Every finding on record at St. Pauls Health Care Center

Based on observation, interview and record review the facility failed to maintain food storage in a sanitary manner.These failures had the potential to cause food borne illnesses for 55 residents. Findings:On 8/9/26 at 8:14 A.M., a concurrent inspection and interview was conducted with the Facility [NAME] (Cook 1). The following expired items were found in a reach-in refrigerator: 1) An unopened container of mozzarella cheese with a handwritten label indicated prepped 7/6/26; use-by 7/15/26. The manufacturer use-by date stamped on the packaging indicated use by June 26, 26; 2) A container of minced garlic with a handwritten label indicated prepped 7/2/26 and use by 8/5/26.; 3) A container of hollandaise sauce with a handwritten label indicated prepped 7/5/26; use by 8/5/26;4) A container of ranch dressing had no label for prep date, or use by date.In addition, the area above the stove had a container of sriracha sauce opened and partly used. The label indicated refrigerate after opening. The bottle had a manufacturer best by date of March 2026. [NAME] 1 stated dietary staff periodically checked labels for expiration dates and should have discarded expired food items.On 8/10/26 at 4:04 P.M., the Registered Dietician (RD 1) was interviewed. RD 1 stated all dietary staff were supposed to check as food is used for labels, expiration dates and for correct storage. RD 1 stated food was supposed to be labeled, stored properly and expired food should have been discarded. A review of the facility's policy titled Labeling and Dating, dated May 2023, indicated .All foods are labeled, dated, and use by dates are monitored and followed .

Based on interview and record review, the facility failed to post nursing staffing information which reflected the actual working hours of the staff responsible for resident care. As a result, the facility's staffing information reflecting actual hours worked were not reviewed and monitored by the facility. Findings: On 8/12/26 at 9:10 A.M., a record review and an interview were conducted with the Unit Coordinator (UC). UC stated he was responsible for the nursing staffing schedule. The facility's Census and Direct Care Service Hours Per Patient Day (DHPPD, also called form 612, official document used by skilled nursing facilities to ensure facilities meet state minimum staffing standards) was reviewed from April 2026 to August 2026. The DHPPD form had missing actual hours for the following months and days:April 2026 - no actual hours in the form 612 on 4/1/26- 4/9/26, 4/16, 4/30/26. UC stated the facility had no Director of staff Development (DSD) at the time. Missing 612 form (projected and actual hours) on 4/10- 4/14/26, 4/17- 4/29.May 2026 - no actual hours in the form 612 on 5/1-5/3, 5/25, 5/27- 5/31. Missing 612 form (projected and actual hours) on 5/5 - 5/24, 5/26. UC stated there was still no DSD at that time, but they had a Director of Nursing (DON).June 2026 - no actual hours in the form 612 on 6/1 - 6/24, 6/28 - 6/29. Missing 612 form (projected and actual hours) on 6/25 - 6.27, 6/30.July 2026 - no actual hours in the form 612 on 7/2 - 7/12, 7/21-7/27. Missing 612 form (projected and actual hours) on 7/1, 7/13-7/20. August 2026 - Missing 612 form (projected and actual hours) on 8/6/26. On 8/12/26 at 9:45 A.M., an interview and record review was conducted with the Administrator (ADM), the Administrator in Training (AIT) and the DSD. The ADM stated the form 612 should have been audited and checked to ensure the facility met the required minimum staffing for the residents. There was no policy provided by the facility.

Based on observation, interview and record review, the facility failed to ensure Licensed Nurses (LNs) follow the physician's order related to oxygen (O2) use on two of two residents (Resident 7, Resident 66) reviewed for Oxygen needs. This failure had the potential to affect Resident 7's and Resident 66's respiratory health. Findings: 1. Resident 7 was admitted on [DATE], with diagnoses which included acute and chronic respiratory failure with hypoxia (a life-threatening medical emergency where a person with long-term, pre-existing low blood oxygen experiences a sudden, severe worsening of their lung function), and chronic obstructive pulmonary disease (a long-term lung disease that blocks the airways and makes it hard to breathe), per the facility's Face Sheet. A review of Resident 7's physician order sheet, dated 8/26, indicated Supplemental Oxygen at 2 LPM (liters per minute- measures the flow rate or speed at which supplemental oxygen is delivered from a tank or concentrator to a person's lungs.) Titrate 2-4 LPM to maintain oxygen saturation greater than 92%. On 8/9/26 at 3:38 P.M., an observation was conducted with Resident 6 in his room. Resident 6 was in his bed, awake and oriented to place, date and time. Resident 6 had oxygen at 5L/minute per nasal cannula. On 8/10/26 at 4:21 P.M., an observation and an interview was conducted with Resident 6 in his room in his bed. Resident 7 stated that he had oxygen since he was admitted at the facility. When asked how many liters of oxygen he was on, he stated at 2 LPM. Resident 7 supplemental oxygen was at 5 LPM per nasal cannula. On 8/11/26 at 8:06 A.M., an observation was conducted with Resident 7 in his room. Resident 7 was in bed with his eyes closed. Resident 7 supplemental oxygen was at 5 LPM per nasal cannula. On 8/11/26 at 9:20 A.M., a concurrent record review and interview with Minimum Data Set Nurse (MDSN). The MDSN stated Resident 7's order for supplemental oxygen was 2 LPM and could be titrated up to 4 LPM to maintain oxygen saturation greater than 92%. On 8/11/26 at 9:23 A.M., a joint observation was conducted with MDSN in Resident 7's room. MDSN stated the supplemental oxygen was at 5 LPM. MDSN stated the Licensed Nurse (LN) was responsible to check the correct liters of supplemental oxygen administered. On 8/11/26 at 3:50 P.M., an interview was conducted with LN 2. LN 2 stated Resident 7 oxygen order was 2-4 LPM. LN 2 stated if Resident 7's oxygen saturation (the percentage of hemoglobin in your red blood cells carrying oxygen compared to the maximum amount it can carry ) level drop below 92%, the Registered Nurse (RN) would be notified, and the RN could titrate the oxygen. On 8/12/26 at 2:10 P.M., an interview was conducted with the Interim Director of Nursing (IDON). The IDON stated physician's order should have been followed. The IDON stated Licensed Vocational Nurse (LVN) could not titrate oxygen but only the RN. The IDON stated LVN was responsible to check the oxygen LPM and should have inform the RN if changes were needed. A review of the facility's policy, titled Oxygen Administration, dated 3/25 indicated . to provide guidelines for safe oxygen administration. verify that there is a physician's order. 2.Resident 66 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), per the Face Sheet. A record review was conducted of Resident 66. Resident 66's minimum data set (MDS – a federally mandated resident assessment tool), dated 8/9/26, indicated Resident 66's brief interview for mental status (BIMS, ability to recall) score was 14/15 which indicated Resident 66 was cognitively intact. The MDS also indicated Resident 66 was on oxygen therapy. A review of Resident 66's physician order was conducted. The physician order indicated 2 Liters (L, unit of measurement) of oxygen was to be given to Resident 66 during the daytime for COPD. A review of Resident 66's Respiratory care plan indicated one of the interventions was O2 therapy as ordered. On 8/9/26 at 11:22 A.M., an observation and an interview with Resident 66 was conducted. Resident 66 had the oxygen nasal cannula (NC-a two-pronged plastic tubing used to deliver oxygen through the nose) regulated at 3 liters per minute (LPM) via oxygen concentrator. Resident 66 stated he had breathing treatment in the hospital. On 8/10/26 at 10:10 A.M. and on 8/10/26 at 4:14 P.M., a follow-up observation of Resident 66 was conducted. Resident 66 laid in bed, with the O2 set at 3 LPM via nasal cannula (NC). On 8/11/26 at 8:16 A.M., an observation and an interview with Resident 66 was conducted. Resident 66 stated he felt warm and thirsty because of the O2. Resident 66 stated the O2 kept his throat dry and made him cough. On 8/11/26 at 10:27 A.M., a concurrent review of Resident 66's record and an interview with the Infection Preventionist (IP) was conducted. The IP stated Resident 66' physician order was to deliver O2 at 2 LPM/ NC during the daytime because of his COPD. On 8/11/26 at 10:48 A.M., a joint observation of Resident 66 and an interview with the Infection Preventionist (IP) and LN 12 was conducted. The IP and LN 12 verified Resident 66's O2 was set at 3 LPM/NC. LN 12 stated LNs should have followed the physicians' orders for Resident 66's safety. LN 12 stated Resident 66's physician had the order to maintain Resident 66's O2 saturation level at 92-94% because of his diagnosis of COPD. On 8/12/26 at 1:47 PM., an interview was conducted with the Interim Director of Nursing (IDON). The IDON stated the expectation was the LNs should have followed the physician's orders for resident safety because of the potential adverse effect of O2 for COPD residents. A review of the facility's policy on Oxygen Administration revised March 2025, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration.1. Verify that there is a physician's order for this procedure. Review the physician's orders.for oxygen administration.

