right thigh was touched . A review of the Physician (Medical doctor) notes dated 5/24/23, indicated, .Patient (Resident 5) reported to have a possible fracture of which an x-ray was done on 5/24/23, showing right intertrochanteric (relating to the bones of the thigh) fracture, staff reports no fall . During an interview and review of the clinical record for Resident 5 on 9/14/23, at 3:05 PM, ADON 1 stated, I don't see an IDT charting about the incident. She's conserved (appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations). The conservator (guardian, protector) transferred her to another facility. The conservator had another resident here. Both residents were transferred to another facility after both had a fracture. The Conservator for Resident 5 was not available for an interview. B2. A review of the face sheet indicated Resident 6 was admitted with diagnoses including dementia, heart failure, and diabetes (high levels of sugar in the blood). A review of the MDS for Resident 6 dated 4/7/23, Brief Interview of Mental Status score of 6 indicated severe cognitive impairment. Under functional status Resident 6 was dependent requiring one-person physical assistance with ADL ' s including mobility, transfer, dressing, and toilet use. A review of the nurses' notes for Resident 6 dated 5/24/23, indicated, CNA reported that the resident has bruising on her right thigh .noted scattered yellowish, greenish discoloration on the right groin, extending to the right hip to entire posterior (back) thigh .No fall incident reported during the past week Resident has cognitive impairment related to dementia, and unable to provide description on the origin of bruising . A review of the ER (emergency room ) notes for Resident 6 dated 5/25/23, indicated, . closed fracture of the right hip . A review of the facility investigation dated 5/30/23, indicated, .Conclusion: Resident (Resident 6) has not experienced any falls or any unusual incidents in the past two weeks. (Resident 6) was found to have a spontaneous fracture which the leading cause is decreased bone mass which has a propensity to affect older female adults . The facility was not able to provide evidence of documentation that addressed Resident 6 had decreased bone mass. The Conservator for Resident 6 was not available for interview. B3. A review of the face sheet indicated Resident 7 was admitted with diagnoses including dementia, diabetes, and hypertension (abnormally high blood pressure). A review of the MDS dated [DATE], BIMS score of 7 indicated severe cognitive impairment. Under functional status Resident 7 was totally dependent and required one-person physical assistance with activities of daily living including mobility, transfer, eating and toileting. A review of care plan for Resident 7 addressing ADL's initiated 3/7/23, indicated, Resident needs assistance with ADL's. At risk for declining self-performance of ADL's related to (r/t) weakness, depression (severe feeling of hopelessness and loneliness), aging, impaired cognitive function, communication, mood and behavior problem due to dementia . Noted sometimes talking to self nonsense when awake. Goal: ADL and safely needs will be anticipated and met by staff daily . refer rehab consult as needed. Turn and reposition as ordered. Provide assistance with ADL's care as needed . The care plan was not revised and updated to include Resident 7 requiring one-person physical assistance with ADL's. During an observation on 10/5/23 at 3:48 PM, Resident 7 was asleep in bed in side lying position. During an interview on 10/5/23, at 3:49 PM, LVN 4 stated, The resident (Resident 7) barely speak, does not understand her condition and is totally dependent to staff with all her ADL needs . A review of the Change in Condition (CIC) Evaluation for Resident 7 dated 3/31/23, indicated . CNA reported .new skin issue . New onset of swelling and tenderness 4/10. Pain with touch . A review of the x-ray results for Resident 7 dated 4/3/23, indicated, .acute oblique fracture in the supracondylar region (when the thigh bone was broken at the knee) . A review of change in condition follow up note for Resident 7 dated 4/4/23, indicated, . Resident was sent to the ER (emergency room ) yesterday to confirm fracture results obtained from the in house X-ray .Returned this morning with orders for oxycodone (used to treat moderate to severe pain) . A review of the emergency department notes for Resident 7 dated 4/3/23, indicated .Displaced (when bones come out of alignment) right distal femoral fracture .called nurses at (facility) .States that the patient is immobile . During an interview on 9/19/23, at 1:50 PM, Director of Staff Development stated she have not provided in-service to address accident prevention for residents for the last 12 months. A review of the Policy and Procedure titled, Fall Management Program, dated 2/1/11, indicated, Purpose: To provide residents a safe environment that minimizes complications associated with falls .The IDT and or the licensed nurse will develop a care plan according to the identified risk factors will initiate, update, and root cause(s) per care area guidelines. The IDT will initiate, review, and update the resident ' s fall risk status and care plan at the following intervals: on admission, quarterly, annually, upon identification of a significant change of condition, post fall and as needed. The license nurse will evaluate the resident ' s response to the interventions on the Weekly Summary and update the resident care plan as necessary . A review of the Policy and Procedure titled Safety and Supervision of Residents dated 1/2011, indicated, .Out facility strives to make the environment as free from accident hazard as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities .Our facility-oriented approach to safety addresses risks for group of residents. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes . When accident hazard are identified, the Safety Committee shall evaluate and analyze the causes of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. Employees shall be trained and Inserviced on potential accident hazards and how to identify and report accident, and try to prevent avoidable accidents. The Safety Committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary . Our resident-oriented approach to safety and accident hazards for individual residents. Staff shall use various sources to identify risks factors for residents, including the information obtained from the medical history, physical exam, observations of the resident, and the MDS. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents. Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff; assigning responsibility for carrying out interventions; providing training, as necessary; ensuring that interventions are implemented; and documenting interventions. Monitoring the effectiveness of interventions shall include the following: ensuring the interventions are implemented correctly and consistently; evaluating the effectiveness of interventions; modifying or replacing interventions as needed; and evaluating the effectiveness of new or revised interventions .The facility-oriented approach and resident-oriented approaches to safety are used together to implement a system approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjust interventions accordingly. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazard in the environment .or if there is a change in condition .risks factors and environmental hazards include: bed safety, safe lifting and movement of the residents, falls, smoking, unsafe wandering, poison control, electrical safety, water temperature .

Based on interview and record review, the facility failed to ensure a diagnostic procedure was provided for Resident 7 when a stat (medical term for rush) x-ray (a procedure to create images of the structure of the inside of the body, used to assess broken bones) was not completed as ordered by the physician. The failure resulted to the delay in identification and treatment of a femur (thigh bone) fracture (broken bone) for Resident 7. Findings: A review of the MDS dated [DATE], BIMS score of 4 indicated severe cognitive impairment. Under functional status Resident 7 was totally dependent and required one-person physical assistance with activities of daily living including mobility, transfer, eating and toileting. During an interview on 10/5/23, at 3:49 PM, Licensed Vocational Nurse (LVN) 4 stated, Resident (Resident 7) barely speak, does not understand her condition and is totally dependent to staff with all her ADL needs. She needs physical help from a staff. She didn't fall when she had the fracture. We use the numerical pain scale. 1-4 for mild pain, 5-7 for moderate pain, 8 -9 for severe pain, 10 and over is excoriating pain. A review of the Change in Condition (CIC) Evaluation dated 3/31/23, indicated . CNA reported .new skin issue . New onset of swelling and tenderness 4/10. Pain with touch . A review of the progress notes dated 3/31/23, indicated, (X-ray services provider named) called at 15:30 (3:30 PM) for stat x-ray and stated would arrive in four to six hours (4-6 hrs.) . A review of progress notes dated 4/1/23, indicated, .(X-ray services provider named) contacted and stated technician is sick . A review of CIC follow up note dated 4/2/23, indicated, .(X-ray services provider named) contacted and no time table for technician to arrive . A review of the x-ray results dated 4/3/23, indicated, .acute oblique fracture in the supracondylar region (when the thigh bone was broken at the knee) . A review of change in condition ff up note dated 4/4/23, indicated, .Resident (Resident 7) was sent to the ER (emergency room ) yesterday to confirm fracture results obtained from the in house X-ray .Returned this morning with orders for oxycodone (used to treat moderate to severe pain) . A review of the ER notes dated 4/3/23, indicated, .Displaced (the bones have come out of alignment) right distal femoral fracture . During an interview on 10/5/23, at 10:55 AM, LVN 8 stated, We always have a problem with X-rays. And the laboratory (labs). Sometimes the urine specimen was picked up after three days. I have reported it. Everyone knows the problem. During an interview on 10/5/23, at 11: 15 AM, LVN 9 stated, X-rays and labs has been a problem with (X-ray and laboratory services provider named). We have reported it to the supervisors and to the DON. We are still using the same company. During an interview on 10/6/23, at 9:10 PM, LVN 3 stated, Stat means as soon as possible. Especially for suspected fracture, it should be right away. Stat x-rays never happened. They were never on time. A doctor will order an X-ray for today, its is not going to be done until the next day. Sometimes a stat order for a Friday will be done on a Monday. It's a long wait. We have been having this problem for so long now. The supervisors and the DON is aware. During an interview on 10/6/23, at 9:19 PM, LVN 10 stated, Stat order means as soon as possible. The stat order for X-ray for the resident (Resident 7) was done on 4/3/23. We have to wait until X-ray send someone. We have reported this problem. During an interview on 10/12/23, at 4:30 PM, Medical Director acknowledged that the staff had reached out to him regarding stat orders for x-rays were not completed as ordered. MD stated, Also the labs (test, ordered by a doctor to take a samples including blood, urine, other bodily fluid, to get information about your health) it takes days before it's done. The facility was not able to provide evidence of documentation the X-ray and Laboratory services were reviewed, and the staff concerns were addressed to ensure that the services are completed as ordered by the physician to meet the residents needs. A review of the Policy and Procedure titled, Laboratory Services dated 1/1/12, indicated, To ensure the provision of Laboratory services as required for the residents at the facility. The facility will provide laboratory services in an accurate and timely manner to meet the needs of residents per Attending Physician orders. Laboratory services will be provided when ordered by the Attending physician

Based on interview and record review, the facility failed to ensure three allegations of sexual abuse (non-consensual sexual contact of any type with a resident) were reported to the State Survey Agency (SSA) within the required timeframe of two (2) hours for three of 3 sampled residents (Resident 1, Resident 2, and Resident 3). 1. Certified Nursing Assistant (CNA) 2 witnessed Resident 1 touched Resident 3's breast in July 2023, alleged incident was not reported to SSA until 8/31/23. 2. A month later, CNA 2 had witnessed same resident (Resident 1) attempted to touch inappropriately another female resident's (Resident 2) vagina in August 2023, the alleged incident was not reported to SSA. 3. On 8/31/23 at 2:10 PM, CNA 2 witnessed Resident 1 in his room sitting on his wheelchair, with pants down while Resident 2 was touching Resident 1's penis, the alleged incident was reported at 6:10 PM (4 hours after the incident). These failures resulted in delayed identification and implementation of interventions to address Resident 1's sexually inappropriate behavior towards Resident 3 and Resident 2. In addition, these failures eventually resulted in further sexual abuse on 8/31/23 when Resident 1 continued to have access to Resident 23. Furthermore, these failures had the potential to compromise the safety of all residents in the facility from unreported and uninvestigated allegations of abuse. Findings: Review of Resident 1's admission record indicated, was admitted to facility on 8/30/22 with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), dementia (a group of symptoms affecting memory, thinking and social abilities), history of alcohol abuse, mild cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions), and cognitive communication deficit (difficulty thinking and communicating). Further review, indicated, Resident 1 was his own responsible party (decision maker). Review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/1/23, indicated, Resident 1's cognition (thought process) was moderately impaired. The MDS indicated, Resident 1 did not exhibit any mood symptoms and physical behavioral symptoms directed towards others such as scratching, grabbing, and abusing others sexually. Further review of the MDS indicated, Resident 1 required supervision with set up help to one-person physical assist for bed mobility, transfer, walking, locomotion (ability to move from one place to another), eating, and toilet use. The MDS also indicated Resident 1 required extensive assistance with one-person physical assist for dressing and personal hygiene. Review of Resident 2's admission record indicated, was admitted to facility on 5/11/23 with diagnoses including encephalopathy (damage or disease that affects the brain), cognitive communication deficit, and catatonic disorder (a behavioral syndrome marked by an inability to moved normally). Review of Resident 2's MDS dated [DATE], indicated, Resident 2 has memory problem and moderately impaired decision-making skills under the staff assessment for mental status. The MDS indicated, Resident 2 had episodes of feeling or appearing down, depressed, or hopeless for 2 to 6 days under the staff assessment of resident mood. The MDS did not indicate any behavioral symptoms for Resident 2. Further review of the MDS indicated, Resident 2 required supervision with one-physical assist for transfer, walk in room, locomotion, and eating; limited assistance with one-physical assist for bed mobility and walk in corridor; extensive assistance with one-physical assist for dressing, toilet use, and personal hygiene. Review of Resident 3's admission record indicated, was admitted to facility on 12/21/22 with diagnoses including hemiplegia (complete paralysis of side of the body), hemiparesis (partial weakness or paralysis of on one side of the body), dementia, and cognitive communication deficit. Review of Resident 3's MDS dated [DATE], indicated, Resident 3's cognition was severely impairment. The MDS indicated, Resident 3 did not exhibit any mood and behavioral symptoms. Further review of the MDS indicated, Resident 3 required extensive assistance with one-person physical assist for bed mobility and total dependence with one-person physical assist for transfer, walking, locomotion, eating, toilet use, and personal hygiene. 