Based on observation, interview, and record review, the facility failed to ensure care plan related to tube feeding (a medical tube device to deliver liquid food, fluids, and medicines directly into the stomach or small intestine) and resident's fall were updated for two of 21 residents reviewed for care plan revision (61, 30).This failure had the potential to affect Resident 61's tube feeding care, accurate intake measurements, and Resident 30's fall safety. Findings:1. Resident 61 was admitted on [DATE], with diagnoses which included cerebral infarction (ischemic stroke- when a blood clot or blocked artery stops blood flow to a part of the brain) and gastrostomy (a small, safe tunnel made through the skin of the belly directly into the stomach), per the facility's Face Sheet.A review of Resident 61 Physician Order Sheet dated 8/26, indicated, TwoCal HN 0.08 gram - 2Kcal/ml (high-calorie, high-protein liquid medical food) oral liquid 120 (ml) milliliter via gastrostomy tube (GT). To give bolus ( a single large dose) of 120 ml if oral intake 50% or less at meals.On 8/9/26 at 8:34 A.M., an observation was conducted with Resident 61. Resident 61 was on her bed with her eyes closed. A breakfast tray was on the bedside table.On 8/9/26 at 10 A.M., an interview was conducted with Resident 61. Resident 61 stated I ate all my breakfast.On 8/10/26 at 4:24 P.M., an interview was conducted with the Certified Nursing Assistant 13 (CNA). CNA 13 stated Resident 61 was ambulatory, verbal, independent, and feeds herself. CNA 13 stated Resident 61 would eat most of her food . On 8/11/26 at 10:17 A.M., a concurrent record review and an interview was conducted with Minimum Data Set Nurse (MDSN). The MDSN stated Resident 61's physician order was to administer the TwoCal HN 120 ml bolus feeding if Resident 61's oral intake was less than 50% . Review of Resident 61's meal intake log and medication administration record (MAR) indicated that on the following dates: 8/6/26 10 am- 80% meal intake - TwoCal HN bolus was administered8/9/26 10 A - 120% meal intake - TwoCal HN bolus was administered8/9/26 1 pm - 75% - meal intake - TwoCal HN bolus was administered8/9/26 -6 PM - 60% - meal intake - TwoCal HN bolus was administered8/10/26 - 10 AM - 75% - meal intake - TwoCal HN bolus was administered8/10/26 at 1 PM - 120% - meal intake - TwoCal HN bolus was administeredOn 8/11/26 at 10:20 A.M., an interview was conducted with the MDSN. The MDSN stated the Medication Administration Record indicated Licensed Nurses (LNs) administered bolus of TwoCal HN to Resident 61 even with the meal intake of more than 50%. The MDSN stated LNs should have followed the physician's order. In addition, the MDSN stated the care plan should have reflected the TwoCal HN bolus was to be administered to Resident 61 if her meal intake was less than 50%.On 8/12/26 at 2:08 P.M., an interview was conducted with the Interim Director of Nursing (IDON). The IDON stated staff should have followed the physician's order and care plan should have been revised to reflect the Two Cal HN bolus to Resident 61. A review of the facility's policy, titled Care Plan, Comprehensive Person - Centered, dated 3/25 indicated . 11. Assessments of residents are on going and care plan are revised as information about the resident and the resident's condition change.2. Resident 30 was admitted on [DATE], with diagnoses which included vascular dementia with psychotic disturbance (a brain condition where poor blood flow causes memory loss, confusion, and false beliefs or seeing things that are not real), per the facility's Face Sheet.Resident 30's fall risk assessment (Assessment of person's risk of falling) was reviewed. Resident 30's fall risks were as follows:3/13/26 - score of 9 - admission fall risk assessment. A score of 10 and above means the resident would have been considered high risk for fall (a person has a very high chance of losing their balance and falling down).6/19/26 at 11:49 A.M. - score of 11 - unwitnessed fall. Found on the floor mat near the right side of her bed. No injury and denied pain.7/25/26 at 5:45 A.M. - score of 10 - unwitnessed fall. Found lying on her left side on the floor mat next to her bed. Resident reported hit the back of her head. Had redness on her left upper cheek but denied pain. Resident was sent out to acute hospital with no acute findings.8/3/26 at 2:15 P.M. - score of 10 - unwitnessed fall. Found on the side of her bed and sustained a laceration/bump to the left temporal area. Resident was sent out to acute hospital with a finding of thoracic compression fracture (when a bone in the spine collapses). A review of Resident 30's fall care plan effective 3/13/26 indicated, on 6/22/26 fall mat was added and remove wheelchair from bedside and on 7/27/26 added non- skid socks and promote quiet environment to minimize sleep disruption and confusion.On 8/9/26 at 9:45 A.M., an observation was conducted in Resident 30's room. Resident 30 was in bed and appeared sleeping with her aspen collar (specialized medical neck brace designed to restrict movement of the neck bones) in placed. A sitter (a person directly watching and providing care) was seated at the bedside.On 8/9/26 at 9:46 A.M., an interview was conducted with the Certified Nursing Assistant 2 (CNA). CNA 2 stated Resident 30 needed a 1:1 supervision for her agitation, impulsive behavior, and tried to get out of bed by herself.On 8/10/26 at 4:24 P.M., an interview was conducted with CNA 13. CNA 13 stated Resident 30 was confused, fall risk and constantly tried to get out of bed without calling for assistance. CNA 13 stated Resident 30 did not have a 1:1 sitter when she fell on 8/3/26.On 8/11/26 at 8:15 A.M., an interview was conducted with CNA 3. CNA 3 stated Resident 30 was a fall risk and had multiple falls. Resident 30 was confused, combative, and would be getting up and out of bed by herself. CNA 3 stated she did not have a 1:1 sitter until the recent fall when she came back from the hospital with a neck brace.On 8/11/26 at 8:55 A.M., a concurrent record review and an interview was conducted with Minimum Data Set Nurse (MDSN) . The MDSN stated Resident 30 was confused, had history of multiple falls, and had poor safety awareness. MDSN stated the care plan should have been revised to prevent further falls and injury. On 8/12/26 at 2:09 P.M., an interview was conducted with the Interim Director of Nursing (IDON). The IDON confirmed that falls interventions were ineffective since Resident 30 kept on falling. IDON stated care plan interventions should have been accelerated to prevent fall injury.A review of the facility's policy, titled Care Plan, Comprehensive Person - Centered, dated 3/25 indicated . 11. Assessments of residents are on going and care plan are revised as information about the resident and the resident's condition change.

Based on interview and record review, the facility failed to provide a written notice of bed hold rights and notification of transfer to the ombudsman for one of three residents (Resident 3) reviewed for closed record. This failure had the potential for the resident and/or the resident's representative not to have information regarding bed hold rights. In addition, the Ombudsman (an advocate for the residents in nursing homes) was not informed of Resident 3's transfer to the hospital. Findings: Resident 3 was admitted to the facility on [DATE] with diagnoses including pneumonia (inflammation of the lungs) and dementia (loss of ability to think, remember and reason) according to Resident 3's Face Sheet. The Face Sheet further indicated Resident 3's daughter as the primary contact. During a concurrent review of the Electronic Medical Record (EMR) for Resident 3 and an interview with the Infection Preventionist (IP) on 8/11/26 at 9:24 A.M., the IP stated Resident 3's transfer form indicated a transfer to hospital dated 8/7/26 due to large amount of vomitus and coarse lung sounds. The IP stated the transfer form did not indicate a written notification of the resident's representative was completed when Resident 3 was transferred to the hospital. The IP stated the social service department was responsible for sending the written notification to the Ombudsman when a resident was discharged . The IP stated she was not sure if we call the ombudsman every time, we transfer a resident out. During an interview with the Resident Care Coordinator/ Social Services (RCC/ SS) on 8/11/26 at 9:44 A.M., the RCC/ SS stated she was not responsible for notifying the Ombudsman when the residents were transferred to the hospital. The RCC stated nurses were responsible for notifying the Ombudsman when they transferred residents out. An interview with the Interim Director of Nursing (IDON) was conducted on 8/12/26 at 1:47 P.M. The IDON stated the expectation was for the facility to follow the regulations for resident transfer. A review of the facility's policy and procedure (P&P) titled, Bed holds and Returns, dated March 2025 was conducted. The P&P indicated, All residents/representatives are provided written information regarding the facility and state bed hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). A review of the facility's P&P titled, Transfer or Discharge, Facility Initiated, dated March 2025 was conducted. The P&P indicated, Notice of Transfer or Discharge (Planned).12. The resident and representative are notified in writing of the following information.l. The notice of Facility Bed-Hold and policies.13. A copy of the notice is sent to the Office of the State Long- Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

Based on observation and interview, the facility failed to demonstrate infection control practices when the Licensed Nurse (LN) did not sanitize the blood pressure (BP) machine (medical device used to measure the pressure of blood pushing against your artery walls) for three residents (29,33, and 48) during medication administration.This failure had the potential to increase residents' risk for exposure to unwanted pathogens (microorganisms that cause disease). Findings: On 8/12/26 at 8:17 A.M., an observation was conducted with LN 3 during medication administration to Resident 48. LN 3 checked Resident 48's blood pressure before medications were administered. LN 3 placed the blood pressure machine on top of the medication cart after without cleaning and disinfected the BP machine.On 8/12/26 at 8:47 A.M., an observation was conducted with LN 3 during the medication administration to Resident 33. LN 3 checked Resident 33's blood pressure before medication administered. LN 3 did not clean and disinfected the BP machine before and after used.On 8/12/26 at 9:08 A.M., an observation was conducted with LN 3 during the medication administration to Resident 29. LN 3 checked Resident 29's blood pressure before medication administered. LN 3 did not clean and disinfected the BP machine before and after used.On 8/12/26 at 9:33 A.M., an interview was conducted with LN 3. LN 3 stated she did not clean or disinfect the BP machine before and after taking the residents' blood pressure. LN 3 stated she should have disinfected the machine between residents but did not.On 8/12/26 at 2:15 P.M., an interview was conducted with the Interim Director of Nursing (IDON). The IDON stated staff should have cleaned and disinfected the BP machine after each resident to prevent the spread of infection. A review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 3/25, indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard.5. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment) .9. Durable medical equipment (DME) is cleaned and disinfected before reuse by another resident.

Based on observation, interview, and record review, the facility failed to ensure medical records were accurate for two of 21 residents reviewed for accuracy of medical records when: 1. Resident 20 had incorrect documentation related to blood sugar checks2. Resident 24 had inaccurate lunch meal delivered to the resident compared to the meal tray card. This failure had the potential for health care providers to receive inaccurate health information. Findings: 1.Resident 20 was readmitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar), per the Face Sheet. A review of Resident 20's physician order dated 11/13/25 indicated to administer insulin (medication to regulate blood sugar) to Resident 20 and to monitor his blood sugar (BS) levels. On 8/11/26 at 8:24 A.M., a joint review of Resident 20's electronic medical record (EMR) and an interview was conducted with Licensed Nurse (LN) 12. LN 12 stated Resident 20 had a diagnosis of diabetes and was to receive 32 units of long-lasting insulin. LN 12 stated Resident 20's BS levels were monitored and documented in the EMR. There were BS entries that were zero and below the normal levels (blood sugar ranges set by the American Diabetes Association are 80 to 130 mg/dL before meals and less than 180 milligram per deciliter [mg/dL, unit of measurement] one to two hours after a meal.). A review of Resident 20's BS checks from February to August 2026 and LNs progress notes were conducted. There were abnormal BS readings for Resident 20: 5/13/26 - 0 – there was no progress note. Per LN 12, the LN assigned to the resident was expected to write a progress note related to the BS reading of zero. 6/6/26 - 32 mg/dL. LN 12 stated there was no documentation on the low BS reading for Resident 20. LN 12 stated the LN could have written down 32 as the amount of insulin administered to Resident 20 and not the blood sugar levels. LN 12 stated the documentation was not accurate. LN 12 stated if Resident 20's blood sugar was low; the LN should have held the insulin and should have called the physician. 7/10/26 – 32 mg/dL. LN 12 stated the LN had documented the blood sugar inaccurately since she indicated Resident 20's BS was 32 and the insulin administered was 131. 7/11/26 - 70 mg/dL, LN 12 stated on 7/11/26, there were 2 documentations of Resident 20's BS readings. On 8/11/26 at 9:05 A.M., a continuation of review of Resident 20's blood sugar levels and progress notes of LNs was conducted with the Infection Preventionist (IP). The IP stated on 7/22/26, the LN documented Resident 20's BS reading at 32 mg/dL. The IP stated there was no progress notes for Resident 20's low BS level. The IP stated the LN could have made a mistake in documenting Resident 20's BS reading. The IP stated if Resident 20's BS level was abnormal, the LN should have documented what was done, and if there were medications that was given. A review of the facility's policy titled Charting Errors and/ or Omissions, dated March 2025 was conducted. The policy indicated, Accurate medical records shall be maintained by this facility. 2. On 8/9/26 at 12:28 P.M., Resident 24 was observed being served a lunch tray after it was checked by the Director of Staff Development (DSD). The plate contained food that had had a dark liquid on it. The meal tray card indicated, No gravy-Use low sodium thickened broth. The DSD stated the dark liquid was a thickened broth in place of gravy per family request. On 8/9/26 at 1:15 P.M., Diet Aide 1 (DA 1) was interviewed. DA 1 stated the item on Resident 24's plate was actually teriyaki sauce, not broth, and was not low sodium. DA 1 stated teriyaki sauce was Resident 24's daughter's current request. On 8/10/26 at 11:04 A.M., the Registered Dietician (RD 1) was interviewed. RD 1 stated Resident 24's daughter regularly communicated with the dietary staff about food preferences and requests. RD 1 stated the requests changed frequently. RD 1 stated the current request for Resident 24 was for teriyaki or barbeque sauce, and low sodium was not required. RD 1 stated the meal tray card that indicated No gravy-Use low sodium thickened broth was not current. RD 1 stated the tray card notes were entered by the Dietician, based on interview with residents or family. RD 1 stated in this case she did not update the tray card note. RD 1 stated the tray card notes should have been updated so communication to dietary staff and nursing was accurate. On 8/12/26 at 1:58 P.M., the Interim Director of Nursing was interviewed (IDON). The IDON stated the meal tray card should have been clear and accurate to ensure nursing gave the resident the correct food items. A review of the facility's policy titled Diets and Menus dated May 2023, indicated, .Selected menus will be reviewed for follow-up needed to promote accuracy, diet compliance, and availability of special requests . A review of the facility's policy titled How To Print Tray Cards, indicated, .obtain food preferences.add any additional information under additional tray card notes. Update tray card as needed.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring for one of three residents (30) who was a known high fall risk (a person has a very high chance of losing their balance and falling down). As a result, Resident 30 sustained a thoracic compression fracture (when a bone in the spine collapses). Findings: Resident 30 was admitted on [DATE], with diagnoses which included vascular dementia with psychotic disturbance (a brain condition where poor blood flow causes memory loss, confusion, and false beliefs or seeing things that are not real), per the facility's Face Sheet.Resident 30's fall risk assessment (A fall risk assessment checks a person's risk of falling) was reviewed. Resident 30's fall risks was as follows:3/13/26 - score of 9 - admission fall risk assessment. A score of 10 and above means the resident would be considered high risk for fall (a person has a very high chance of losing their balance and falling down).6/19/26 at 11:49 A.M. - score of 11 - unwitnessed fall. Found on the floor mat near the right side of her bed. No injury and denied pain.7/25/26 at 5:45 A.M. - score10 - unwitnessed fall. Found lying on her left side on the floor mat next to her bed. Resident reported hit the back of her head. Had redness on her left upper cheek but denied pain. Resident was sent out to acute hospital with no acute findings.8/3/26 at 2:15 P.M. - score 10 - unwitnessed fall. Found on the side of her bed and sustained a laceration/bump to the left temporal area. Resident was sent out to acute hospital with a finding of thoracic compression fracture (when a bone in the spine collapses). On 8/9/26 at 9:45 A.M., an observation was conducted in Resident 30's room. Resident 30 was in bed and appeared to be sleeping with her aspen collar (specialized medical neck brace designed to restrict movement of the neck bones) in placed. A sitter was seated at the bedside.On 8/9/26 at 9:46 A.M., an interview was conducted with Certified Nursing Assistant 2 (CNA). CNA 2 stated Resident 30 needed a 1:1 supervision for her agitation, impulsive behavior, and tried to get out of bed by herself.On 8/10/26 at 4:24 P.M., an interview was conducted with CNA 13.CNA 13 stated Resident 30 was confused, fall risk and constantly tried to get of bed without calling for assistance. CNA 13 stated Resident 30 did not have a 1:1 sitter when she fell on 8/3/26.On 8/11/26 at 8:15 A.M., an interview was conducted with CNA 3. CNA 3 stated Resident was a fall risk and had multiple falls. Resident 30 was confused, combative, and would be getting up and out of bed by herself. CNA 3 stated she did not have a 1:1 sitter until the recent fall when she came back from the hospital with a neck brace.On 8/11/26 at 8:55 A.M., a concurrent record review and an interview was conducted with Minimum Data Set Nurse (MDSN) . The MDSN stated Resident 30 was confused, had history of multiple falls, and had poor safety awareness. On 8/11/26 at 3:50 P.M., an interview was conducted with Licensed Nurse 2 (LN). LN 2 stated Resident 30 had multiple falls; she was agitated and combative during the afternoon shift and constantly getting out from her bed without assistance. LN 2 stated to monitor her during the shift, we would put her in the wheelchair in front of the nurse's station but would constantly stand up and down in the wheelchair.On 8/12/26 at 9:40 A.M. an interview was conducted with LN 1. LN 1 stated he worked when Resident 30 fell on 8/3/26. LN 1 stated Resident 30 was agitated that day; she was put in bed to rest and was found sitting upright on the right side of the bed. Resident 30 did not have a sitter during her fall. On 8/12/26 at 2:09 P.M., an interview was conducted with the Interim Director of Nursing (IDON). The IDON stated the fall interventions for Resident 30 were ineffective because Resident 30 kept on falling. A review of the facility's policy, titled Falls - Clinical Protocol, dated 3/25 indicated . the physician will help identify individuals with a history of falls and risk factors of falling.staff and physician will identify pertinent interventions to try to prevent subsequent falls.

Based on observation, interview and record review, the facility failed to ensure consistent urine output monitoring was provided for one of two residents (Resident 21) screened for an indwelling catheter (a thin, flexible tube inserted and left in the bladder to collect and drain urine). This failure had the potential for Resident 21 to have urine retention and develop a urinary tract infection (UTI- an infection in the bladder/urinary tract). Findings: Resident 21 was readmitted to the facility on [DATE] with diagnoses including sepsis (life-threatening reaction to an infection) and infection caused by the presence of indwelling catheter, per the Face Sheet. A review of Resident 21's history and physical (H&P) dated 6/25/26 indicated Resident 21 had UTI, had indwelling catheter and was recently hospitalized . The H&P also indicated that Resident 21 did not have the capacity to understand and make decisions. On 8/9/26 at 11:03 A.M., an observation of Resident 21 was conducted in the dining room. Resident 21 had an indwelling catheter attached to his wheelchair. On 8/10/26 at 4:39 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 14. CNA 14 stated she provided care to Resident 21 and was familiar with the resident. CNA 14 stated Resident 21 had indwelling catheter and one of the CNAs responsibilities was to measure and document Resident 21's urine output in his electronic medical record (EMR). On 8/11/26 at 9:43 A.M., a concurrent review of Resident 21's EMR and an interview with the Infection Preventionist (IP) was conducted. The IP stated Resident 21 was hospitalized in January 2026 and in June 2026 due to infection related to the indwelling catheter. The IP stated there was a physician's order to document Resident 21's urine output every shift. The urine output review was conducted from January through August 2026. The IP stated there were missing entries on the following dates and shifts: Morning shift (7 AM - 3 PM) - 3/5, 3/7, 3/8, 3/13, 4/11, 5/11, 5/24, 7/29Afternoon shift (3 PM - 11 PM) - 1/13, 1/16, 2/6, 3/28, 4/1, 4/10, 5/1, 5/9, 5/30, 6/1, 7/29Night shift (11 PM- 7 AM) - 1/17, 1/25, 2/14, 2/15, 2/20, 3/4, 3/5, 4/9, 4/11, 4/19, 5/30, 5/31, 7/29, 8/5 The IP stated the nurses should have monitored and documented Resident 21's urine output to ensure he was getting enough hydration. An interview with the Interim Director of Nursing (IDON) was conducted on 8/12/26 at 1:47 P.M. The IDON stated the expectation was for the nurses to follow the physicians orders and document the urine output to ensure the indwelling catheter was draining, the urine did not back up and the resident did not develop UTI. A review of the facility's policy titled Catheter Care, Urinary, dated March 2025, indicated .The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .Input/ Output, 2. Follow the facility procedure for measuring and documenting input and output. A review of the facility's policy titled Output, Measuring and Recording, dated March 2025, indicated Carefully observe the level of urine in the graduate.Record the amount noted in the output side of the intake and output record.