1. Review of facility's untitled letter document dated 9/7/23, indicated, .On 8/31/2023, our resident [Resident 1] was observed in his room with a female resident who was touching his penis. The nurse separated the two residents. During the course of the investigation, it was found that [Resident 1] was involved in previous incident in July, in which he was seen touching a different resident on the breast . Review of CDPH's document titled, Complaint/Incident Intake Report, known as HS 802 indicated, the incident of Resident 1 touching Resident 3's breast was received on 9/1/23 at 5:20 PM by fax. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 8/31/23, indicated, date and time of the incident Resident 1 touching Resident 3's breast was sometime in July. This alleged incident was reported to the police by phone on 8/31/23, no time indicated; and to CDPH and Ombudsman by fax on 8/31/23, no time indicated. Review of facility document titled, Transmission Result Report, indicated, the facility faxed to CDPH on 8/31/23 at 8:03 PM. During an interview on 9/14/23, at 3:30 PM, CNA 2 stated, she witnessed the first incident involving Resident 1 and Resident 3 in July 2023 on the second-floor dining room. CNA 2 recalled the incident and stated, [Resident 1] was wheeling himself towards the dining area. I saw [Resident 1] rubbing left breast of [Resident 3] in circular motion. CNA 2 also stated, she reported the incident immediately to Licensed Vocation Nurse (LVN) 1 and took Resident 1 back to his room. During an interview on 9/14/23 at 3:46 PM, LVN 1 confirmed and stated, CNA 2 reported to her regarding Resident 1 touching Resident 3's breast but cannot remember the exact date of the incident. LVN 1 stated, I reported it (referring to touching Resident 3's breast) to Resident Care Coordinator (RCC). I don't know what happened after. No investigation after. LVN 1 explained that the witness should report to RCC and Administrator (ADM) and that she doesn't do anything after reporting an allegation of abuse. LVN 1 added, the RCC will then report to the Administrator and complete the documentation and investigation. During further interview on 9/14/23 at 3:48 PM, LVN 1 stated, Everybody are mandated reporters. LVN 1 also stated, I don't report (to the State Agency/Ombudsman). Only (report) to RCC. During concurrent interview and record review on 9/14/23 at 3:53 PM, LVN 1 was unable to find documentation of the incident in Resident 1 and Resident 3's clinical record. LVN 1 stated, I don't see it here. During an interview on 9/14/23 at 4:23 PM, RCC stated, she received two reports that involved Resident 1. RCC stated, the incident of Resident 1 touching Resident 3's breast was not reported to the Administrator/Abuse Coordinator. RCC stated, the way she understood the report was that Resident 1 tap or grab Resident 3's shoulder, therefore concluded that it was not abuse. Thus, no report and no further investigation was conducted. During further interview on 9/14/23 at 4:28 PM, RCC stated, any alleged incidents should be reported directly to the Administrator and/or designee and reporting should be whoever witness the incident. RCC further stated, a change of condition and staff interview should be conducted after a report of alleged abuse was made. During an interview on 9/14/23 at 4:52 PM, Social Worker (SW) 1 stated, she learned about the incident of Resident 1 touching Resident 3's breast during her interview with CNA 2 regarding the incident between Resident 1 and Resident 2 on 8/31/23. SW 1 further stated, the CNA, LVN, or RCC were expected to report the alleged incident of Resident 1 touching Resident 2's breast immediately or within two hours from the time they knew about the incident. During an interview on 9/14/23 at 4:59 PM, Assistant Director of Nursing (ADON) stated, the Abuse Coordinator was not notified of the touching of the breast. ADON stated, Abuse Coordinator should have been notified immediately which did not happen. During further interview on 9/14/23 at 5:03 PM, SW 1 stated that the alleged incident of Resident 1 touching Resident 3' breast was not investigated after learning about the incident. SW 1 stated, At that time the DON and Administrator said it will be taken care of but did not happen (referring to reporting and investigation of the incident). During an interview on 9/14/23 at 5:09 PM, Director of Nursing (DON) stated, There was a miscommunication between LVN 1 and RCC. RCC did not understand what LVN explained. No follow-up interview to clarify the reported incident. During a follow-up interview on 9/14/23 at 5:14 PM, RCC stated, I should have followed up more. Get more information. RCC also stated that there was no report or documentation regarding the alleged incident (referring to Resident 1 touching Resident 3's breast), I didn't do anything. No action done. 2. During an interview on 9/14/23 at 3:34 PM, CNA 2 stated, a month later, she witnessed and reported two incidents that involved Resident 1 and Resident 2. CNA 2 stated, on the same month (August 2023), prior to the reported incident on 8/31/23, [Resident 1] attempted to touch [Resident 2] vagina by the social worker's office. CNA 2 added, she reported the incident to the evening nurse and was told to monitor Resident 1 since it was only an attempt. CNA 2 further stated, she did not document the incident and cannot remember the exact date it happened. Review of Resident 1 and Resident 2's progress notes for August 2023 indicated, there was no documentation regarding Resident 1's attempt to touch Resident 2's vagina. During an interview on 9/14/23 at 4:52 PM, SW 1 stated, she was not aware of Resident 1 attempted to touch Resident 2's vagina. During an interview on 9/14/23 at 5:19 PM, RCC stated, she did not get a report regarding Resident 1 attempted to touch Resident 2's vagina in August 2023. During a follow up telephone interview on 9/26/23 at 11:58 AM, CNA 2 stated, she reported the incident of Resident 1 attempted to touch Resident 2's vagina to the evening shift nurse (LVN 3) since the incident happened before dinner. CNA 2 added, [LVN 3] told me to monitor [Resident 1] since it was only an attempt. During a telephone interview on 9/27/23 at 10:35 AM, LVN 3 confirmed and stated, CNA 2 reported Resident 1 attempted to touch Resident 2's vagina during the evening shift and the two residents were separated immediately and monitored. LVN 3 also stated, I didn't document (referring to the incident). It was an attempt. I can't remember if I reported it. During an interview on 9/27/23 at 10:38 AM, DON stated, she was not aware of the attempt of Resident 1 touching Resident 2 that was reported by CNA 2 to LVN 3. DON added, If there's a report attempting to touch, it needs to be reported immediately. We need to do something right away. 3. Review of CDPH's document titled, Complaint/Incident Intake Report, known as HS 802 indicated, the incident of Resident 2 touching Resident 1's penis was received on 9/1/23 at 10:39 AM by fax. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 8/31/23, indicated, date and time of the incident of Resident 2 touching Resident 1's penis was 8/31/23 at 2:10 PM. The incident was reported to the police by phone on 8/31/23 at 4:30 PM; the facility reported to CDPH and Ombudsman by fax on 8/31/23, no time indicated. Review of facility document titled, Transmission Result Report, indicated, the facility faxed to CDPH on 8/31/23 at 6:10 PM and to Ombudsman on 8/31/23 at 6:11 PM (4 hours after the incident). During an interview on 9/14/23 at 3:40 PM, CNA 2 stated that on 8/31/23, she was walking by Resident 1's room towards the nursing station and noticed the door was open and saw Resident 2 standing in front of Resident 1 who was sitting on his wheelchair. CNA 2 stated, [Resident 1] pull-ups (disposable brief) were down. [Resident 2] was touching his penis. CNA 2 further stated, she called Resident Care Coordinator (RCC) and was told to separate the two residents and bring Resident 2 back to her room. During further interview, CNA 2 stated, she was suspended during the investigation of the incident on 8/31/23 (Resident 1 and Resident 2) because she did not report the July 2023 (breast) incident directly to the Administrator. CNA 2 added that she reported the incident immediately to the charge nurse. CNA 2 then stated, It doesn't make sense to suspend me. Now I'm afraid to report. I might get suspended again. During an interview on 9/14/23 at 4:19 PM, RCC stated, CNA 2 called her to go to Resident 1's room whose sitting on a wheelchair with his pants down while Resident 2 was standing in front holding his penis. RCC stated, the two residents were separated immediately and told CNA 2 to assist Resident 2 to her room. RCC also stated that she brought CNA 2 to the ADON to report the incident. During an interview on 9/14/23 at 4:52 PM, SW 1 stated, she interviewed the staff regarding the incident and assisted the ADON in completing form SOC 341. SW 1 then stated, the DON and Administrator did the reporting and investigation of the incident. Review of Resident 1's Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together toward the goals of the residents) Note dated 9/7/23, indicated, Staff reported this resident (Resident 1) was with a female resident (Resident 2) in his room, touching his penis on 8/31/23 . Upon investigation of this incident on 8/31/23, we found that this same resident (Resident 1) was involved with another incident of touching the breast area of a female resident (Resident 3) in the dining hall in the month of July . The IDT Note indicated, Administrator, Abuse Coordinator, DON (Director of Nursing), MD (Medical Doctor), RP (responsible party), police, CDPH and Ombudsman were notified of the incident. The IDT Note did not indicate the incident of Resident 1 touching Resident 3's breast and attempt to touch Resident 2's vagina was further discussed and investigated. During a joint interview on 9/14/23 at 5:27 PM, ADM and Nurse Consultant stated, the two staff (CNA 2 and LVN 1) were suspended for not reporting immediately to the Administrator. During a concurrent interview and record review on 9/27/23 at 10:44 AM, DON stated there was no investigation and IDT conducted regarding the two incidents of Resident 1 touching Resident 3's breast and the attempt to touch Resident 2's vagina. During an interview on 9/27/23 at 1:08 PM, ADM stated, any allegations of abuse need to be reported by phone right away and faxed SOC 341 to SSA within two hours of the incident. Review of the facility's policy and procedure titled, Abuse Reporting and Investigations, revised 7/31/23 with effective date of 8/18/23, indicated, .The Facility promptly reports and thorough investigates allegations of resident abuse, mistreatment, neglect, exploitation, abuse facilitated or enabled by the use of technology, misappropriation of resident property, or injuries of unknown source, and suspicions of crimes . a. Allegations of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime to be reported to the Administrator or designated representative immediately. b. When the Administrator or designated representative receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, abuse facilitated or enabled technology, exploitation, or injuries of unknow source, or suspicion of a crime, the Administrator or designated representative will initiate an investigation immediately . ii. The facility will not inhibit facility staff/covered individuals from their mandated reporting obligations. iii. Facility staff/covered individuals will not be disciplined or retaliated against for good-faith reporting . 3. Notification of Outside Agencies of Allegations of Abuse . b. Administrator or designed representative will notify the LTC (Long Term Care) Ombudsman, and CDPH (California Department of Public Health) by telephone and in writing (SOC 341) within two (2) hours of an initial report. 4. Notification of Outside Agencies of Allegations of Abuse Caused by a Resident with Dementia diagnosed by a Physician . i. The Administrator or designated representative will notify within two (2) hours, notify by telephone, CDPH, the Ombudsman and Law Enforcement. ii. The Administrator or designated representative will send a written SOC 341 report to the Ombudsman and Law Enforcement and CDPH Licensing and Certification within 2 hours. 5. Notification of Outside Agencies of Allegation of Abuse With No Serious Bodily Injury - a. The Administrator or designated representative will notify within two (2) hours notify, by telephone, CDPH, the Ombudsman and Law Enforcement. b. The Administrator or designated representative will send a written SOC 341 report to the Ombudsman and Law Enforcement and CDPH Licensing and Certification within two (2) hours .