Based on record review and interview, the facility failed to obtain a written consent from the resident representative for psychotherapeutic drugs (prescription medications that affect the mind, mood, and behavior by balancing natural chemicals in the brain) for one of four sampled residents reviewed for psychotropic drugs (4).This failure had the potential to affect resident's health and safety related to the side effects of the medication. Findings: Resident 4 was admitted on [DATE], with diagnoses which included vascular dementia (decline in brain function caused by blocked or damaged blood vessels that reduce blood and oxygen flow to the brain), per the facility's Face Sheet.A review of Resident 4's physician order sheet dated 8/26 was conducted. The order sheet included Risperidone (psychotherapeutic medication) 0.25 milligram (mg) for mood disorder with psychotic features (person has temporarily lost touch with reality). Resident 4's Risperidone 0.25 mg was ordered on 12/18/25.A review of Resident's 4 Psychotherapeutic Drug Informed Consent for Risperidone was originally signed on 1/8/26 by the Resident 4's representative.On 8/12/26 at 10:18 A.M., a concurrent record review and an interview was conducted with the Minimum Data Set Nurse (MDSN). The MDSN stated Resident 4's Risperidone medication was considered a psychotherapeutic drug and would need consent every six months. MDSN stated Resident 4 had been taking the Risperidone 0.25 mg since the medication was ordered on 12/8/25 through 8/12/26. The MDSN stated there was no renewal of the Psychotherapeutic Drug written consent found in Resident 4's records since 1/8/26. The MDSN stated that there should have been a written consent for 7/26.On 8/12/26 at 2:06 P.M., an interview was conducted with the Interim Director of Nursing (IDON). The IDON stated psychotherapeutic drugs written consent should have been renewed every six months.A review of the facility's provided documentation, titled Psychotherapeutic Drug Informed Consent Form, CDPH 9168, dated 12/25 indicated . within six months after the consent form is signed, and every six months thereafter during which the resident receives the psychotherapeutic drug.

Based on interviews and record reviews, the facility failed to develop a care plan (detailed plan with information about a resident's treatment, goal, and interventions) and implement care plan interventions for two of 21 residents reviewed when: 1. Resident 62's out-of-bed orders from the physician and care plan were not implemented, and2. Resident 57's refusal of care and services related to vaccination refusal had not been care planned. As a result, the lack of a resident centered care plan with specific interventions had the potential to result in delayed care, miscommunication among caregivers, and a decreased physical well-being of the residents. Findings: 1.Resident 62 was admitted on [DATE], with diagnoses which included pressure ulcer of sacral area (bedsore) and peripheral vascular disease (PVD - a blood circulation problem), per the facility's Face Sheet. On 8/9/26 at 9:30 A.M., an observation was conducted with Resident 62 in her room. Resident 62 was in her bed with the head of bed elevated. Resident 62 stared in the ceiling and did not respond when calling her name. On 8/10/26 at 10 A.M., an observation was conducted with Resident 62 in her room. Resident 62 was in bed. On 8/10/26 at 4:20 P.M., an observation was conducted with Resident 62. Resident 62 was in her bed. On 8/10/26 at 4:24 P.M., an interview was conducted with Certified Nursing Assistant 13 (CNA). CNA 13 stated Resident 62 was bed bound (required total assistance from staff). CNA 13 stated Resident 62 stayed in bed all the time, she did not get up in the chair. CNA 13 stated there was a nursing binder that listed residents who needed to get out of bed and Resident 62's name was not included in the list. On 8/11/26 at 8:15 A.M., an interview was conducted with CNA 3. CNA 3 stated Resident 62 was bedbound . ON 8/11/26 at 8:30 A.M., a concurrent record review and interview was conducted with the Minimum data Set Nurse (MDSN). The MDSN stated Resident 62 had an order of getting up to Geri – chair (recliner use for adult and with mobility issues) daily and prn (if needed). Resident 62's care plan also indicated to be up in Geri- chair daily. The MDSN stated staff should have followed the physician's order and care plan should have been implemented. On 8/12/26 at 2:12 P.M., an interview was conducted with the Interim Director of Nursing (IDON). The IDON stated the care plan should have been implemented per the physician's order. 2. Resident 57 was admitted to the facility on [DATE], with diagnoses which included osteomyelitis (infection in a bone), per the facility's Face Sheet. During a concurrent review of Resident 57's vaccination record and an interview with the Infection Preventionist (IP) was conducted on 8/11/26 at 4:39 P.M., the IP stated Resident 57 declined vaccinations for pneumonia (lung infection) and COVID (coronavirus, highly communicable disease). The IP stated she did not develop a care plan related to Resident 57's refusal to vaccinations. The IP stated Resident 57's refusal of the vaccinations should have been care planned because it was a part of care and services provided to the residents. An interview with the Interim Director of Nursing (IDON) was conducted on 8/12/26 at 1:47 P.M. The IDON stated the expectation was for the nurses to develop a care plan related to the resident's refusal of care and to indicate education related to the risks and benefits were provided to the resident. A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated March 2025, indicated, A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.7. The comprehensive person-centered care plan.J. describes the services that are to be furnished.including; 1. Services that would otherwise be provided.but are not provided due to resident exercising his or her rights, including the right to refuse treatment.

Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) was free from physical abuse when:Certified nursing assistant (CNA) 6 did not respect Resident 1's request for CNA 6 to stop touching her and to get out of her room.CNA 6 was assigned to provide care to Resident 1 after the resident had a prior complaint regarding CNA 6 and did not want the CNA as a caregiver.The facility received multiple complaints from residents regarding CNA 6's provision of care. The facility did not implement increased supervision of CNA 6 while providing resident care.As a result of these deficient practices:Resident 1 defended herself by grabbing CNA 6's hair to make her stop. CNA 6 attempted to remove the resident's hand causing a skin tear to the resident's left upper arm.Resident 1 felt attacked by CNA 6 and that she had to fight for her life. Resident 1 experienced anxiety and fear after the incident.Resident 1 was prescribed an antibiotic (medication to treat bacterial infections) as a prophylactic (preventative) treatment for the left upper arm skin tear.Cross reference F684 and F656Findings:A review of Resident 1's Face Sheet, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include generalized muscle weakness, right eye blindness, unspecified urinary incontinence, and mild dementia.A review of Resident 1's minimum data set assessment (MDS, a comprehensive assessment tool), section GG, with Assessment Reference Date of 2/16/26, indicated the resident required substantial/maximal assistance from staff for personal hygiene and upper body dressing, and the resident was dependent on staff to provide toileting hygiene, bathing, and lower body dressing activities. A further review of the same MDS assessment indicated the resident's Brief Interview for Mental Status (BIMS, used to determine cognition) score was seven out of 15 which meant the resident had cognitive impairment.A review of Resident 1's undated ADL (activities of daily living) Care Plan Report indicated, .2 female CG's[care givers] at all times when providing care. A review of the facility's Report of Suspected Dependent Adult/Elder Abuse (SOC 341, a standardized form used to report allegations of abuse) dated 4/3/26, indicated, . [CNA 6] was in room doing a brief change on patient. As she was turning her [Resident 1], the patient grabbed [CNA 6]'s hair and started pulling it .In the process of attempting to remove pt's [patient's] hand from her [CNA 6] hair, [CNA 6] grabbed pt's. [left] upper arm, where patient sustained a bruise and skin tear.A review of Resident 1's Clinical Notes Report dated 4/3/26, indicated the resident had a skin tear on the left upper arm that measured 11 centimeters (cm) by 7 cm and had bruising around the skin tear that was actively bleeding.A review of Resident 1's Clinical Notes Report dated 4/7/26, indicated, .prophylactic ABT [antibiotic] due to skin tear @ [at] lft [left arm], and possible fluid collection, resident Primary Care.gave orders for Bactrim [antibiotic] 400 mg [milligrams]-80 mg for 10 days.A review of the facility's Employee Counseling/Disciplinary Notice Form for CNA 6 related to a previous incident involving Resident 1, dated 4/16/24, indicated, .Family [Resident 1's family] complaint regarding patient care [provided by CNA 6], being rude and attitude.Expected improvement: The violations mentioned above is unacceptable and will not be allowed to continue now or in the future.The incidents mentioned above are serious. CNA 6 refused to sign the form.A review of the facility's Employee Counseling/Disciplinary Notice Form for CNA 6 involving an unsampled resident, dated 12/2/25, indicated, .On Saturday 11/29/25 you were assigned to a patient and the patient stated that you were very indifferent to him and speaking [foreign language] to another CNA while caring for him. This is considered a violation of resident rights. The behavior mentioned above is a violation of our guiding principles, our company policies, Standards of Conduct, and our Code of Conduct. The violations mentioned above is unacceptable and will not be allowed to continue now or in the future. The incidents mentioned above are serious.A review of CNA 6's 2025 Annual Performance Evaluation completed on 2/6/26, covering the employment period of 1/1/25 to 12/31/25, indicated, .1. Customer Focus. [CNA 6], It has been observed that there are challenges regarding interactions with residents, particularly related to tone and attitude. A couple residents have asked that you not be assigned to them going forward because of this.3. Effective Communication.there are times when residents have expressed concerns regarding the way messages are conveyed. Moving forward, maintaining a consistently empathetic and clear communication approach will enhance resident satisfaction and trust.A review of the facility's Witness Statement form completed by CNA 6 regarding the incident between Resident 1 and CNA 6 dated 4/3/26, indicated, .[Resident 1] initially agreed to care, including a brief change. While providing care [Resident 1] suddenly became agitated yelling and using verbal aggression. [CNA 8] briefly entered to check on the situation, and I informed [CNA 8] I was managing [Resident 1]. As I repositioned [Resident 1] to complete hygiene care, she grabbed my hair and would not let go, pulling my head back and forth. I attempted to safely disengage and touch [sic] her hand asking her to release me. When I asked for her to let me go and she kept holding on, I called [CNA 7] for assistance. [CNA 7] came to help calm [Resident 1] and [Resident 1] eventually let go. After we noticed a skin tear.[Resident 1] has a history of claiming rape and abuse during changes.On 4/8/26 at 10:43 A.M., a concurrent observation and interview was conducted with Resident 2. Resident 2 was in her room, lying down in bed, awake, alert, and conversant. Resident 2 stated she had received care from CNA 6 in the past. Resident 2 stated CNA 6 would start taking off her clothes and brief without warning. Resident 2 stated CNA 6 did not provide any explanations prior to providing care. Resident 2 stated CNA 6 was rough and would push her hard back and forth during brief changes. Resident 2 stated CNA 6's care felt rushed. Resident 2 stated CNA 6 would not speak to her during care, except to say turn. Resident 2 stated CNA 6 would speak (foreign language) to another staff in front of her. Resident 2 stated she did not understand (foreign language). Resident 2 stated she felt disrespected by CNA 6's actions and CNA 6 needed to be more respectful. Resident 2 stated she was too old to be pushed around. Resident 2 stated she reported CNA 6's rough and disrespectful care to the Charge Nurse.A confidential interview was conducted with a responsible party (RP) for an unsampled resident. The RP requested to remain anonymous. The RP stated she did not want CNA 6 to provide care for her family member. The RP stated that she gave CNA 6 multiple opportunities to show care and compassion, and CNA 6 continued to be rude and indifferent. The RP stated that every time she would talk to CNA 6 about the care, CNA 6 would have a rude and dismissive attitude, and would make disrespectful facial gestures towards her.On 4/8/26 at 11:20 A.M., a concurrent observation and interview was conducted in Resident 1' room. Resident 1 was lying in bed, awake, and alert. Resident 1 had a gauze and bandage dressing around her left upper arm. Resident 1 had scattered bruises on both forearms that were light purplish to brown in color. Resident 1 stated she had reported the incident that occurred on 4/3/26 to the facility leadership. Resident 1 stated she did not want CNA 6 to touch her and to provide care. Resident 1 stated CNA 6 had been rude and rough in the past. Resident 1 stated that on Friday (4/3/26), CNA 6 came into her room alone. Resident 1 stated CNA 6 started to push her hard and fast without any explanation and was then trying to change her brief. Resident 1 stated she was screaming and yelling for help. Resident 1 stated she felt like she was fighting for her life. Resident 1 pointed to her left upper arm and stated CNA 6 caused this and that she bled a lot from the skin tear. Resident 1 stated CNA 6 made her feel like an object.On 4/8/26 at 5:03 P.M., an interview was conducted with the director of nursing (DON). The DON stated the incident on 4/3/26 had a psychosocial (thoughts, emotions, and mental well-being) effect on Resident 1. The DON stated she had to check on the resident daily. The DON stated there should always be two CNAs for the care of Resident 1 as care planned.A review of the facility's Witness Statement form completed by Resident' 1's RP (RP 9) regarding the incident between Resident 1 and CNA 6 dated 4/3/26, indicated, .[CNA 6] was on [Resident 1's] left side and [Resident 1] was yelling and resisting. [Resident 1] doesn't like [CNA 6], and she can only defend herself by pulling [CNA 6's] hair. [Resident 1] states she doesn't want [CNA 6] as her caregiver. She's too rough. [Resident 1] stated she was screaming like crazy for help when this occurred.On 4/9/26 at 5 P.M., a phone interview was conducted with RP 9. RP 9 stated that Resident 1 was very sensitive to touch especially on her right forearm. RP 9 stated Resident 1 was weak and had an atrophied (a partial or permanent shrinking of muscles) right hand. RP 9 stated Resident 1 preferred staff who were gentle and friendly, and staff who did not talk over her. RP 9 stated the facility and everyone including CNA 6, knew Resident 1 did not want CNA 6 as her caregiver. RP 9 stated Resident 1's request had been known for at least over a year. RP 9 stated she received a call from Resident 1 on the day of the incident with CNA 6. RP 9 stated Resident 1 sounded afraid and wanted her to come to the facility immediately. RP 9 stated that the incident was traumatic for the resident. RP 9 stated Resident 1 had been consistent with her recall of events. RP 9 stated Resident 1 expressed anger towards her because she (RP 9) was not at the bedside to protect her from CNA 6. RP 9 stated that after the incident, Resident 1's phone calls to her had noticeably increased. RP 9 stated Resident 1 repeatedly told her she was afraid and was having nightmares. RP 9 stated Resident 1 was scared that CNA 6 would come back to her room. RP 9 stated Resident 1 was vulnerable in bed and that there were a lot of things that went wrong that morning with CNA 6. RP 9 stated she did not understand why the request to not assign CNA 6 to Resident 1 was not honored. RP 9 stated, since the incident with CNA 6, Resident 1 was afraid every day.A review of the facility's Witness Statement form completed by licensed nurse (LN) 3 regarding the incident between Resident 1 and CNA 6 dated 4/7/26, indicated, .[CNA 6] knows she should not be taking care of [Resident 1] because of previous incidents.On 5/8/26 at 4:14 P.M., a phone interview was conducted with LN 3. LN 3 stated she was familiar with Resident 1. LN 3 stated she had provided care to Resident 1 days after the incident with CNA 6. LN 3 stated Resident 1 was experiencing a lot of anxiety, fear, and was constantly asking if CNA 6 was coming back to her room. LN 3 stated it was considered abuse when CNA 6 ignored the resident's plea to stop and to leave her room on 4/3/26. LN 3 stated it was known that CNA 6 could not provide care to Resident 1 due to previous interactions. LN 3 stated CNA 6 should have refused the assignment on 4/3/26, and should not have gone into Resident 1's room. LN 3 stated Resident 1 was direct and vocal with what she wanted and needed. LN 3 stated Resident 1 had made her wishes clear that she did not want CNA 6 to provide care to her prior to the incident on 4/3/26. LN 3 stated, Why would [CNA 6] agree to that assignment when [CNA 6] knows [Resident 1] doesn't like her? LN 3 stated she felt sorry for what had happened to Resident 1. LN 3 further stated she had never heard Resident 1 make abuse allegations about staff providing care.A review of the facility's Witness Statement form completed by LN 10 regarding the incident between Resident 1 and CNA 6 dated 4/7/26, indicated, .[CNA 7] called this nurse to help check [Resident 1]. When [I] walked into the room, [Resident 1] was yelling at [CNA 6] to get out. [Resident 1] stated [CNA 6] attacked her. [CNA 6] kept brushing [Resident 1's] hair while [Resident 1] yelling and screaming to [CNA 6] to get out. This nurse asked [CNA 6] to step out.[Resident 1] stated that [CNA 6] is very rough on her, she always comes in and throws me around. [CNA 6] cannot have many residents: [Resident 1, an unsampled resident, and Resident 3].On 5/11/26 at 8:16 A.M., a phone interview was conducted with LN 10. LN 10 stated she was the dayshift Charge Nurse on 4/3/26. LN 10 stated CNA 7 called her to Resident 1's room. LN 10 stated CNA 7 informed her that Resident 1 was pulling CNA 6's hair. LN 10 stated she went to Resident 1's room and saw CNA 6 brushing Resident 1's hair while Resident 1 was screaming for CNA 6 to stop and to get out of her room. LN 10 stated she saw Resident 1's left upper arm actively bleeding from an open skin tear. LN 10 stated Resident 1's blood was on the bedsheets and on the resident's clothing. LN 10 stated the blood was alarming. LN 10 stated that she and the MDS Coordinator (MDSC) told CNA 6 to leave the room. LN 10 and the MDSC finished Resident 1's care. LN 10 stated Resident 1 calmed down after CNA 6 left the room. LN 10 stated it was required for two CNAs to take care of Resident 1. LN 10 stated Resident 1 strongly dislikes CNA 6. LN 10 stated she did not understand why CNA 6 took the assignment with Resident 1 and why CNA 6 was by herself with Resident 1. LN 10 stated CNA 6 should not have been assigned to provide Resident 1's care. LN 10 stated she was unsure who made the CNA assignments. LN 10 stated, Maybe night shift? LN 10 stated that it was abuse when CNA 6 did not stop and leave the room when Resident 1 told her to. LN 10 stated not honoring a resident's request to stop was a form of abuse. LN 10 stated that after the incident with CNA 6, Resident 1 was fearful that another incident would happen again. LN 10 further stated there were other residents in the facility who complained about the care CNA 6 provided to them. LN 10 stated as the charge nurse, she had not observed CNA 6 when she provided care to residents.On 5/11/26 at 10 A.M., an interview was conducted with CNA 3. CNA 3 stated she had taken care of Resident 1 many times over the years. CNA 3 stated she never had any problems with Resident 1. CNA 3 stated she built a rapport with Resident 1. CNA 3 stated Resident 1 can be forgetful but always had been pleasant with her. CNA 3 stated when she would be assigned to Resident 1, she would start by introducing herself and communicating with the resident what she would be doing. CNA 3 stated if Resident 1 was not ready for the care, she would respect resident's wishes. CNA 3 stated Resident 1 required two CNAs to provide care. CNA 3 stated she never heard Resident 1 screaming for help or alleging rape and abuse during care. CNA 3 stated she saw Resident 1 after the 4/3/26 incident. CNA 3 stated Resident 1 was quieter and did not want to talk. CNA 3 stated she thought Resident 1 was not her normal self. CNA 3 stated everyone knows that Resident 1 did not want CNA 6 to be her caregiver. CNA 3 stated that she had worked with CNA 6 before and that CNA 6 had an attitude that could be perceived as rude. CNA 3 stated she did not understand why CNA 6 did not speak up about being assigned to Resident 1 on 4/3/26. CNA 3 stated it was considered abuse when a staff did not stop touching them and leave when a resident requested that.A review of the facility's Witness Statement form completed by CNA 8 regarding the incident between Resident 1 and CNA 6 dated 4/3/26, indicated, .I heard [Resident 1] crying for help over and over. I knocked on the door as it was closed and came in and saw [CNA 6] attending to and changing [Resident 1]. After checking that everything is ok, I left to continue my own changes. [Resident 1] continued yelling asking me to come back and help her.On 5/11/26 at 12:52 P.M., a phone interview was conducted with CNA 8. CNA 8 stated she heard Resident 1 yelling for help on 4/3/26. CNA 8 stated she went to the resident's room, opened the door, and entered the room. CNA 8 stated she saw CNA 6 standing over Resident 1 and it looked like CNA 6 was getting ready to change Resident 1's brief. CNA 8 stated Resident 1 looked distressed and was yelling for help. CNA 8 stated that she offered to help CNA 6 who was alone in Resident 1's room but CNA 6 refused her help. CNA 8 stated she had been told by other staff that Resident 1 could get agitated during care. CNA 8 stated she trusted CNA 6 when she told her that Resident 1 was being cared for. CNA 8 stated she heard Resident 1 yelling and asking her to come back when she left the room. CNA 8 stated she had only worked at the facility for two months and did not know everyone. CNA 8 stated, after the incident, she found out that CNA 6 and Resident 1 had a history of not getting along. CNA 8 stated knowing this now, she would have done things differently and would not have left Resident 1 alone with CNA 6. CNA 8 stated she would have helped Resident 1. CNA 8 stated that if she were Resident 1, she would feel unsafe and violated when CNA 6 did not honor her request to stop and leave. CNA 8 stated, I harbor guilt that I didn't help [Resident 1].On 5/11/26 at 1:19 P.M., an interview was conducted with the MDSC. The MDSC stated she went to Resident 1's room to respond to the incident on 4/3/26. The MDSC stated it was not normal for Resident 1 to be yelling out for help. The MDSC stated she saw CNA 6 in the room while Resident 1 continued to be upset. The MDSC stated she told CNA 6 to leave the room. The MDSC stated she saw an open, bleeding skin tear on Resident 1's left upper arm. The MDSC stated blood was on the resident's gown and sheets. The MDSC stated she did not understand why CNA 6 did not leave the resident's room when Resident 1 told her to. The MDSC stated she did not know why CNA 6 was alone in the room with Resident 1 with the door closed. The MDSC stated Resident 1's ADL care required two CNAs at all times. The MDSC stated she did not know why CNA 6 was assigned to Resident 1. The MDSC stated CNA 6 was not supposed to take care of Resident 1 and that CNA 6 was well aware of that. The MDSC stated CNA 6 had other residents refusing her to provide care for them. The MDSC stated CNA 6 demonstrated rudeness and lacked accountability. The MDSC stated CNA 6 was a difficult employee. The MDSC stated CNA 6 should have been more closely supervised during the provision of care.On 5/11/26 at 2:35 P.M., an interview was conducted with the DON. The DON stated CNA 6 had a prior incident with Resident 1 in the year 2024. The DON stated CNA 6 was aware Resident 1 did not want to receive care from her since 2024. The DON stated Resident 1 had been adamant regarding this longstanding request not to have CNA 6 assigned to her. The DON stated CNA 6 should not have taken the assignment with Resident 1 on 4/3/26. The DON stated there should have been a clear process when making CNA assignments to ensure residents were not assigned CNAs they did not get along with. The DON stated CNA 6 did not follow the care plan for Resident 1 related to the resident's need for two caregivers during ADL care. The DON stated it was abuse when CNA 6 did not honor Resident 1's wishes to stop touching her and to leave the room. The DON further stated she never heard or received any reports that Resident 1 alleged rape or abuse during care. The DON stated based on CNA 6's history with residents, there should have been closer supervision of CNA 6 when she provided care to her residents. On 5/12/26 at 2 P.M., a phone call was made to CNA 6. CNA 6 did not respond to the interview request.A review of the facility's untitled letter to CNA 6 dated 4/10/26, indicated, .On April 3, 2026, while providing care to [Resident 1] .During that interaction, your response resulted in an injury to the resident, including a bruise and a skin tear to the resident's upper arm. The injury required medical evaluation, and the resident was placed on antibiotics as a precaution to prevent infection. Because of the seriousness of the incident, we were required to self-report.We also confirmed that you had previously been instructed not to provide care to this resident. While investigating, [DON] found there were prior requests from two other residents who asked not to have you.due to concerns about the way care was provided.Under California law, elder abuse includes physical abuse and neglect, including failure to protect a resident from harm and the failure to provide care in a safe and appropriate manner.Residents also have the right to be treated with dignity and respect and to be free from abuse.Additionally, your conduct is a violation of California Nursing Home Residents' Rights.The expectation is clear and is the foundation of care we provide.Your conduct is also in violation of.Standards of Conduct, and Codes of Conduct.Due to the severity of this incident, we have decided to terminate your at-will employment effective Friday, April 10, 2026.A review of the facility's undated employees' Standards of Conduct indicated, .I will respect others as human beings.A review of the facility's policy titled Resident Rights dated 2/20/24, indicated, .Employees shall treat all residents with kindness, respect, and dignity.1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.b. be treated with respect, kindness and dignity; c. be free from abuse.A review of the facility's policy titled Dignity dated 2/20/24, indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences.3. Individual needs and preferences of the resident are identified through the assessment process.A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating dated 2/20/24, did not provide guidance related to abuse prevention.