Based on observation, interview and record review, the facility failed to monitor and manage the pain Resident 13 was experiencing in the stomach, groin and catheter insertion area when the resident was lying in distress alone in his room. This untimely pain monitoring, management and intervention deficient practice on this morning shift, resulted in Resident 13 experiencing excruciating and uncontrollable pain level of 10 out of 10 in the numerical pain scale, when zero is no pain and 10 is the worst pain. Findings: During concurrent observation and interview on 9/7/22 at 11:00am, Surveyor walked into the resident's room and saw him in distress, moving his head side to side, almost crying and pointing his fingers to his stomach, groin and catheter insertion area. Resident who does not talk could not explain to Surveyor what his problem was. At this point his finger pointing intensified and his face color turned reddish. Surveyor checked his catheter, it had 600cc of brown colored urine. Surveyor called on his primary certified nurse assistant (CNA 3) to find out what was going on. CNA 3 could not make out the reason for the resident's distress. Surveyor called for the nurse manager. Registered Nurse 1 (RN1) assessed the situation, then emptied the catheter bag with brownish urine content. Resident 13 signaled feeling a relief. CNA 3 checked the catheter connection. Licensed Vocational Nurse (LVN 5) came in, spoke to the resident in Spanish and translated that the resident said that he was in pain and that he wanted to urinate but could not get the urine out. Asked CNA3 of the last time she saw the resident that morning. CNA 3 could not answer though she documented that his pain that morning was zero. During concurrent observation and interview at 2:30 pm on 9/7/22, after walking back into the resident's room to check on the resident, surveyor saw the urine content of the new catheter bag bloody, the resident's waist area was completely wet and he was pointing at these. During interview with the RN 1 about the color of the urine and wetness of the whole waist area, she stated she had just changed the catheter. Then she began to examine the wet area. When asked if she flushed the catheter after the change, she stated that the resident had neurogenic bladder (loss of bladder control). She also stated that one of the resident's problems before the catheter change was that the resident had said he wanted to urinate but he could not and he felt distressed. She further stated that resident wanted the catheter changed and that he was in pain. She also stated that resident complained that the tape on the stat lock (foley catheter stabilization device) was causing him the pain in the groin area. When asked about the intensity of the resident's pain, she stated that it was 9/10 before the catheter change but had gone down to 5/10 after. When asked if she assessed for fever, she stated that there was no fever, resident had neurogenic bladder (lack of bladder control) problem hence on permanent catheter. When asked how often they change the catheter; she stated if there's an obstruction or leakage. During observation and concurrent interview on 9/8/22 at 10:00am, Surveyor went back to check on Resident who was still complaining of pain. Surveyor inquired from the RN 1 if his Physician and family were called, she stated she had done that today, 9/8/22. Later that day resident was transferred to an acute care hospital for an excruciating and uncontrollable pain. During the Surveyor's call back to the facility, on 9/8/22 at 5:00 pm to check on Resident 13, RN 1 stated that Resident 13 was sent to the acute care hospital for excruciating and uncontrollable pain but he was sent back to the facility after the catheter was changed and resident got relief. Nurse's Note on 9/8/22 at 18:50 indicated, resident was sent to acute hospital on a gurney for uncontrollable pain. The writer flushed resident foley catheter with 20 cc of normal saline to help with pain. Patient pain did not reside. Family wanted pt sent out to the hospital. During the review of the Minimum Data Set (MDS), an assessment instrument dated 07/7/22, it indicated that Resident 13's Brief Interview for Mental Status (BIMS) score was 99 (resident unable to complete the interview). The MDS indicated that Resident was diagnosed with neurogenic bladder and bowel (lack of bladder and bowel control due to a brain, spinal cord or nerve problem), aphasia (loss of ability to understand or express speech), Cerebrovascular Accident (CVA, Stroke), severe cognitive impairment, was totally dependent with one-person physical assist for bed mobility, locomotion (movement) on and off the unit, dressing, toilet use, personal hygiene and bathing, and was always incontinent of bowel and bladder. During the review of a document titled [Named Hospital] Primary dated 9/27/22, page 12 indicated, [AGE] year old male lying supine in facility bed with fire department in care. Per caregiver present at scene, patient complains of pain from catheter Medical History: 110 - . personal history of (healed) traumatic fracture, dysphagia, . Other chronic pain . During the review of the Doctor's (Dr's) order dated 6/24/22 (still active) on 9/14/22 at 10:00am, it indicated: assess for pain per shift and chart the intensity of pain using 1-10 numeric pain level in pain scale 0-1 = no pain, 1-4 =mild pain, 5-7 = moderate pain, 8-9 = severe pain and 10 excruciating pain. The Physician order also indicated change catheter every 30 days or as needed. During the review of Nurses Care plan intervention on 9/14/22 dated 6/25/22 (still active), it indicated: Monitor and/document for pain/discomfort due to catheter (initiated). Monitor/record/report to MD for s/sx (sign/symptom) of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature Change in behavior. During a review of the Progress Notes on 9/28/22, it indicated that Resident 13 was diagnosed with Chronic pain. During the review of Medication Administration Record (MAR) on 9/28/22 at 3:13 pm for July 1-31, 22 and August 1-31, 22, there was no indication of pain monitoring or medication administration. It stated N/A. The MAR for [DATE]-30, 22, indicated that Tylenol 325 MG was administered to Resident 13 at 1631 with a pain level of 8. During record review of the facility's Policy and Procedure (P&P) on 9/28/22, page 1-2 of 4, it indicated that: a) The Licensed Nurse will complete a Pain Assessment for residents identified as having pain. the Nurse will complete the pain flow sheet for residents receiving PRN pain medication to evaluate effectiveness of the pain medication regimen Nursing staff will implement timely interventions to reduce an increase in severity of pain

Based on interview and record review, the facility failed to ensure neglect did not occur for seven Residents (Residents 9, 10, 11, 12, 13, 14, and 15) reviewed by the DOJ (Department of Justice) and abuse did not occur for Resident 8, one of four sampled residents reviewed by this Department (CDPH, California Department of Public Health). 1. The facility failed to ensure there was enough staff to provide ROM (range of motion) services to residents. A DOJ inspection found seven residents (Residents 9, 10, 11, 12, 13, 14, and 15) with documented functional limitations in range of motion and lack of current plans of care related to those limitations. Further investigation by this Department (CDPH) uncovered evidence staff were unable to provide ROM services due to inadequate staffing. Failure to provide ROM services to residents had the potential to lead to contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and decrease mobility for residents with ROM problems . 2. CNA (Certified Nursing Assistant) 5 threw and hit Resident 8 on the face (one of 4 sampled residents) with dirty linen. A reasonable person living in the facility and requiring extensive assistance of staff with care would feel angry, unsafe, anxious, and fearful after having soiled linen thrown in their face. Failure to protect resident 8 from abuse did not ensure all resident were protected from abuse. Findings: 1. Lack of ROM Review of a DOJ subcontractor's emails sent to CDPH on 04/16/2022 at 3:36 PM and 5:01 PM, indicated the DOJ conducted an inspection of the facility from 04/14/2022 to 04/15/2022. During the inspection, the DOJ team identified Seven of these residents . had previously documented contractures. All these residents' contractures may have worsened due to no treatment or inadequate treatment. On 04/29/2022 at 12:08 PM, the DON (Director of Nursing) and the Administrator were interviewed regarding the DOJ's ROM findings. The Administrator stated these were mostly documentations issues and she was sure that her staff were providing ROM services. However, statements provided by a family member and three employees regarding staffing shortages and lack of provision of ROM services to residents contradicted the Administrator's conclusion that the DOJ's ROM findings were purely documentation issues. During an interview on 06/16/2022 at 9:12AM, Resident 1's Family Member (RFM1) stated The staff tell me all the time that they are short and they have to do double (working an extra shift to cover for lack of staffing). The management they don't seem to be hiring much. I used to go there three times a day before the COVID lock down. (my mom) used to walk before. But now she doesn't walk. They tell me they have no people to walk her. During an interview on 6/15/22 3:38 PM, CNA 1 stated Staffing is a problem. We are short. They have registry but it's not enough. When asked about ROM and walking her residents, CNA 1 stated .I'm telling you the truth we cannot do it (ROM and walking the resident). There is an RNA (Restorative Nursing Assistant) I don't know what they are doing. They (only work with) specific .(residents). I'm a CNA it's really hard for me. it's not good. We cannot give the right care. During an interview on 6/15/22 3:59 PM, CNA 2 stated Most of the time (we are) short of staff, CNA, and nurses we cannot give quality care.Mostly . of the time we are short . ROM and walking the patient the RNA and PT (Physical Therapist) delegate to the CNA we cannot do the ROM . you need another 8 hours to complete the ROM for . (your) patients with 2 meals. (for) Contracted (residents) it's very hard to work with them 15-20 minutes. Then you have to clean them and give them bed bath it's very hard. There's no time to do ROM. During an interview on 6/15/22 4:14 PM, CNA 3 stated (I have a lot of) . (residents) almost every day and I can tell you, how can you give good care to . (all your residents) in 8 hours. CNA 3 was asked if she can do ROM and walking for her residents. CNA 3 stated . with .(my residents), we cannot. Review of a facility's policy titled Abuse - Prevention, Screening, & Training Program, revised on 6/2022, defined neglect as .failure to provide goods and services necessary to attain or maintain physical, mental, and psychosocial well-being, and avoid physical harm, pain, mental anguish, or emotional distress. 2. Resident 8 Review of Resident 8's MDS (Minimum Data Set, a standardized resident assessment tool), dated 05/25/2022, indicated Resident 8 was an elderly female admitted to the facility on [DATE] with multiple diagnoses including [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 8's MDS indicated she required extensive assistance of one staff for bed mobility, transfers, and dressing. Review of a facility letter sent to this Department (CDPH), dated 04/01/2022, indicated .On Sunday, March 27, 2022, at around 10:30 AM, the Medical Records Supervisor informed the Administrator that she witnessed a Certified Nursing Assistant (CNA 5) . hitting .(Resident 8) with dirty linen. According to the Medical Records Supervisor, . she was near . (Resident 8's) room when she saw . (CNA 5) smack the resident on the face with soiled linen. (based on staff interview, CNA 5) positioned the soiled linen that he was holding and placed it on .(Resident 8's) face using his right hand Based on the investigation, the . (facility) finds the allegation substantiated due to witness statements. The accused . (CNA 5) was placed on administrative leave during the investigation and was subsequently terminated. During an interview on 06/30/2022 at 10:15 AM, the MRS (Medical Record Supervisor) stated I don't remember the exact date. I was in unit 3 with my other staff. On 2nd floor. We were doing the door labeling. Around 9:45 to 10 AM, I heard the resident (from bed 1, Resident 8) started screaming and then I saw . (CNA 5), he was throwing on her face the soiled cloth and linen from bed 2 to . (resident 8's) face. I told the CNA stop. During an interview on 06/30/2022 at 11:37 AM, Resident 8 was unable to remember or provide any information regarding her interactions with CNA 5 on 03/27/2022. Resident 8 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . However, a reasonable person (with no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 06/30/2022 at 10:38 AM, the Assistant Administrator (AA) stated QA (Quality Assurance Department) has looked at this (abuse) issue. The initial part would be an IDT meeting (Inter-disciplinary Team, a team consisting of health care professionals from various fields) so that we can create immediate interventions. Facility failed to analyze root cause of the abuse and implement systemic changes to prevent abuse During an interview on 06/30/2022 at 1:10 PM, the QA (Quality Assurance) nurse stated she was involved in abuse cases as soon as possible. The QA nurse stated part of her job was to ensure all documentations were done regarding abuse cases. The QA nurse stated in general it would take one to two weeks to do a root cause analysis of an abuse case. The QA nurse was able to identify staffing problems, staff burn out, inadequate monitoring of direct care staff by supervisors, and abuse/neglect training as potential systemic issues that could lead to abuse. The QA nurse was asked to provide documented evidence of a root cause analysis of Resident 8's abuse, back on 03/27/2022 (almost 95 days ago) and documented evidence the facility has implemented systemic changes to prevent abuse. The QA nurse was unable to provide the requested documents. The facility knew another resident made an allegation of abuse against CNA 5 (see F867) back in 04/18/2021. The facility was unable to provide documented evidence CNA 5 was under increased supervisory monitoring after the allegation. The facility was unable to provide documented evidence there was regular monitoring of residents under CNA 5's care for evidence of abuse/neglect when CNA 5 returned to his regular duties after the 04/18/2021 abuse allegation investigation. Review of a facility policy titled Abuse - Prevention, Screening, & Training Program, revised on 6/2022, indicated The facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. The facility develops policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. The Administrator as the Abuse Prevention Coordinator, is responsible for the coordination and implementation of the facility's abuse prevention, screening, and training program policies and procedures.

Based on observation, interview and record review, the facility failed to permit a resident to return to the facility after hospitalization for one of three sampled residents (Resident 1). Resident 1 was transferred to an acute care hospital for evaluation of high temperature on [DATE], and ready to return by [DATE]. The facility decided not to readmit Resident 1. On [DATE], the facility told the acute care hospital on their refusal to accept Resident 1. This failure to readmit Resident 1 resulted in Resident 1 emotional stress, was upset and feeling belittled. The facility did not follow their own policy and procedures on Bed Hold, Transfer and Discharge, and Readmission. Findings: Resident 1 was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was on Medicare and Medicaid. During a telephone interview on [DATE] at 10 a.m. with the Complainant, the Complainant stated, Resident 1 had filed an involuntary discharge hearing, and waiting for the result. Resident 1 needed (urinary) indwelling catheter changes often. Resident 1 had urinary infection, a lot of pain and was not treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was transferred to an acute care hospital for treatment on [DATE], and was not readmitted to the facility as of [DATE]. The facility stated no bed, incomparable with Resident 1. Resident 1 was a large size. Resident 1 was very upset and feeling belittled on the facility's refusal for re-admission. Resident 1 specified the desire to return to the facility and happy with the nursing care. Complainant visited the facility and found Resident 1's bed was empty and the personal belongings were still there on [DATE]. Complainant stated the facility was possibly in retaliation by not readmitting Resident 1, based on an early complaint (CA 982 regarding Quality of Care/Treatment. A complaint on the facility for a misread laboratory report and delayed in treatments for urinary infection of Resident 1). Resident 1 was transferred to another facility on [DATE]. During an interview on [DATE] at 10:50 a.m. with the Administrator Assistant, the Administrator Assistant stated Resident 1 was transferred to an acute care hospital for treatments on [DATE]. The Administrator Assistant stated the facility might re-admit Resident 1 if the hearing for involuntary discharge call for re-admission. During an interview on [DATE] at 11 a.m. with the Director of Nurses (DON), DON stated Resident 1 was transferred to an acute care hospital, emergency room (ER), on [DATE] and not readmitted (since [DATE]). DON stated there was no written notification of bed hold and refusal for re-admission. DON stated Resident 1 was not readmitted and the facility had requested the acute care hospital to transfer Resident 1 to another hospital due to need was not able to meet. DON stated before there was a laboratory result (urinary infection), a delay in treatments, and Resident 1 complained. DON stated the facility had no written documentation on the refusal to readmit Resident 1, no written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated there was a hearing for involuntary discharge and waiting for the result. DON had given their reasons for the refusal to re-admit Resident 1 during the hearing. DON stated understanding of the bed hold policy and there was no doctor's order not to re-admit Resident 1. DON stated DON did not refused to re-admit Resident 1. During an interview on [DATE] at 3:50 p.m., with Regulatory Affairs Program Manager, the Regulatory Affairs Program Manager stated the acute care hospital had requested re-admission for Resident 1 by [DATE] and provided documentation. During record review of The State Of California, Department Of Health Care Services, Office Of Administrative Hearings And Appeals. Appeal No.: RTR[DATE]-[NAME], Decision And Order, dated [DATE], indicated, under ISSUE: Whether facility must readmit Resident 1. Under FINDINGS OF FACT: The facility was a long-term health care facility that participates in the Medicare and Medicaid (Medi-Cal) programs. Resident 1 was a Medicare and Medi-Cal beneficiary who was admitted to the facility on [DATE]. On [DATE], Resident 1 moved from the facility, where Resident 1 had been residing, to a hospital for treatment. On ,d+[DATE] and ,d+[DATE], Resident 1 requested re-admission to the facility. On [DATE], the facility informed the hospital by phone, that it would not readmit Resident 1. On the refusal to readmit Resident 1, the facility did not provide Resident 1 with a written transfer/discharge notice including the location to which Resident 1 was to be transferred or discharged . It was also established on record that Resident 1 or representative did not receive a written bed-hold notice. On [DATE], Resident 1 was admitted to another facility, where Resident 1 currently resided. On [DATE], Resident 1 filed an appeal of the facility's refusal to readmit. Under REASONS FOR DECISION: A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. Under the law, the refusal of a facility to readmit a resident following a period of hospitalization was treated as an involuntary transfer. The same rights and procedures apply. To conduct a transfer/discharge, a facility must follow designated procedures including providing written notice stating the location to which the resident is to be transferred or discharged . In this case, the facility refused to permit Resident 1 to return to the facility following a period of hospitalization . Therefore, the refusal must be treated as a transfer/discharge and the same rights and procedures apply, including issuing a notice of transfer/discharge. This notice requirement on a refusal to readmit was in addition to any notice requirement that might apply to an initial transfer from a facility to the hospital. For the refusal to readmit, the facility did not provide Resident 1 with a written transfer/discharge notice including the location to which the resident was to be transferred or discharged . Accordingly, the refusal to readmit was improper and the facility must follow a general policy of permitting Resident 1 to return after the period of hospitalization . Facility offered arguments in support of its refusal to readmit Resident 1. None of its arguments constituted a legally recognized exception to the requirement of complying with the discharge/transfer regulation when there was a refusal to readmit. Therefore, the facility's arguments did not change the outcome in this case. Under ORDER: The appeal was granted. The facility should permit Resident 1 to return to the facility. This was the final decision and order of the Department and no further administrative remedies were available. If disagree with this decision, the facility might file a Petition for Writ of Mandate with the Superior Court. During a record review of the acute care hospital Case Manager 1's (CM 1) notes, dated [DATE], indicated CM 1 spoke to the facility's admission coordinator on Resident 1's return by 3 p.m. on [DATE]. During a record review of the acute care hospital Case Manager 2's (CM 2) notes, dated ,d+[DATE] and ,d+[DATE], CM 2 indicated Resident 1 was medically cleared for discharge on [DATE], and the facility's admission coordinator stated no available bed and Resident 1's bed hold was expired. On [DATE], when CM 2 tried to verify with the facility on when to admit Resident 1, the facility's admission coordinator stated no available beds at the moment and the other answer was no staffing. CM 2 was also advised by the facility's admission coordinator that new admissions were already lined up. During a record review of the acute care hospital Case Manager 3's (CM 3) notes, dated [DATE], CM 3 indicated a message was sent to the facility regarding Resident 1 was ready for discharge today, and the facility's admission coordinator response, they are not doing admission today. During a record review of the acute care hospital Community Case Manager 1's (CCM 1) notes, dated [DATE], indicated, CCM 1 requested to assist with Resident 1's return to the facility and spoke to the facility's admission coordinator. The facility's admission coordinator stated Resident 1's bedhold had expired and the bed was filled by a new admission, but that he would discuss with clinical team regarding Resident 1. Resident 1 was previously in a private room, which had been given away and currently only three-person room beds available. CCM 1 advised the facility's admission coordinator of Resident 1's right to return to the home facility and requested clarification of the clinical needs that could not be met at their facility, including clinical indication for isolation/private room? The facility's admission coordinator stated would discuss with clinical team. Later in the day of [DATE], the facility's admission coordinator call back and stated, We cannot accept Resident 1 back because the family member is not satisfied with the care here. CCM 1 indicated an acute care hospital Case Manager had previously documented that both Resident 1 and the family member were in agreement to return to the facility. During a record review of the acute care hospital CCM 1 notes, dated [DATE], indicated, the facility's Director of Nurses (DON) stated Resident 1 and the family had dissatisfaction with the care at the facility, including an incident with inserting a Foley catheter (a urinary tract catheter for urination) that caused Resident 1 a lot of pain and led Resident 1 to question the competency of staff at the facility. DON stated that she was confident in the capabilities of the staff and that Resident 1's clinical needs could be met at the facility. DON stated since Resident 1 and the family member had expressed dissatisfaction with the facility, it would be best for Resident 1 to find alternative placement and therefore the facility was refusing to accept Resident 1's return. During a record review of the acute care hospital Regulatory Affairs Program Manager email to the facility's Chief Executive Officer (CEO), dated [DATE], indicated, Resident 1 had been a resident at the facility for a year until the acute care hospital admission on [DATE]. On [DATE], Resident 1's physicians had cleared discharge to the facility and at that time the acute care hospital was informed that the bed hold had expired and there were no beds. On [DATE], the facility's admission coordinator informed the acute care hospital that despite the facility's ability to meet Resident's medical needs, the facility was refusing to take the patient back. On [DATE], CCM 1 spoke with the facility's DON about the refusal and DON informed the acute care hospital that the decision was based upon Resident 1 and the family's dissatisfaction with the care at the facility. The acute care hospital Director of Care Coordination spoke with both Resident 1 and the family member, who stated they were content with the clinical care there and had asked to return to the facility. There was no documented evidence of a response from the facility's CEO. Review of the facility's Admission/Discharge To/From Report for [DATE] to [DATE] indicated a total of 17 discharges [Ten (10) in October, 2021, six (6) in November, 2021, and one (1) in [DATE]-2, 2021]. [There was an error in the record when it indicated Resident was discharged to an acute care hospital on [DATE] when in fact Resident 1 was discharged to another acute care hospital and the date was since [DATE] but the seven-day bed hold could make the date to become [DATE]]. The facility had stated Resident 1's bed was filled by a new admission on [DATE] when the acute care hospital community case manager (CCM 1) requested to assist Resident 1's return to the facility [the acute care hospital Community Case Manager 1's notes, dated [DATE]]. Review of the facility's Care Conference Summary, dated [DATE] (latest Resident 1's Care Conference Summary provided by the Administrator Assistant on [DATE]), indicated Resident 1 was alert to person, place, time, and situation. Able to verbalize needs. Incontinent of Bowel and Bladder. Complains of burning pain with urination .No other c/o (complaint of) pain at this time .Lungs are clear .Bowel sounds present .No [CONDITION(S)] to lower extremities. No SOB (shortness of breath) or respiratory distress. MD (medical doctor) aware of residents return to facility and medication was reviewed .SS (social services) confirmed the resident's upcoming appointments and transportation services. RP (resident representative) made aware of visitation guidelines and the facility's current COVID-19 (a pandemic infection) protocols. Resident continues to participate independent activities in room, ie (that is): reading, watching TV (television), and doing puzzles. Resident receives visits from Activity Staff to offer activities materials of preference. There was no documented evidence to indicate in the Care Conference Summary of not able to care for Resident 1 or short of staffing. During a review of the facility's policy and procedures titled, Bed Hold, revised date was in July, 2017, indicated, the purpose was To ensure that the resident and the representative is aware of the facility's bed-hold policy, and that such policy complies with state and federal law and regulations. The policy included, In the event that the resident is in the hospital for more than seven (7) days, meets the standards for skilled nursing care, and is Medi-Cal/Medicaid eligible, the facility will readmit the resident to his/her previous room or the first available bed in a semi-private room. The Procedure included, Transfer to an acute care hospital/therapeutic leave .The Facility notifies the resident and/or representative, in writing, of the bed hold, option, any time the resident is transferred to an acute care hospital or requests therapeutic leave. There was no documented evidence on meeting the purpose, policy, and procedures of the facility's Bed Hold policy and procedures. The facility failed to meet their own policy and procedures for Bed Hold. During a review of the facility's policy and procedures titled, Transfer and Discharge, revised date was in October, 2017, indicated, the purpose was To ensure that adequate preparation and assistance is provided to residents prior to transfer or discharge from the facility. The policy included, Social Services Staff will participate in assisting the resident with transfers and discharges, and preparing the Discharge Summary and post discharge plan of care/discharge instructions. Social Services Staff will conduct a discharge Planning Assessment, develop a post discharge plan of care, and orient the resident to the impending discharge. The Procedure included, Notice of Discharge .When possible, the facility should provide at least 30 days' notice before the resident is transferred or discharged . Less than 30 days's notice may be made as soon as practicable before transfer or discharge when: An immediate transfer or discharge is required by the resident's urgent medical needs .The Notice of Proposed Transfer and Discharge will be signed by the resident .Discharge Car Plan. A. Based on resident needs, Social Services Staff will develop a Discharge Care Plan in coordination with the IDT (interdisciplinary team). B. Post discharge instructions will be provided to the resident and/or responsible party at the time of discharge. There was no documented evidence on meeting the purpose, policy, and procedures of the facility's Transfer and Discharge policy and procedures. The facility failed to meet their own policy and procedures for Transfer and Discharge. During a review of the facility's policy and procedures titled, Readmission, revised date on [DATE], indicated, the purpose was to provide for the readmission of residents who require skilled nursing care at the facility. The Policy included, The facility will provide for the readmission of residents who require services provided by the facility .An individual is a readmit if he or she was readmitted to a facility from a hospital to which he or she was transferred for the purpose of receiving care. The Procedure included, The facility will allow residents who were previously residents of the facility to be readmitted to the facility. There was no documented evidence on meeting the purpose, policy, and procedures of the facility's Readmission policy and procedures. The facility failed to follow their own policy and procedures for Readmission.