Based on interview and record review, the facility failed to develop an individualized written care plan for one of three residents (Resident 1) that addressed Resident 1's preference not to have care provided by certified nursing assistant (CNA) 6 after the resident made a complaint about CNA 6.This deficient practice had the potential to cause distress to Resident 1. Cross reference F 600.Findings:A review of Resident 1's Face Sheet, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses to include generalized muscle weakness, right eye blindness, unspecified urinary incontinence, and mild dementia.A review of the facility's Employee Counseling/Disciplinary Notice Form for CNA 6 related to a previous incident involving Resident 1, dated 4/16/24, indicated, .Family [Resident 1's family] complaint regarding patient care [provided by CNA 6], being rude and attitude.Expected improvement: The violations mentioned above is unacceptable and will not be allowed to continue now or in the future.The incidents mentioned above are serious. CNA 6 refused to sign the form.A review of the facility's Report of Suspected Dependent Adult/Elder Abuse (SOC 341, a standardized form used to report allegations of abuse) dated 4/3/26, indicated, . [CNA 6] was in room doing a brief change on patient. As she was turning her [Resident 1], the patient grabbed [CNA 6]'s hair and started pulling it .In the process of attempting to remove pt's [patient's] hand from her [CNA 6] hair, [CNA 6] grabbed pt's. [left] upper arm, where patient sustained a bruise and skin tear.On 4/8/26 at 11:20 A.M., an interview was conducted with Resident 1 while inside the resident's room. Resident 1 stated that on 4/3/26, CNA 6 came into her room alone, and was then trying to change her brief. Resident 1 stated she did not want CNA 6 to touch her and to provide care.On 4/9/26 at 5 P.M., a phone interview was conducted with Resident 1's RP (RP 9). RP 9 stated the facility and everyone including CNA 6 knew Resident 1 did not want CNA 6 as her caregiver. RP 9 stated Resident 1's request had been known for at least over a year. RP 9 stated she did not understand why the request to not assign CNA 6 to Resident 1 was not honored. On 5/8/26 at 4:14 P.M., a phone interview was conducted with LN 3. LN 3 stated she was familiar with Resident 1. LN 3 stated it was known that CNA 6 could not provide care to Resident 1 due to previous interactions. LN 3 stated CNA 6 should have refused the assignment on 4/3/26, and should not have gone into Resident 1's room. LN 3 stated Resident 1 was direct and vocal with what she wanted and needed. LN 3 stated Resident 1 had made her wishes clear that she did not want CNA 6 to provide care to her prior to the incident on 4/3/26. LN 3 stated, Why would [CNA 6] agree to that assignment when [CNA 6] knows [Resident 1] doesn't like her? On 5/11/26 at 8:16 A.M., a phone interview was conducted with LN 10. LN 10 stated that on 4/3/26 she went to Resident 1's room and saw CNA 6 brushing resident's hair while Resident 1 was screaming for CNA 6 to stop and to get out of her room. LN 10 stated that she and the MDS Coordinator (MDSC) told CNA 6 to leave the room. LN 10 stated Resident 1 calmed down after CNA 6 left the room. LN 10 stated Resident 1 strongly disliked CNA 6. LN 10 stated Resident 1's choice and request not to have CNA 6 should have been care planned.On 5/11/26 at 1:19 P.M., an interview was conducted with MDSC. The MDSC stated that on 4/3/26 she went into Resident 1's room and saw CNA 6 there. The MDSC stated she did not know why CNA 6 was assigned to Resident 1 on 4/3/26. The MDSC stated CNA 6 was not supposed to take care of Resident 1 and that CNA 6 was well aware of that. The MDSC stated the incident on 4/3/26 could not happen again. The MDSC stated the facility had to create a process of care planning and communication to include residents' choices and preferences regarding their caregivers. The MDSC stated the facility did not have a care plan for Resident 1's preference to not have CNA 6 provide her care. On 5/11/26 at 2:35 P.M., an interview was conducted with the director of nursing (DON). The DON stated CNA 6 had a prior incident with Resident 1 in the year 2024. The DON stated CNA 6 was aware Resident 1 did not want to receive care from her since 2024. The DON stated Resident 1 had been adamant regarding this longstanding request not to have CNA 6 assigned to her. The DON stated CNA 6 should not have taken the assignment to provide care to Resident 1 on 4/3/26. The DON stated Resident 1's preference of not having CNA 6 as her caregiver should have been included in Resident 1's care plan. The DON stated the facility did not currently have a clear process for communicating residents' preferences regarding their caregivers.A review of the facility's policy titled Care Plans, Comprehensive Person-Centered dated 2/20/24, indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .7. The comprehensive, person-centered care plan.j. describes the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to ensure the comprehensive assessment and care plan were followed for one of three residents (Resident 1).As a result, Resident 1's activities of daily living (ADL) care was not provided in a manner that was consistent with her minimum data set assessment (MDS-a comprehensive assessment tool) and written ADL care plan. This had the potential to risk the resident's safety and to cause discomfort.Findings: A review of Resident 1's Face Sheet, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses to include generalized muscle weakness, right eye blindness, unspecified urinary incontinence, and mild dementia.A review of Resident 1's minimum data set assessment (MDS, a comprehensive assessment tool), section GG, with Assessment Reference Date of 2/16/26, indicated the resident required substantial/maximal assistance from staff for personal hygiene and upper body dressing, and the resident was dependent on staff to provide toileting hygiene, bathing, and lower body dressing activities.A review of Resident 1's undated ADL (activities of daily living) Care Plan Report indicated, .2 female CG's[care givers] at all times when providing care. A review of the facility's Witness Statement form completed by CNA 6 regarding an incident between Resident 1 and CNA 6 dated 4/3/26, indicated, .[Resident 1] initially agreed to care, including a brief change. While providing care [Resident 1] suddenly became agitated yelling and using verbal aggression. [CNA 8] briefly entered to check on the situation, and I informed [CNA 8] I was managing [Resident 1].A review of the facility's Witness Statement form completed by CNA 8 regarding an incident between Resident 1 and CNA 6 dated 4/3/26, indicated, .I heard [Resident 1] crying for help over and over. I knocked on the door as it was closed and came in and saw [CNA 6] attending to and changing [Resident 1]. After checking that everything is ok, I left to continue my own changes. [Resident 1] continued yelling asking me to come back and help her.On 4/8/26 at 3:40 P.M., a concurrent interview and record review was conducted with the minimum data set coordinator (MDSC). The MDSC reviewed Resident 1's MDS assessment dated [DATE], including section GG. THE MDSC stated when a resident's MDS assessment was coded as dependent, it meant the resident required assistance from two or more staff. The MDSC reviewed Resident 1's written undated ADL care plan. The MDSC stated Resident 1 required two caregivers at all times for toileting, bathing, and upper and lower body dressing. The MDSC stated CNAs were supposed to review their residents' plan of care on the Resident Summary. The MDSC stated the residents' care plans had to be followed to ensure resident safety. The MDSC stated Resident 1's ADL care plan was not followed when there was only one CNA (CNA 6) providing care on 4/3/26.On 4/8/26 at 4:15 P.M., an interview was conducted with the director of staff development (DSD). The DSD stated Resident 1's requirement for two caregivers should always be followed, otherwise the resident's safety and comfort would be at risk.On 4/8/26 at 5:03 P.M., an interview was conducted with the director of nursing (DON). The DON stated it was very important to follow Resident 1's ADL care plan. The DON stated there should have been two CNAs to provide Resident 1's ADL care on 4/3/26. The DON stated CNA 6 should have allowed CNA 8 to help her instead of declining CNA 8's offer to help.On 5/11/26 at 12:52 P.M., a phone interview was conducted with CNA 8. CNA 8 stated on 4/3/26 she went to Resident 1's room. CNA 8 stated she saw CNA 6 standing over Resident 1. CNA 8 stated she offered to help CNA 6 who was by herself in the room with Resident 1. CNA 8 stated CNA 6 refused her help. CNA 8 stated CNA 6 told her that Resident 1 was being cared for. A review of the facility's policy titled Care Plans, Comprehensive Person-Centered dated 2/20/24, indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment.3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure effective monitoring, and evaluation of nutritional and hydration needs for 2 of 3 sampled Residents (Resident 2 and Resident 3).1.) Resident 2 experienced a change in oral intake when he was observed pocketing his food (holding food inside the mouth, without chewing or swallowing). The RD did not reassess Resident 2 to determine appropriate interventions, the IDT (IDT- an interdisciplinary team comprised of professionals from various disciplines who work in collaboration to address a resident with multiple physical and psychological needs) did not address Resident 2's change in dietary needs and possible risks to Resident 2's health. Resident 2's care plan did not reflect the pocketing food nor interventions were implemented.2.) Resident 3 experienced poor intake of food and fluids and was determined to be at higher risk for dehydration (the loss of water and electrolytes from the body that prevents it from functioning normally). The facility did not monitor Resident 3's total daily fluid intake to ensure adequate fluids were being consumed.These failures places Resident 2 and Resident 3 at risk for dehydration and to experience a decline in health.Findings:1.) According to a record review of Resident 2's Face Sheet, Resident 2 was admitted to the facility on [DATE] and discharged on 11/25/25 with diagnoses which included hemiplegia (weakness on one side of the body) following cerebral infarction (stroke), aphasia (the inability to speak) following cerebral infarction, and dysphagia (difficulty swallowing). According to Resident 2's Minimum Data Set (MDS- a federally mandated assessment tool) dated 9/2/25, Resident 2 had a Brief Interview for Mental Status (BIMS- a tool to measure cognition skills) of 3, which indicated Resident 2 had severe cognitive impairment. The MDS indicated Resident 2 was dependent on staff for all ADL's (Activities of Daily Living- such as eating, dressing, transferring, and bathing). The MDS further indicated Resident 2 had no swallowing disorders, such as holding food in mouth/cheeks or residual food in mouth after meals.During an interview with Certified Nursing Assistant (CNA) 1 on 1/13/26 at 10:11 A.M., CNA1 stated she had worked with Resident 2 as his CNA. CNA1 stated Resident 2, always needed help with feeding. CNA1 stated, I noticed he wasn't interested in his food or eating towards the end [of his stay at the facility]. He was congested and choked sometimes while eating. Towards the end, he was pocketing his food and coughing but it was not a normal thing.During a concurrent interview and record review with the Registered Dietitian (RD) 1 on 1/30/26 at 1:26 P.M., the RD stated on 11/23/25, Resident 2 had a change in condition and was noted to be pocketing food during meals. The RD stated pocketing food placed Resident 2 at risk for not meeting food and fluid intake, which could lead to dehydration, weight loss, and a possible shift in electrolytes. The RD further stated pocketing food also placed Resident 2 at risk for aspiration. The RD stated she did not see that the IDT met to discuss Resident 2's change of condition, and there was no new nutritional assessment done.During a review of the facility policy titled Resident Hydration and Prevention of Dehydration dated 3/2025, the policy indicated, This facility will strive to provide adequate hydration and to prevent and treat dehydration.The dietitian will assess all residents for hydration as part of the comprehensive assessment quarterly, and more often as necessary per resident need.If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan.Nursing will monitor and document fluid intake and the dietitian will be kept informed of status. The interdisciplinary team will update the care plan and document resident response to interventions until the team agrees that fluid intake and relating factors are resolved. 2.) According to the Face Sheet, Resident 3 was admitted on [DATE] and discharged on 1/21/26 with diagnoses which included severe protein-calorie malnutrition and dysphagia.According to the Minimum Data Set (MDS- a federally mandated assessment tool) dated 11/28/25, Resident 3 had a Brief Interview for Mental Status (BIMS- a tool to measure cognition skills) of 13, which indicated Resident 3 was cognitively intact. The MDS indicated Resident 3 required supervision for eating. The MDS further indicated Resident 3 had no swallowing disorders, such as holding food in mouth/cheeks or residual food in mouth after meals.During a concurrent observation and interview with Restorative Nursing Assistant (RNA) 1 on 1/12/26 at 11:09 A.M., Resident 3 was observed laying in bed, flat on his back with his eyes closed. There was a small cup of a thick pink liquid on his bedside table. There was a plastic spoon next to the cup. RNA 1 stated the cup of liquid was for the 10 A.M. nourishment pass, which was provided to residents daily between 10 A.M. and 10:30 A.M. RNA 1 stated the nourishment pass was intended to provide extra fluids and snacks to residents, to avoid dehydration and weight loss. RNA 1 stated it looked like Resident 3 consumed less than half of his drink.During a concurrent interview and record review with RD 1 on 1/30/26 at 1:26 P.M., the RD stated Resident 3 was seen by a speech therapist on 1/9/26. The RD further stated per speech therapy, Resident 3 could only consume liquids with a spoon for safety. RD 1 stated this placed Resident 3 at higher risk for dehydration. RD 1 stated per the Nutritional Screening and assessment dated [DATE], Resident 3 required between 1875ml and 2188ml of fluids to be adequately hydrated. Per the ADL Verification Worksheet, on 1/11/26, Resident 3 consumed 236ml of fluids but there was no documented fluid intake for 1/12/26 or 1/13/26. The RD stated Resident 3 did not meet the minimum fluid intake requirements between 1/11/26 and 1/13/26, therefore he was not adequately hydrated.During an interview with the Director of Nursing (DON) on 1/30/26 at 3:25 P.M., the DON stated CNA's were only documenting fluid intake during meals, but there was no other documentation of Resident 3's fluid intake during med pass or nourishments. The DON stated it was important to document all fluid intake to ensure Resident 3 was receiving enough fluids, especially when Resident 3 was at risk for dehydration. The DON stated it was her expectation for staff to offer fluids to residents and document to ensure they are meeting their minimum fluid requirements.During a review of the facility's policy titled Resident Hydration and Prevention of Dehydration dated 3/2025, the policy indicated, Nurses' aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care.Intake will be documented in the medical records.Aides will report intake of less than 1200ml/day to nursing staff.