Based on interview and record review, the facility failed to evaluate and implement interventions that are consistent with the nutritional status for one of 3 sampled residents (Resident 1) when: 1. There were no interventions implemented when Resident 1 was experiencing a decline in nutrition and hydration. 2. There was no referral for the registered dietitian (RD - a health professional with special training in diet and nutrition) to evaluate Resident 1's nutritional status. 3. Resident monitoring and assessment was not completed when Resident 1 had a change of condition related to decreased meal intake and onset of low grade fever. These failures resulted in progressive decline in nutrition and compromised the health of Resident 1. Findings: 1. Review of the clinical record for Resident 1 indicated, Resident 1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 1/11/21 indicated, impaired memory and cognitive skills for daily decision making. The mood and behavior assessment dated [DATE] indicated, no signs of poor appetite present. The functional status assessment dated [DATE] indicated, total dependence with one-person assist on her activities of daily living (ADL) that includes eating. During an interview with Registered Nurse (RN) 1, on 3/5/21, at 4:20 PM, RN 1 stated Resident 1 was exposed to roommate on 1/7/21 and staff on 1/12/20 who tested positive for coronavirus disease 2019 (COVID-19 - a [CONDITION(S)] disease caused by coronavirus called [CONDITION(S)]-CoV-2). Resident 1 was transferred to the yellow zone (a designated unit for residents under investigation post exposure to COVID-19) on 1/7/21 after being exposed to the roommate. RN 1 stated the all residents were tested every Saturday and that Resident 1's COVID-19 test result were all negative. Review of the SBAR (an acronym for Situation, Background, Assessment, Recommendation - a technique used to facilitate prompt and appropriate communication) dated 1/12/21, indicated, a change of condition for COVID-19 exposure was completed. The observation summary indicated Resident 1 remained stable with no symptoms; RP was then notified of resident's possible exposure from a resident who tested positive for COVID-19. Resident 1 was placed on transmission-based precautions, the second tier of basic infection control and are to be used in addition to Standard Precautions (the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered) for patients who may be infected or colonized (presence of microorganisms in or on a host with growth and multiplication but without tissue invasion or damage) with certain infectious agents for which additional precautions are needed to prevent infection transmission. Review of the Progress Notes for Resident 1, dated 1/19/21, indicated, It has been more than 14 days since onset of symptoms and more than 7 days since resolution of fever and respiratory symptoms. N.O. (new order) for D/C (discontinue) transmission based precautions . N.O. to d/c initiate transmission based precautions standard + (plus/and) contact + droplet + eye protection every shift for suspected covid-19 (PUI [persons under investigation]). During a review of the clinical record for Resident 1, the SBAR dated 1/21/21, indicated, Resident 1 had a change of condition due to decrease in meal intake with new onset of low grade fever. The observation summary indicated, All meal intake is less than 25%. Fluid intake less than 25%. Low grade fever (a temperature that falls between 99.5 degrees Fahrenheit [ F, a temperature scale] and 100.3 F) of 99.5. No apparent distress noted. Review of the Progress Notes dated 1/21/21, indicated, Noted decrease in all meal intake . No other signs of covid-19 suspected besides fever and decrease in appetite . Will continue to monitor I & O (intake and output) . The Progress Notes dated 1/21/21 indicated, Late entry for 1/20/2021 - able to have FaceTime (a software used for video calling) with her children. During an interview with Resident 1's RP on 3/1/21, at 11:47 AM, the RP stated Resident 1 passed away on 1/30/21. RP stated on 1/4/21, Resident 1 celebrated her birthday , had no problems with food intake and was eating 100%. On 1/13/21, RP was notified that the assigned Certified Nursing Assistant (CNA) for Resident 1 was sent home to quarantine (a restriction on the movement of people, animals and goods which is intended to prevent the spread of disease or pests). On 1/20/21, RP did FaceTime with Resident 1; per RP, Resident 1 has lost so much and appeared sluggish and sleepy. On 1/21/21, RP was notified that Resident 1 had a fever of 99.9 F and was not eating; RP was also informed that Resident 1 tested negative for COVID-19. On 1/27/21, RP last saw Resident 1 on FaceTime; per RP, Resident 1 was not responding . not eating . mom shrank . so skinny . really thin . Hospice care (a type of health care that focuses on comfort and quality of life by reducing pain and suffering.) was recommended and RP agreed to admit Resident 1 on hospice care on 1/29/21. RP stated Resident 1 was skin and bones when she passed away on 1/30/21. During a review of the clinical record for Resident 1, the Doctor's Progress Notes dated 1/29/21, indicated, . now appears to be transitioning, legs mottled, not eating . continue supportive care. The Progress Notes dated 1/31/21, indicated, Resident 1 passed away at 8:26 PM. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with CNA 1, on 3/5/21, at 4:27 PM, CNA 1 stated Resident 1 was total dependent with eating and though resident was slow to feed, resident had a good appetite and was eating well. CNA 1 was the regular CNA for Resident 1 prior to being placed on quarantine due to COVID-19 and last took care of resident on 1/13/21. During an interview with RN 1 on 5/19/21, at 12:54 PM, RN 1 stated Resident 1 had a significant change related to poor oral intake for more than a week, thus a change of condition was completed on 1/21/21. Review of Resident 1's meal intake record for the month of January 2021, indicated, Resident 1 ate an average of 75% from 1/1/21 to 1/10/21. Resident 1's meal intake indicated a decline from 1/11/21 to 1/23/21 with an average of 20%. From 1/24/21 to 1/29/21, Resident 1's meal intake continue to decline from 20% to 0%. Review of Resident 1's care plan dated 10/12/20, indicated, resident was at risk for weight loss and dehydration. The nutritional status care plan indicated interventions including dietitian to assess nutrition and hydration as needed, maintain intake and output (I & O) log, and to weigh resident. The change of condition care plan, dated 1/21/21, indicated decrease in meal intake with low grade fever with a goal of will minimize risk for further decline in condition; and interventions including obtain laboratory test, X-ray and refer for further consultation with dietary. The care plan indicated no specific interventions addressing Resident 1's recent change in nutrition and hydration status. During an interview on 5/19/21, at 2:22 PM, RN 1 acknowledged the interventions in the care plan was not specific to the recent change in nutrition and hydration status for Resident 1. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders obtained for laboratory tests, I & O monitoring, weight monitoring, and a dietary consult related to Resident 1's change of condition. During a concurrent interview and record review on 5/19/21, at 2:22 PM, with RN 1, the clinical record for Resident 1 was reviewed. RN 1 was unable to find documentation of laboratory results, I & O log and the most recent record of weight. RN 1 stated the RD was not notified of Resident 1's recent change in nutrition and hydration on 1/21/21. RN 1 acknowledged the interventions in Resident 1's care plan was not implemented. During an interview on 5/25/21, at 8:45 AM, with RD 1, RD 1 stated weights should be obtained for residents experiencing weight changes or variances, decline in oral intake, and/or any change in nutritional status. RD 1 acknowledged she was not notified of Resident 1's change in nutritional status and that her last nutritional evaluation for Resident 1 was on 1/11/21 when Resident 1 was still stable. Review of the facility's policy and procedure titled, Change of Condition Notification, dated 4/1/15, indicated, .II. The Licensed Nurse will assess the change of condition and determine what nursing interventions are appropriate . Review of the facility's policy and procedure titled, Evaluation of Weight and Nutritional Status, dated 10/2018, indicated, .I. The Facility will work to maintain an acceptable nutritional status for residents by: . C. Defining and implementing interventions for maintaining, or improving nutritional status that are consistent with resident needs, goals, and recognized standards of practice. E. Revising or discontinuing the approaches as appropriate, or justifying the continuation of current approaches . 2. Review of the Nutritional Evaluation for Resident 1, dated 1/11/21, indicated, the reason for assessment as Annual. Resident 1's weight on 1/11/21 was 93.8 pounds (lbs.). Resident 1 was on thickened liquids, mechanically altered diet (foods that can be safely and successfully swallowed), Glucerna (a brand name of nutritional supplement) twice a day (BID). Resident 1's diet was regular, pureed (a smooth, creamy substance made of liquidized or crushed vegetables); fluid was nectar thick. The Nutrition Interventions/Recommendations section indicated, Rt [sic] (Resident) has had a stable weight over the quarter. BMI (Body Mass Index-a measure of body fat based on height and weight) 15.2. on appropriate supplementation. Recommend to continue with current plan. The Monitoring/Evaluation section indicated, Monitor po (oral) intake, wt (weight), labs. During a concurrent interview and record review on 5/19/21, at 1:10 PM, with RN 1, the clinical record for Resident 1 was reviewed. RN 1 was unable to find documentation the RD was notified of the change in resident's nutritional status. RN 1 acknowledged that the RD was not notified when resident's meal intake was declining. RN 1 stated Resident 1 should have been referred to the RD. Any change of condition related to nutrition will be discussed with the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their clients) including the RD. During an interview with RD 1 on 5/25/21, at 8:41 AM RD 1 acknowledged she did not receive a dietary consult for Resident 1 and was not aware of the change of condition. RD 1 stated the last nutritional evaluation for Resident 1 was completed on 1/11/21 with resident being stable. Review of the facility's policy and procedure titled, Evaluation of Weight and Nutritional Status, dated 10/2018, indicated, .I. The Facility will work to maintain an acceptable nutritional status for residents by: A. Assessing the resident's nutritional status and the factors that put the resident at risk of not maintaining acceptable parameters of nutritional status . II. Nutritional Assessment - A. Nutritional assessments will also be completed upon readmission, annually, and upon change of condition . 3. During a concurrent interview and record review with RN 1, on 5/19/21, at 1:10 PM, RN 1 reviewed the clinical record for Resident 1 and verified there was no documentation of resident monitoring and assessment perataining to Resident 1's condition in the Progress Notes on 1/22/21, 1/23/21, 1/24/21, 1/25/21, and 1/26/21. RN 1 was also unable to find a Weekly Summary for Resident 1. A Weekly Summary is a resident care note summarizing a resident's current condition including any significant change or incidents that occurred, resident's progress, and any follow-up action taken. RN 1 stated, the weekly summary is an overall assessment of the resident's condition and any changes should be documented. During a concurrent interview and record review on 5/19/21, at 2:22 PM, with RN 1, the clinical record for Resident 1 was reviewed. RN 1 was unable to find documentation of the most recent weight, laboratory results and I & O log for January 2021. RN 1 acknowledged the findings. RN 1 added, Resident 1's weight should have been taken when she was experiencing a decline in meal intake. During a concurrent interview and record review on 5/19/21, at 2:40 PM, with CNA 2, the meal intake record on the ADL Flow Sheet for January 2021 was reviewed. CNA 2 acknowledged there was no documentation of meals consumed in various shifts on 1/7/21, 1/8/21, 1/9/21, 1/10/21, 1/13/21, and 1/24/21. CNA 2 was also unable to find Resident 1's I & O monitoring log for January 2021. CNA 2 stated the I & O and meal intake should have been documented every shift and report to the nurse for any changes specially when resident's intake has decreased or resident refused. During an interview with Licensed Vocational Nurse (LVN) 1, on 5/19/21, at 3:35 PM, LVN 1 stated a 72-hour resident monitoring is required in resident's experiencing a change of condition and should be documented in the nursing progress notes. LVN 1 added, staff are expected to document weekly summary notes on all residents. These weekly notes highlight any changes and interventions implemented. Resident 1 was identified as having a change in condition on 1/21/21 however, the change in condition charting policy was not followed when there was no monitoring and assessment of Resident for at least 72 hours. Review of the facility's policy and procedure titled, Change of Condition Notification, dated 4/1/15, indicated, .II. The Licensed Nurse will assess the change of condition and determine what nursing interventions are appropriate. VI. Documentation: B. A Licensed nurse will communicate any changes in required interventions to the CNAs involved in the resident's care. C. A Licensed Nurse will document each shift for at least seventy-two (72) hours. D. Documentation pertaining to a change in the resident's condition will be maintained in the resident's medical record and on the twenty-four hour report. VII. The Facility may utilize the Change of Condition . to audit and assess the success monitoring changes in condition. Review of the facility's policy and procedure titled, Food Intake - Recording Percentage & Nutritional Assessment, dated 1/1/12, indicated, To ensure the optimal nutritional status, an assessment of nutritional intake will be performed for each resident. In order to assess the nutritional status of the resident, the percentage of food taken will be recorded by the Certified Nurse Assistant (C.N.A.). II. After a resident has completed the meal, the C.N.A. will record the amount eaten on the resident's food intake record after the completion of each meal. III. If any resident refuses a meal, or the food eaten is less than 50%, a nourishment or meal replacement will be offered. IV. A. The Charge Nurse (Licensed Nurse) may request a dietary evaluation and/or notify the Attending Physician if appropriate. The nurse will document the evaluation in the Progress Notes and update the care plan as necessary. i. The nurse will review percentage intake record prior to writing a resident's weekly progress notes. Review of the facility's policy and procedure titled, Progress Notes, dated 1/1/12, indicated, To provide an interdisciplinary record of each resident's progress. II. Progress notes will reflect the resident's current status, progress or lack of progress, changes in condition, adjustment to the facility, and other relevant information. VI. Progress notes are to be documented in a timely manner.

Based on observation, interview and record review the facility failed to provide adequate supervision during mealtime for one of three sampled residents (Resident 1) in accordance with Resident 1's assessment and plan of care. Resident 1, who had difficulty swallowing, was left unsupervised while eating in the dining room. This failure resulted in Resident 1 choking on a glove during mealtime and being transferred to the emergency room for medical treatment on [DATE]. Resident 1 expired on [DATE] due to asphyxiation(choking) caused by a laryngeal(throat) blockage by a foreign object. Findings: Review of the admission record titled, FACESHEET, indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of his quarterly Minimum Data Set (MDS - an assessment tool) dated [DATE], indicated Resident 1 had long-term and short-term memory problems. Resident 1 had unclear speech, required total dependence with one-person assistance during meals. Resident 1 had functional limitation in range of motion to one upper extremity. Resident 1 had difficulty swallowing requiring a mechanically altered and therapeutic diet. Resident 1 had a POLST (Physicians Order for Life Sustaining Treatment) indicating attempt resuscitation/CPR (Basic Life Support). Review of the POLST for Resident 1, dated [DATE], indicated under section A, Cardiopulmonary Resuscitation, attempt resuscitation/CPR. Under section B, Medical Interventions, full treatment. Review of Physician Orders, dated [DATE], indicated, Mechanical soft diet with honey thick liquids, renal diet and high protein. Review of the care plan titled, Nutrition - Swallowing Impairment, dated ,[DATE], indicated a problem related to drooling, intolerance to thin liquids, dementia and dysphagia with written interventions around food intake to include: instruct/cue resident to swallow after each bite, double swallow to clear throat and monitor for signs and symptoms of aspiration (choking). During record review of the swallowing assessment by the Speech Pathologist (SP), dated [DATE] at 9:31 am, SP indicated Resident 1 was a moderate aspiration risk due to dysphagia resulting in coughing intermittently during food intake and coughing with residual food in mouth after swallowing. Certified Nursing Assistant (CNA) staff were Educated and advised on safety awareness with monitoring oral food intake, administering small bites, alternating consistencies of mechanical soft texture foods with nectar thick liquids. During an interview on [DATE] at 2:20 pm, the SP stated, He (Resident 1) has a moderate swallowing deficit and requires close monitoring and supervision. Review of the ADL (Activities of Daily Living) Flow sheet for Resident 1 dated [DATE] indicated D/1 for eating and drinking during the AM shift. During a concurrent interview on [DATE] at 4 pm, the DON stated Staff code the sections of the ADL Flow Sheet to represent the most help they provided to care for the Resident at that time. 'D' stands for total dependence and '1' stands for minimal one person assist. During an interview on [DATE] at 2:30 pm, the Director of Nursing (DON) stated that an unusual occurrence happened on [DATE] with Resident 1 on the first floor dining room by the main entrance adjacent to unit 1. At 10am, Resident 1 was escorted to the dining room to participate in a sensory activity that involved listening to music. At 11am lunch began and his food tray was placed at his table away from his reach because no one was available to assist with feeding. An Activity Assistant (AA) was walking into the dining room and witnessed Resident 1 grabbing at his food with no CNA at the table to assist him with eating. When it appeared that Resident 1 was choking, a Certified Nursing Assistant (CNA) 1 retrieved the Licensed Vocational Nurse (LVN) 1 from the staff lounge where LVN 1 was taking her lunch break. Usually there are assigned staff to the dining room. The DON further stated LVN 1 received corrective action because there should always be a Licensed Vocational Nurse in the resident dining room during meal time. After returning to the dining room, LVN 1 wheeled Resident 1 back to his room and initiated cardiopulmonary resuscitation (CPR - basic life support). When asked if this was the facility's standard emergency response protocol, the DON stated Ideally they should have cleared the dining room and immediately attended to the Resident's (Resident 1) choking status where he was. Staff initiated a Code Blue (medical emergency) Response, 911 was called and Resident 1 was transferred to an acute care hospital where he passed away. During observation of the dining room on [DATE] at 12:00 pm, accompanied by the Activity Assistant (AA), there were five tables around the perimeter of the room. One of the tables was on the south wall by the window. During concurrent interview AA stated during shift on [DATE] at 11:45 am, Resident 1 was seated at the table next to the window by himself with his food tray in front of him. AA stated she observed Resident 1 feeding himself and had food all over his mouth and shirt. AA wiped the food from his mouth and shirt with a cloth napkin and continued to observe residents. AA observed CNA 1 feeding another resident two tables away from Resident 1. AA acknowledged Resident 1 required assistance with feeding and stated she did not inform CNA 1 of her concerns before leaving for her break because she assumed CNA 1 was aware. During an interview on [DATE] at 4:45pm, the Administrative Support Staff (AdminSS) stated he usually does rounds along the whole floor during lunchtime. At 12 noon he saw food all over Resident 1 and noticed he was short of breath and patted Resident 1 on the back. Admin SS cleaned up the food on Resident 1's mouth and shirt. AdminSS stated there were approximately ,[DATE] residents in the dining room at that time and one staff member feeding a resident. Called/signaled LVN 2 from the nursing station for assistance. LVN 2 patted Resident 1 on the back and left to go get the medical chart. AdminSS stated there were approximately ,[DATE] residents in the dining room at that time and one staff member feeding a resident. Called/signaled LVN 2 from the nursing station for assistance. LVN 2 patted Resident 1 on the back and left to go get the medical chart. During an interview on [DATE] at 1:35 pm, LVN 1 stated CNA1 got her from the break room when Resident 1 was experiencing a medical emergency. LVN1 stated she ran to the dining room and saw Resident 1 slumped down, pale and his tongue sticking out of his mouth. Resident 1 did not respond to LVN 1's voice or touch. LVN 1 stated that due to the number of other residents in the dining room she made the decision to wheel Resident 1 down the hall to his room and then left the room to go and obtain oxygen. LVN 1 stated she should not have wheeled Resident 1 from the dining room to his room and should have initiated CPR in the dining room. During an interview on [DATE] at 9:50 am, Licensed Vocation Nurse (LVN) 3 stated while in the breakroom on [DATE] at 12:07pm, LVN 3 overheard there was a medical emergency. LVN 3 saw LVN1 quickly leave the breakroom and LVN 3 followed LVN 1 to the emergency, heading straight to Resident 1's room. Resident 1 was in his wheelchair, looked pale and his lips were white. LVN 3 stated Resident 1 was not breathing and was unresponsive. LVN3 and a Rehabilitative Nurse Aide (RNA1) moved Resident 1 from his wheelchair to the bed and attempted to give the [MEDICATION NAME] maneuver. LVN 3 stated If had it to do over again, would do CPR immediately at room when saw him. Lay him down of the floor from his wheelchair (sic) . During review of the Resident Progress Notes signed by Licensed Vocational Nurse (LVN3) for Resident 1, dated [DATE] and untimed, indicated .at 12:10p, a staff member (CNA1) went inside the break room and reported that a Resident (Resident 1) was having an emergency. Rushed to the Resident's (Resident 1) room and saw (Resident 1) in wheelchair. Transferred (Resident 1) to the bed. Seen (Resident 1) gasping for air. Performed [MEDICATION NAME] maneuver 2 times at 12:15pm. After knowing (Resident 1) was full code, me and one staff (RNA1) transferred (Resident 1) on the floor. Performed CPR, 4 cycles of chest compressions and one staff was doing ambu bag (an artificial manual breathing unit). Paramedics came in and took over and told us to leave the room. During review of the Resident Progress Notes, signed by Registered Nurse (RN1) for Resident 1 dated [DATE] and untimed, indicated at around lunch time, noted a LN (Licensed Nurse - LVN1) rushing and I immediately followed her. Arrived in (Resident 1) room. (Resident 1) was in bed and RNA1 was doing the [MEDICATION NAME] maneuver on him. When they saw that he was no longer conscious, they started to lower the head of the bed down. Instructed staff to move him to the floor and I called the code (Code Blue - a medical emergency protocol for a life threatening circumstance) and told them to call 911, 12:15 pm. (LVN 3) started compressions. Crash cart came in. I went to grab the ambu bag. I tilted his head and opened his mouth with my finger in it, finger sweep performed. I visually did not see any food particles in his mouth or anything obstructing his airway. I did two puffs, when (RNA 1) took over for me. During my two puffs, I could clearly see his chest rising. During this time (RNA 1) was on the phone with 911. At 12:20 pm, the paramedics arrived and a female officer. They wanted everyone out of the room except for a nurse that knew (Resident 1). (LVN 1) stayed in the room close to the bathroom wall. ACLS (Advanced Cardiac Life Support) starts. At 12:31 pm the Fire Department arrived followed shortly by a male officer. I am standing outside the doorway frame, with my ear pointing in, when I hear is that a glove. They brought a Lucas CPR device (a mechanical chest compression machine). I ran to the elevator and told them to hold the elevator door open. At 12:46 pm (Resident 1) was on his way to the ER (emergency room ) . Review of the (Name of Ambulance Company) Patient Care Report dated [DATE] at 12:31 pm indicated, Removed an entire medical glove from the patient's (Resident 1) mouth covered in blood. During an interview on [DATE] at 12:20 pm the Physician (MD) from the GACH stated Patient (Resident 1) was in full arrest when he got here. He was already gone. Several minutes of no oxygen is all it takes. Once the pupils are already fixed and dilated you are faced with potential brain death. Review of the General Acute Care Hospital (GACH) discharge summary dated [DATE] 2350 (11:50 pm) indicated (Resident 1) remained critically ill despite Ventilator support and chest tube and vasopressors and antibiotics. (Resident 1) had fixed and dilated pupils. Therefore, after discussions with family .it was decided to transition to comfort care on [DATE] and the terminal extubation (removal of breathing tube) was done at (YEAR) hrs (8:17 pm) and (Resident 1) promptly expired at [DATE] @ 2253 (10:53pm). Review of the Policy and Procedure titled Dining Program dated (MONTH) 1, 2012 indicated Procedure .IV. Distribution of Trays .C. Residents will be monitored by RNAs/CNAs through their meal to ensure assistance is provided .VI. Staff Assignments .[NAME] RNAs/CNAs .ii. Assist in transporting residents to their assigned dining programs and with distribution of trays, and then report to feeding/supervision assignments. Review of the County Coroner's Office dated [DATE] indicated Anatomical diagnoses; 1. Latex glove in airway .Disease or Condition leading to death: [NAME] Asphyxiation due to laryngeal blockage by a foreign object .

Based on interview, observation, and record review, the facility failed to identify the risk factors and need for supervision for one of three residents (Resident 1), who fell on [DATE] and sustained a subdural hematoma (collection of blood between the layer covering the brain and the surface of the brain). The facility failed to implement interventions to reduce the risk for fall when 1) resident was placed in a room near the far end of the hallway the nursing station and not in direct line of sight of the nursing station, 2) there was a delay of at least 15 minutes in responding to his call light, and 3) no fall prevention devices or precautions were implemented. The facility's failure to plan and provide close monitoring and supervision resulted in Resident 1 falling nine hours after admission to the facility, requiring transport back to the General Acute Care Hospital (GACH) for for evaluation and treatment of [REDACTED]., safety, or security. Findings: Record review of the facility admission orders [REDACTED]. Occupational Therapy and Physical Therapy evaluation and treatment were ordered. No orders for resident activity were specified. Resident 1's Physician admission orders [REDACTED]. Record review of the facility's Resident Admission Assessment, for Resident 1, dated 1/5/17, noted: weakness and pain of right hip, confused, dementia (memory disorder), and incontinent (unable to control urination or defecation) of bowel and bladder. The same assessment noted Resident 1 required extensive assistance with bathing, dressing, hygiene, and transferring. This assessment indicated Resident 1 was totally dependent on staff for toileting and ambulating, had fall risk factors of history of fall in last six months, was disoriented and confused, had poor safety judgment, and impaired balance. This assessment indicated [MEDICAL CONDITION] (used to treat psychiatric or psychological conditions) and pain medications as additional fall risk factors. Record review on 1/23/17 of Resident 1's, Elopement Risk Assessment, dated 1/5/17, noted resident with, Intermittent Confusion, and, Two or More Behaviors Resident States Desire to Go Home, Wanders Aimlessly, etc., was noted as part of, Confounding Behaviors that Increase risk. Record review on 1/23/17 of Resident 1's, Fall Risk Assessment form, dated 1/15/17, noted risk factors of intermittent confusion, history of falls, incontinent, impaired gait and balance, and medications that place resident at risk of fall, with a total score of 16, which indicated resident assessed as at high risk of falling. Resident 1's assessment matched the clinical profile of individuals with a high predictability of another fall. Record review on 1/23/17 of Resident 1's, ADL (Activities of Daily Living) Flow Sheet, for 1/5/17, noted resident required extensive to limited assistance with toileting and needed either a walker or a wheelchair for mobility. During an interview on 2/6/17 at 2:36 pm with the Director of Nursing (DON), she confirmed record review findings for Resident 1's, Resident Admission Assessment, Elopement Risk Assessment, Fall Risk Assessment Form, ADL Flow Sheet, Physical Restraint Device Assessment; and that Resident 1 had not been provided with a walker, as a physical therapy assessment was pending the day after admission. These findings indicated Resident 1 was predictably at risk for another fall, especially since he was admitted to the facility after major right hip surgery. Record review on 1/27/17 of, Census List, noted room [ROOM NUMBER], bed 2, across the hallway from the nursing station, was marked vacant. Record review on 1/27/17 of, Daily Staffing Schedule, for 1/6/17 night shift, noted CNA 1 had 17 residents assigned to his care when Resident 1 fell . During an interview with the DON on 1/25/17 at 11:05 am, DON was asked why Resident 1 was not placed in room [ROOM NUMBER] 2 on admission, which is closer to the nursing station, yet, transferred to 104 2, was noted in careplan, Fall Risk Prevention and Management, in, Approaches on 1/6/17, after Resident 1's fall with injury on the night shift beginning at 11 pm on 1/5/17. DON stated, I'm not sure why there was a decision for him to move . there might be some room changes they would have done. DON confirmed Resident 1 was high risk for falls, had received [MEDICATION NAME] during the admission, and had a history of [REDACTED]. Record review on 1/20/17 of, Intra Agency Referral Form, dated 1/6/17, noted Resident 1 was, .found lying on the floor at near (sic) bathroom. sustain (sic) laceration right occipital with 3 cm (centimeters, a metric measure) length 1 cm depth with moderate amount of bleeding. Record review on 1/20/17 of, Resident Progress Notes, for Resident 1, noted on 1/6/17 at 3:15 4:25 am, Resident was found lying on the floor near bathroom with blood on his body., and noted Resident 1 was transported by ambulance to a GACH on 1/6/17. During an interview with CNA 1 on 1/23/17 at 8:30 am: when asked how long it took for him to answer the call light on the 1/6/17 night shift when Resident 1 fell , he stated, 15 minutes. Record review on 1/27/17 of facility policy and procedure, Communication Call System (revision 1.0, dated 1/1/12), stated, Nursing Staff will answer call bells promptly, in a courteous manner. During an interview on 2/6/17 at 2:36 pm with DON, she was asked if 15 minutes to answer a call light/bell met the facility's policy and procedure to, .answer call bells promptly., she replied, No. During an observation on 1/20/17 at 10:09 am, the Administrator confirmed Resident 1 fell in room [ROOM NUMBER] near the opposite end of the hallway shared by the nursing station and across from room [ROOM NUMBER]. Concurrent interview with the Administrator confirmed room [ROOM NUMBER] was not in direct line of sight of the nursing station, which was seven resident rooms away from room [ROOM NUMBER], and located near the opposite end of the hallway. During an interview on 1/27/17 at 2:45 PM with RN Supervisor (RNS), she stated for residents identified as high risk for falls on admission before a care plan is written, common nursing actions included placing resident in a room that is closest to the nursing station, staff would be alerted that resident is at high risk for falls and to check on the resident frequently, .at least every 2 hours . RNS stated these nursing actions came from experience and training. Record review on 2/8/17 of, Hospitalist History and Physical (H & P), from GACH, dated 1/16/17, noted, 'Active problems: Subdural hematoma (collection of blood between the layer covering the brain and the surface of the brain) . , and, #Fall resulting in small subdural/subarachnoid (bleeding in to the protective tissue layers surrounding the brain) hematoma (bruise), and, .regarding recurrent falls, suspect multifactorial (st p (status [REDACTED]. Document review on 2/8/17 of, Subdural hematoma, accessed at https://medlineplus.gov/ency/article/ 13.htm , noted, A subdural hematoma is most often the result of a severe head injury. This type of subdural hematoma is among the deadliest of all head injuries. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in [MEDICAL CONDITION] and may lead to death. Subdural hematomas can also occur after a minor head injry. The amount of bleeding is smaller and occurs more slowly. This type of subdural hematoma is often seen in older adults. Record review on 2/8/17 of same GACH History and Physical noted, CT (three dimensional imaging) Brain WO (without) Contrast, Edited Result Final, in, Impression: 1. Acute trace left parietal (lobe of brain on upper lateral region) subdural hematoma . 2. Acute trace posterior falx (layer of tissue in the brain) subdural hematoma . , and, Evidence of [MEDICAL CONDITION] (bleeding within the brain) . Yes. Document review on 1/25/17 of, Evidence Based Falls Management Program in the Nursing Home, accessed at http://scholarworks.bellarmine.edu/cgi/viewcontent.cgi?article=1008&context=tdc , noted an unfamiliar environment, sedating medications, weakness, and cognitive impairment as common precursors to falls.