Based on observation, interview and record review, the facility failed to ensure oral care/dentures were provided prior to serving breakfast to one of three sampled residents (Resident 1).This failure had the potential for Resident 1 to experience health complications including choking, aspiration (food enters airway and lungs).Findings:During a record review on 2/7/26, the Face Sheet indicated Resident 1 was admitted on [DATE] with diagnoses which included dysphagia (difficulty swallowing) following a cerebral infarction (a stroke) and type 2 diabetes.During a record review on 2/7/26, the Minimum Data Set (MDS- a federally mandated assessment tool) indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition, or mental processes) of 8, which indicated severe cognitive impairment. The MDS further indicated Resident 1 required substantial assistance with oral hygiene.During a record review on 2/7/26, Resident 1's Physician's Order indicated, Dependent with all meals.On 2/7/26 at 8:10 A.M., a concurrent observation and interview was conducted in Resident 1's bedroom. Resident 1 was sitting up in bed and was being fed by Certified Nursing Assistant (CNA) 1. An open denture cup was observed on Resident 1's nightstand with a pair of dentures inside the cup. CNA 1 stated the dentures must belong to Resident 1 because Resident 1 did not have a roommate. CNA 1 stated she did not know that Resident 1 wore dentures and did not provide oral or denture care prior to breakfast. CNA 1 continued to feed Resident 1 breakfast without placing his dentures in his mouth.On 2/7/26 at 8:13 A.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 1 should have been assisted with placing the dentures in his mouth prior to eating breakfast. LN 1 stated it was important that Resident 1 wore dentures while eating to be able to chew his food and avoid any choking.During a telephone interview with the Director of Nursing (DON) on 2/12/26 at 11:07 A.M., the DON stated it was her expectation that dentures were placed in Resident 1's mouth prior to every meal. The DON stated it was important that residents' dentures were provided prior to meals, .so they can consume an adequate amount of food and the texture that they like. We don't want them to choke or aspirate. During a review of the facility's policy titled Dentures, Cleaning and Storing dated 2/20/25, the policy indicated, Provide denture care before breakfast and at bedtime.Encourage the resident to keep the dentures in his or her mouth as much as possible. When dentures are left out of the mouth for several days, the bone structure to the mouth changes and the gums will shrink causing the dentures to fit improperly.During a review of the facility's policy titled Dental Services, dated 3/2025, the policy indicated, Direct care staff will assist residents with denture care, including removing, cleaning and storing dentures.