Based on observation, interview and record review, the facility failed to ensure Resident 1 was free from accident and hazards when Resident 1 fell and had injuries. This deficiency resulted in Resident 1 sustaining a bump on her forehead, abrasion (superficial damage) on her nose and her left knee. Findings: Review of the Minimum Data Set (MDS), an assessment tool, dated 12/26/2017, indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Inter Disciplinary Team (IDT) meeting notes dated 8/18/17 indicated Resident 1 was alert and oriented to person, verbally responsive and able to make needs known. The note also indicated Resident 1 required 1 person assist with bed mobility (getting in and out of her bed), dependent on toileting and 2 persons assist with transfers (getting in and out of her bed and wheelchair). During a telephone interview on 2/15/18 at 2:26 pm, Registered Nurse (RN) 1, stated that on 8/17/17 at 2 pm, Resident 1 was getting up from her wheelchair in her room and fell on the floor facing down. RN 1 said there was a bump on Resident's forehead and abrasion on her nose and left knee. RN 1 stated Resident 1 was bleeding from her nose and knee. RN 1 further stated Resident 1 fell again in her room on 11/14/17, in the hallway on 1/30/18, in her room on 2/1/18 and 2/11/18. During a telephone interview on 2/15/18 at 3:30 pm, Licensed Vocational Nurse (LVN) 1, stated Certified Nurse Assistant (CNA) 1 informed him CNA 1 was in front of another room when CNA 1 saw Resident 1 fall from her wheelchair to the floor of her room. During a telephone interview on 2/15/18 at 3:36 pm, CNA 1 stated, I saw the Resident (Resident 1) jump over from her wheelchair and throw herself over to the floor of her room. Resident called for help and people came and helped her. Review of Resident 1's Care Plan after a fall on 7/28/17 indicated not to put Resident 1 in her room by herself while sitting in her wheelchair. During an observation of Resident 1 on 2/26/18 at 2:26 pm, there was a mattress pad on the floor by Resident 1's bedside and Resident 1's wheelchair was placed on the mattress. Review of Resident 1's Care Plan, Fall Risk Prevention & Management, dated 1/25/17, indicated remove clusters after dinner. During an observation on 3/9/18 at 10 am, Resident 1 was sitting in her wheelchair, along the hallway close to the activity room in unit 2, far from the Nurses' Station. Resident 1 was sliding down from her wheelchair. The wheelchair had no footrest. Resident 1 continued to slide down from the wheelchair until her low back area was at the level of the wheelchair seat. A staff member assisted Resident 1 back up on the wheelchair and wheeled her to the Nurse's Station. Review of Resident 1's Care Plan on Fall Risk Prevention & Management dated 1/25/17, indicated, remove .footrest after dinner. Review of Resident 1's Care Plan after a fall on 1/30/18 indicated, sit resident closer to Nurses' Station. A review of the Progress Notes, dated 8/17/17 at 3 pm, indicated Resident 1 sneezed a blood clot out of her left nostril and Resident 1 was very uncomfortable in her bed. Further review of the Progress Notes, dated 8/18/17 at 6:30 pm, indicated Resident 1 was transferred to Acute Care Hospital emergency room with a complaint of 10/10 pain level (the highest level in the pain assessment scale) on her forehead which was swollen, nasal area was swollen and discoloration of both eyes were noted. Review of the facility's Fall Management Program, Nursing Manual-Falls, Policy No-FA-01 (page 2 of 3) . procedure . indicated: V. Recurrent Falls: A. A resident who sustains multiple falls defined as more than one fall in a day, week or month, will be considered a high risk to fall as a result may sustain a major injury. B. These residents may: i. be identified by a special logo or designation to alert staff to their high risk activity; ii. (MONTH) require more frequent observation of activities and whereabouts iii. (MONTH) require structured environment or routine. C. These interventions will be documented on the resident's plan of care and in the resident's clinical record.

Based on observation, interview, and record review, the facility failed to provide adequate preventive treatment and services to maintain and improve range of motion (ROM) for three of 55 (Resident 20, Resident 21, Resident 23) sampled residents when the physician ordered visit frequency of the Restorative Nursing Program (RNP) or Restorative Nursing Assistant (RNA - certified nursing assistants that have additional training in assisting residents with exercise and mobility to promote their safety and independence) was not implemented. The deficient practice resulted in a decline in Resident 21's ADL (Activities of Daily Living including feeding and transfers). For Resident 20 and Resident 23, there was a potential decline because the RNA was not providing the exercises needed to maintain or improve the residents' function. Findings: 1. Resident 21 was admitted with [DIAGNOSES REDACTED]. A record review of the recapitulated physician's orders [REDACTED]., RNA 3X week x 3 months, Sit to stand with wall rails. During an observation on 7/20/17 at 12:15 PM in the dining room, Resident 21 was observed eating his lunch and reaching for his drink. Food particles were spilled on his clothes, his clothing protector (bib), his cheeks, chin and neck areas. Resident 21's hands were shaky as he used his utensils to feed himself. During an observation on 7/24/17 at 3:10 PM in the activity room, Resident 21 had difficulty grasping his [MEDICATION NAME] to draw because his hands were shaking. During an interview with RNA 1 on 7/24/17 at 11:10 AM, RNA 1 said, sometimes they use me as CNA on the floor. RNA 1 stated her managers and the DON (Director of Nursing) know the resident is not being seen all the time and missing his RNA. In an interview with Occupational Therapist 1 (OT 1) on 7/24/17 at 3:20 PM, OT 1 stated the resident was referred to us due to a decline in function affecting his ability to perform ADLs, over-all feeding and transfers. During an interview with Licensed Vocational Nurse 10 (LVN 10) on 7/24/17 at 3:30 PM, LVN 10 said I guess I have to tell the supervisor in charge when the RNA is being pulled to the floor. During an interview with Unit Manager 1 (UM 1) on 7/24/17 at 3:50 PM, UM 1 stated when we don't have RNAs the CNAs do the ROM and do the ADLs together. UM 1 stated he (Resident 21) is able to propel himself on his wheelchair. In an interview with PM (evening shift) Registered Nurse (RN) 1 on 7/24/17 at 5 PM, RN 1 said when the RNA is missed, the morning shift gives us report and we do it. RN 1 said that she did not know that there were missed RNA visits for Resident 21. During an interview with Certified Nursing Assistant (CNA) 3 on 7/25/17 at 1:47 PM, CNA 3 stated, He (Resident 21) needs help and assistance with eating now and he struggles every so often with his wheelchair to reach his destination. I have to help him and push his chair. A review of Resident 21's Restorative Nursing Program records indicated: On 3/08/17 to 3/31/17, the RNP was provided seven times on 7/14/17, 7/16/17, 7/18/17, 7/20/17, 7/23/17, 7/25/17, 7/27/17. On 04/01/17 to 04/30/17, the RNP was provided nine times on 4/1/17, 4/5/17, 4/7/17, 4/8/17, 4/12/17, 4/15/17, 4/19/17, 4/24/17, 4/26/17. On 05/01/17 to 05/31/17, the RNP was provided nine times on 5/2/17, 5/4/17, 5/8/17, 5/10/17, 5/12/17, 5/17/17, 5/20/17, 5/23/17, 5/27/17. On 06/01/17 to 06/08/17, the RNP program was provided twice on 6/6/17 and 6/8/17. A record review of the Occupational Therapy OT Evaluation and Plan of Treatment with certification period dated 6/7/17 to 7/3/2017 indicated referred to skilled OT secondary to decline in function affecting his ability to perform ADLs and functional transfers, presents with decreased endurance. In an interview on 7/24/17 at 3:20 PM, OT 1 stated, If RNA was more consistent, it could have prevented his (Resident 21) decline. 2. Resident 20 was admitted to the facility with [DIAGNOSES REDACTED]. A review of Resident 20's two most recent Minimum Data Sets (MDS, an assessment tool) on 5/9/17 and 2/7/17 indicated he had impairment on one arm and both legs. In an observation and interview on 7/20/17 at 4:20 PM with Resident 20 and a family member, Resident 20 was lying in bed with his head elevated and his feet exposed. The family member stated Resident 20's right hand was stiff. The family member then gently lifted his bare feet and said his feet were now dropping. A review of the recapitulated physician's orders [REDACTED]. These orders indicated on 6/2/17 Resident 20 was to have RNA visits five times per week for three months for PROM (passive range of motion, exercises where the RNA moves the limb) on his right leg. The 6/2/17 orders indicated Resident 20 was to have AROM (active range of motion, exercises where the resident moves their limbs) three times per week for three months on his left leg and both arms. The Physician order [REDACTED]. A review of the RNA record of visits indicated the RNA performed 15 minutes of exercises on Resident 20 on 7/5/17, 7/14/17, 7/15/17, 7/18/17, 7/21/17, 7/22/17, and 7/24/17 (seven times in July as of 7/26/17). A review of the RNA visit record for June 2017 indicated at the top of the form, RNA 5x/wk (week) x 3 months. This record indicated the RNA performed 15 minutes of exercises on Resident 20 on 6/11/17, 6/13/17, 6/18/17, 6/21/17, and 6/26/17 (five times a month). Notes on the back of this form signed by the RNA for 6/11/17, 6/21/17, and 6/26/17 indicated Resident 20 tolerated the exercises and had no complaints of pain. A review of the RNA visit record for May of 2017 indicated the physician's orders [REDACTED]. This record indicated, Resident 20 had 15 minutes of exercises on 5/10/17, 5/25/17, and 5/30/17. The note on the back of this form, signed by a Registered Nurse (RN) on 5/9/17, indicated Resident 20 tolerated the exercises with the RNA. A review of the RNA visit record for April of 2017 indicated the physician's orders [REDACTED]. This record indicated Resident 20 had exercises for 15 minutes with the RNA on 4/24/17, 4/25/17, and 4/26/17. The back of this form indicated Resident 20 tolerated AROM/PROM exercises without discomfort on 4/25/17. A RN noted on 5/10/17 at the bottom of this form that Resident 20 tolerated these exercises. A review of the Restorative Nursing Record of March 2017 indicated the physician's orders [REDACTED]. This record indicated, Resident 20 received 15 minutes of exercise from the RNA on 3/2/17, 3/3/17, 3/13/17, 3/15/17, 3/23/17, and 3/29/17. Notes by the RNA on the back of this form indicated on 3/3/17 and 3/13/17, Resident 20 tolerated the exercises. A RN signed this form on 4/10/17 noting Resident 20 tolerated the exercises. A review of Resident 20's care plan, Need for restorative nursing related to Passive ROM and Active ROM, indicated this care plan started on 11/25/16 with goal dates of 2/17, 5/2/17, and 7/27/17. The care plan indicated, next to the date 10/11/16, the RNA visits were three times per week for three months for exercising Resident 20's arms and five times per week for three months for exercising Resident 20's legs. In an interview with Licensed Nurse 1 (LN 1) on 7/26/17 at 12:25 PM, she stated the physician's orders [REDACTED]. She said this order was for five times per week for three months. LN 1 stated the physical therapist and registered nurse help each other. LN 1 said she was looking at the July 2017 record in the RNA binder and Resident 20 was only seen by the RNA seven times. LN 1 stated there was no other documentation of RNA visits. In an interview with Certified Nursing Assistant (CNA) 3 on 7/26/17 at 11:55 AM, she stated she does not do range of motion exercises with Resident 20. She said the CNAs do not do exercises with Resident 20. CNA 3 stated Resident 20 cannot bear weight and does not have a forward wheel walker. 3. Review of medical records indicated Resident 23 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS, an assessment instrument) dated 5/23/17, indicated Resident 23 was cognitively intact as evidenced by her BIMS score (Brief Interview of Mental Status) of 14. She weighed 195 pounds, and has functional impairment to one side of her upper extremities, and to her left and right lower extremities. Review of the Occupational Therapist's order dated 7/17/17 indicated, OT (occupational therapy) eval (evaluation) completed RNA (restorative nurse aide) for AAROM (active assisted range of motion) on all planes for (B)UE (bilateral upper extremities) as patient tolerates for 3x/wk (week) x 3 mos (months). During observation with RN 2 on 7/21/17 at 3:15 p.m., Resident 23 was asleep and observed lying supine (on her back with her face upward). During concurrent interview, RN2 stated, She was last up on her feet with a walker 2 to 3 years ago . During record review on 7/24/17 at 3:05 p.m., Resident 23's medical record did not contain documentation the resident was getting range of motion exercise. During concurrent interview, LVN 3 stated, The exercise was not done because we have been short staffed. The RNAs were pulled to cover the CNAs.

Based on observation, interview, and record review the facility failed to prevent the decline in range of motion for one of 39 sampled residents( Resident 13). The facility did not identify the risk for decline in the range of motion, do a comprehensive care plan, and institute interventions to prevent the decline in the range of motion of Resident 13's hands and feet. Failure to do so resulted in the loss of motor function of both hands and feet, wherein Resident 13 was not able to walk, because of the drop of both fore foot, and needs full staff performance to eat, because of the inability to stretch both hands. Findings: Review of the history and physical by Medical Doctor (MD ) dated 1/29/14, Resident 13 is .60 -year-old .history of [MEDICAL CONDITION] in the past because of generalized weakness. On the day of admission, .difficulty standing and walking and eating. During an observation on 6/17/15, at 10:00 AM, in room [ROOM NUMBER] bed 2, Resident 13 was not able to extend the fingers of both hands open and flex both feet upward when the surveyor asked him to do so. During an interview with Resident 13, on 6/17/15, at 10:15 AM, in room [ROOM NUMBER] bed 2, he stated, My hands and feet has been like this for a year. The surveyor asked if he has been out of bed. Resident 13 said, Yes, and I would like to drive a motor wheelchair. When asked how he eats, he stated, They feed me. During an interview with Nurse Manager (NM), at 11:00 AM, on 6/17/15, in the conference room, she confirmed that both hands and feet, of Resident 13, are contracted and flexed and there was no interventions instituted after 2/20/14, that the nursing admission assessment dated [DATE] was not adequate, and there was no nursing care plan addressing the weakness of both extremities. During an interview with Medical Doctor (MD), at 12:00 Noon, on 6/17/15, in the conference room, he confirmed that both hands and feet, of Resident 13, are contracted and flexed and there was no interventions instituted after 2/20/14. During an interview with the Occupational Therapist, at 9:00 AM, on 6/23/15, in the conference room, she confirmed that Occupational Therapy (OT) was ordered on [DATE] for Resident 13, and OT evaluation was done 2/6/14, and OT was discontinued on 2/20/14, and no follow-up, no further evaluation, no further intervention or orders instituted to continue therapy, again for Resident 13. During an interview with License Vocational Nurse 6 (LVN 6), at 1:00 PM, on 6/23/15, in the dinning room, she stated, I admitted Resident 13, and I cannot remember exactly when the fingers started to be what it is now. During review of the clinical records for Resident 13, the following were noted: 1) Consultation Report dated 1/29/14 Motor examination shows him to be akinetic (loss of normal motor function, resulting in impaired muscle movement, according to the Medical Dictionary) at rest. On movement, he is very bradykinetic (pertaining to slow movement, as defined by the Medical Dictionary) attempting to shift in bed or to raise arms or legs. Tone is markedly increased in the neck and the upper extremities, moderately increased in the legs. Plantar responses are flexor. There is no ataxia (loss of full control of bodily movements, as defined ny the medical dictionary) or incoordination, but rapid alternating and successive movements are slowed with minimal excursion. 2) History and Physical dated 11/13/14 Extremities: Joint and Spine: Has flexure contraction of the fingers of both hands. 3) LVN Admission Assessment Report dated 2/5/14 Patient stated reason for admission: [MEDICAL CONDITION] Generalized Weakness Diagnosis: [REDACTED]. 4) Nurses Weekly Summary: 2/10/14 Ambulation: Assist X (once) 1 front wheel walker; Feeding assistance: Dependent 3/11/14 Ambulation: not marked; Feeding assistance: Dependent 4/7/14 Ambulation: N/A; Feeding assistance: Dependent 5/13/14 Ambulation: N/A; Feeding assistance: Dependent 6/10/14 Ambulation: wheelchair; Feeding assistance: Dependent 7/8/14 Ambulation: N/A wheelchair daily; Feeding assistance: Dependent 8/18/14 Ambulation: not marked; Feeding assistance: Dependent 9/8/14 Ambulation: N/A; Feeding assistance: Dependent 10/10/14 Ambulation: N/A; Feeding assistance: Dependent 11/11/14 Ambulation: N/A; Feeding assistance: Dependent 12/8/14 Ambulation: not marked; Feeding assistance: Dependent 1/3/15 Ambulation: N/A; Feeding assistance: Dependent 2/10/15 Ambulation: N/A; Feeding assistance: Dependent 3/10/15 Ambulation: non-ambulatory, wheelchair; Feeding assistance: Dependent 4/9/15 Ambulation: non-ambulatory, wheelchair; Feeding assistance: Dependent 5/12/15 Ambulation: non-ambulatory; Feeding assistance: Dependent 6/9/15 Ambulation: N/A; Feeding assistance: Dependent 5) Interdisciplinary Meeting Notes 2/13/14 Nursing: Resident is now able to feed self but still needs help in most ADL's OT/PT (Physical Therapy): Progressing slowly with participation in UB (upper Body)/LB (Lower Body) ADL's (Activities of Daily Living). Max A showering tasks CGA (Care Giver Assist) self-feeding with red (Adaptive Equipment) foam that is used with utensil. Will continue to follow. 2/27/14 OT/PT: Patient currently not on case load. Nursing: Resident is a feeder and very hard to feed. Gets agitated easily 3/6/14 OT: pt. currently not on case load. PT: Pt. is no longer on PT case load Nursing: Moderate to Maximum assist for ambulation 5/22/14 OT: Pt. currently not on case load PT: Pt. not on case load 8/20/14 No mention of OT, PT Nursing: total 11/21/14 Nursing: Cont. total assist most of care 6) Nursing Care Plan for weakness of both extremities - none Activities of Daily Living: Problem - inadequately assess Goals - not comprehensive Approaches - inadequate and not consistent , no revision 7) Medical order sheet : 2/05/14 15:00 OT Evaluation and Treatment Fall and aspiration precaution once 2/05/14 15:00 PT Evaluation and Treatment Fall precaution once 8) OT Notes: OT 5 X/wk X 4 wks for ADL retraining, there ex (exercise), nm (neuro muscular) ed (education), ae (adaptive equipment)/safety ed. (education) pt/cg (care giver) ed. d/c (discontinue) ed. The following facility policy and procedure indicated: 1) Long Term Care (LTC) Interdisciplinary Meeting (IDT): Care of Patients: dated 11/13/02 Procedure: 3. Using the IDT Worksheet, participants discuss all aspects of the resident's care and update documentation, including, but not limited to: A. The resident's current medical, functional and safety status. 4. Team members update the functional levels, goals and safety categories in the plan of care and other documents, during the meeting, to ensure consistency. 2) Assessment of resident: Long Term Care SVCS: Main Campus: dated 8/25/04 Policy: The assessment of the resident's physical, functional, psycho-social and nutritional needs will be used to develop a plan of care and guide care giving. All residents will have a comprehensive assessment initiated upon admission . K. The RN (Registered Nurse) shall be responsible for reviewing all assessment documents and resolving any differences of opinion that arise regarding the resident's current status. The care planning conference will provide an additional forum for discussing assessment data collected and opinions as to the meaning of the data. L. During the resident's stay on the unit she/he will continually assessed by the interdisciplinary team. M. Each member of the interdisciplinary team shall have the responsibility for reporting a significant change in condition, . B. Each member of the interdisciplinary team shall be held accountable for the accuracy of his or her assessment. 3) Care Planning, Interdisciplinary Team Conference: Long Term Care Services: dated 8/25/04: Purpose: To provide a central source of information that sets forth a comprehensive, individualized, resident-centered interdisciplinary approach to the delivery of care. 2. Each of the problem/need categories shall contain the following care plan components: a description of the problem/need the interventions/approaches necessary to accomplish the outcome or goal 3. The interdisciplinary team shall continuously assess the resident's problems and/or needs 5. The care plan shall be reviewed on a continuous basis and at least quarterly. 4) MDS (Minimum Data Set) - Long-term care facility resident assessment instrument Section G Assessment Reference Date (ARD) - 2/18/14 G0110 Activities of Daily Living (ADL) Assistance C. Walk in room - 8 Self-performance (Activity did not occur), 8 Support (Activity did not occur) Walk in corridor - 8 Self-performance (Activity did not occur), 8 Support (Activity did not occur) F. Locomotion off unit - 7 Self-performance (Activity occurred only once or twice), 2 Support (One person assist) H. Eating - 4 Self-performance (Total dependence), 2 Support (one person assist) G0300. Balance During Transitions and Walking, A. Moving from seated to standing position, 2 (Not steady) G0400. Functional Limitation in Range of Motion A. Upper extremity (shoulder, elbow, wrist, hand) - 2 (Impairment on both side) B. Lower extremity ( hip, knee, ankle, foot) - 2 Assessment Reference Date (ARD) - 5/21/14 G0110 Activities of Daily Living (ADL) Assistance C. Walk in room - 8 Self-performance (Activity did not occur), 8 Support (Activity did not occur) Walk in corridor - 8 Self-performance (Activity did not occur), 8 Support (Activity did not occur) F. Locomotion off unit - 7 Self-performance (Activity occurred only once or twice), 2 Support (One person assist) H. Eating - 4 Self-performance (Total dependence), 2 Support (one person assist) G0300. Balance During Transitions and Walking, A. Moving from seated to standing position, 8 (Activity did not occur) G0400. Functional Limitation in Range of Motion A. Upper extremity (shoulder, elbow, wrist, hand) - 1 (Impairment on one side) B. Lower extremity ( hip, knee, ankle, foot) - 2 Assessment Reference Date (ARD) - 8/21/14 G0110 Activities of Daily Living (ADL) Assistance C. Walk in room - 8 Self-performance (Activity did not occur), 8 Support (Activity did not occur) Walk in corridor - 8 Self-performance (Activity did not occur), 8 Support (Activity did not occur) F. Locomotion off unit - 7 Self-performance (Activity occurred only once or twice), 2 Support (One person assist) H. Eating - 4 Self-performance (Total dependence), 2 Support (one person assist) G0300. Balance During Transitions and Walking, A. Moving from seated to standing position, 8 (Activity did not occur) G0400. Functional Limitation in Range of Motion A. Upper extremity (shoulder, elbow, wrist, hand) - 2 (Impairment on both side) B. Lower extremity ( hip, knee, ankle, foot) - 2 Assessment Reference Date (ARD) - 11/21/14 G0110 Activities of Daily Living (ADL) Assistance C. Walk in room - 8 Self-performance (Activity did not occur), 8 Support (Activity did not occur) Walk in corridor - 8 Self-performance (Activity did not occur), 8 Support (Activity did not occur) F. Locomotion off unit - 7 Self-performance (Activity occurred only once or twice), 2 Support (One person assist) H. Eating - 4 Self-performance (Total dependence), 2 Support (one person assist) G0300. Balance During Transitions and Walking, A. Moving from seated to standing position, 8 (Activity did nor occur) G0400. Functional Limitation in Range of Motion A. Upper extremity (shoulder, elbow, wrist, hand) - 2 (Impairmemt on both side) B. Lower extremity ( hip, knee, ankle, foot) - 2 Assessment Reference Date (ARD) - 2/21/15 G0110 Activities of Daily Living (ADL) Assistance C. Walk in room - 8 Self-performance (Activity did not occur), 8 Support (Activity did not occur) Walk in corridor - 8 Self-performance (Activity did not occur), 8 Support (Activity did not occur) F. Locomotion off unit - 7 Self-performance (Activity occurred only once or twice), 2 Support (One person assist) H. Eating - 4 Self-performance (Total dependence), 2 Support (one person assist) G0300. Balance During Transitions and Walking, A. Moving from seated to standing position, 8 (Activity did not occur) G0400. Functional Limitation in Range of Motion A. Upper extremity (shoulder, elbow, wrist, hand) - 2 (Impairment on both side) B. Lower extremity ( hip, knee, ankle, foot) - 2 Assessment Reference Date (ARD) - 5/24/15 G0110 Activities of Daily Living (ADL) Assistance C. Walk in room - 8 Self-performance (Activity did not occur), 8 Support (Activity did not occur) Walk in corridor - 8 Self-performance (Activity did not occur), 8 Support (Activity did not occur) F. Locomotion off unit - 7 Self-performance (Activity occurred only once or twice), 2 Support (One person assist) H. Eating - 4 Self-performance (Total dependence), 2 Support (one person assist) G0300. Balance During Transitions and Walking, A. Moving from seated to standing position, 8 (Activity did not occur) G0400. Functional Limitation in Range of Motion A. Upper extremity (shoulder, elbow, wrist, hand) - 1 (Impairment on one side) B. Lower extremity ( hip, knee, ankle, foot) - 2