Based on interview and record review, the facility failed to ensure residents rights were honored for one of three sampled residents (Resident 5), when the facility asked Resident 5's representative to sign a waiver in response to missing dentures.This failure caused Resident 5 to experience delay in having her lost dentures replaced and had the potential for Resident 5's property to not be safeguarded against loss, theft, or misappropriation.Findings:Resident 5's record was reviewed. According to the Face Sheet, Resident 5 was admitted on [DATE] with diagnoses which included dementia (the loss of cognitive functions such as thinking, remembering, and reasoning) and dysphagia (difficulty swallowing). According to the Minimum Data Set (MDS- a federally mandated assessment tool) dated 12/2/25, Resident 5 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition, or thinking skills) of 3, which indicated Resident 5 had severe cognitive impairment.During a concurrent interview and record review with Licensed Nurse (LN) 1 on 2/7/26 at 7:36 A.M., LN 1 stated Resident 5's dentures had been lost since 1/24/26. LN 1 stated the dentures had not yet been replaced, but Resident 5 had a dental referral which was made on 1/26/26.During a telephone interview with Resident 5's Responsible Party (RP) 1 on 2/7/26 at 9:03 A.M., RP 1 stated the facility agreed to pay to have Resident 5's dentures replaced, on the condition that RP 1 signed a waiver. RP 1 stated the waiver released the facility from any responsibility for any lost, missing, or damaged items prior and up to 2/6/26. RP 1 stated she was not comfortable signing the waiver.During an interview with the Administrator (ADM) on 2/7/26 at 9:50 A.M., the ADM stated the facility agreed to pay for Resident 5's replacement dentures and provided RP 1 with a waiver and release to sign. The ADM stated the facility determined it was Resident 5's fault, not the facility's, the dentures were lost.During a telephone interview with the Dentist (DEN) 1 on 2/10/26 at 9:20 A.M. DEN 1 stated Resident 5 was scheduled to have dental impressions done at the facility later that day between 1 P.M. and 5 P.M. DEN 1 stated he was instructed by the facility not to come to the facility until RP 1 signed the waiver. During a follow up telephone interview with RP 1 on 2/10/26 at 5:02 P.M., RP 1 stated Resident 5's dentist was scheduled to arrive at the facility between 1 P.M. and 5 P.M. to perform Resident 5's dental impressions for replacement. RP 1 stated the dentist did not show up to the skilled nursing facility for the scheduled appointment with Resident 5. RP 1 further stated she had not signed the release waiver provided by the facility.During a telephone interview with the Social Services Director (SSD) on 2/11/26 at 3:30 P.M., the SSD stated acknowledged the facility provided RP 1 with a waiver, which the facility required her to sign prior to proceeding with the dental impressions. The SSD also stated Resident 5 was scheduled to have dental impressions taken on 2/10/26, but cancelled the appointment because RP 1 refused to sign the waiver. The SSD stated, [RP 1] didn't want to sign [the waiver].she said why would I sign it? The SSD stated, The right thing to do was to go ahead and schedule [the dentist].the resident was put in the middle of it.at the end of the day it's the resident that matters. The SSD stated requiring RP 1 to sign the waiver had delayed the process for Resident 5 to receive new dentures.During a telephone interview with the Director of Nursing (DON) on 2/12/26 at 11:07 A.M., the DON stated the waiver was not satisfactory and Resident 5 had the right to have dentures replaced, to be able to eat her preferred food textures, without being required to sign a waiver.During a review of the facility's policy titled Resident Rights dated 3/2025, the policy indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .exercise his or her rights without interference, coercion, discrimination or reprisal from the facility .

Based on observation, interviews, and record review the facility failed to provide a homelike environment for two of four sampled residents (Resident 1 and 2), when it did not maintain a comfortable temperature in one resident room.This failure had the potential to make residents uncomfortable.Findings:Record review of Face Sheet indicated Resident 1 was admitted on [DATE] with diagnoses which included: Dementia (severe cognitive decline affecting memory, thinking, language, and daily function, caused by damaged brain cells), Alzheimer's Disease (a progressive brain disorder, the most common form of dementia, causing severe memory loss, thinking, and behavioral problems that interfere with daily life), and Muscle Weakness.Record review of Resident 1's Minimum Data Set (MDS-assessment tool used in nursing homes) section C, Cognitive Patterns indicated a Brief Interview for Mental Status (BIMS) score of 3 indicating Resident 1 has severe cognitive impairment.Record review of Face Sheet indicated Resident 2 was admitted with diagnoses which included: Dementia, Malnutrition (lack of proper nutrition), Major Depressive Disorder (serious mental illness causing persistent sadness, loss of interest in activities, and impacting how you feel, think, and act, significantly interfering with daily life for at least two weeks), and Muscle weakness.Record review of Resident 2's MDS section C, Cognitive Patterns indicated a BIMS score of 10 indicating Resident 2 has moderate cognitive impairment.On 12/9/25 at 10:57 A.M., an observation and interview with Resident 1 was conducted. Resident 1 was observed sleeping. Resident 1 was arousable only to a loud voice. Resident 1 was observed with thick fleece blanket over her head. Resident 1 was alert, but hard of hearing (HOH), Resident 1 was able to answer questions translated by Spanish speaking staff, Unit Clerk 1 (UC). Resident 1 stated she was not cold under the thick blanket, but did not want to come out from under the blanket. Resident 1's room felt drafty with a cool breeze coming from the vent directly above her head. An observation of Resident 1's room thermostat indicated it was set at 74 degrees Fahrenheit (F-measure of temperature).On 12/9/25 at 11:10 A.M., an observation and interview with Resident 2 was conducted. Resident 2 was observed sitting in bed with her jacket on. Resident 2 was alert and able to answer questions via Spanish translator, UC. Resident 2 stated that she felt cold, and that a wind was coming from the vent making her cold. Resident 2 stated that .she preferred to be warmer and would like it if we could warm up the room for her.On 12/9/25 at 11:20 A.M., an interview with CNA 1 was conducted. CNA 1 stated that Resident 1 typically stayed under the blanket while in the room and could be cold at times. CNA 1 stated that Resident 1' daughter wrote on the board not to change the temperature on the thermostat and to leave it set at 74 F.On 12/9/25 at 11:50 A.M., a concurrent observation and interview with Maintenance Supervisor (MS) was conducted. MS stated that they check the room temperatures weekly. MS's then measured the temperature of air vents above resident's bed with a laser thermometer at 60 degrees F. MS measurement of temperatures of surface temp of Resident's 1's and 2's beds was 72 degrees. MS acknowledged the cool draft coming from the vent could be uncomfortable for the residents. MS acknowledged Resident 1 underneath her thick fleece blanket and Resident 2 wearing her coat in bed. MS stated that the expectation was for the residents' rooms to be comfortable and homelike for them. MS stated that if residents were uncomfortable and cold their room was not homelike. MS stated the Resident's rooms should be homelike, because it's better for the residents' quality of life.On 12/9/25 at 12:05 P.M., a concurrent observation and interview with Licensed Nurse 1 (LN 1) was conducted. LN 1 stated that Resident 1's thermostat was not locked and anyone can change the temperature, but Resident 1's daughter insists that the temperature stay at 74 F. LN 1 stated that Resident 1 and Resident 2 seemed cold in their room. LN 1 stated the expectation for room temperature was that it should be comfortable for both residents and home like.On 12/18/2025 at 10:43 A.M., an interview with the Director of Nursing (DON-[NAME]) was conducted. The DON stated that residents should have a temperature in their room that is comfortable for both residents. The DON stated that temperature in Resident 1 an 2's room on 12/9/25 was not homelike and could have negatively affected the residents' mood and health.Review of facility policy titled Home Environment dated 2/2025, indicated Residents are provided with a safe, clean, comfortable, and homelike environment .1. Staff provides person-centered care that emphasizes the resident's comfort, independence, and personal needs and preferences. 2. The facility staff and management maximizes to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting: These characteristics include.h. comfortable temperatures (71 F-81 FF) .

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (1) received continence care in accordance with professional standards, when staff applied two incontinence briefs improperly with the inner brief folded and a hole cut in the center through which the penis protruded.This failure resulted in swelling and pain for Resident 1 that required hospital evaluation and caused psychosocial harm related to embarrassment.Resident 1 was admitted to the facility on [DATE] with diagnoses of prostatic hyperplasia with lower urinary tract symptoms (and enlarged prostate that can block urine flow) and obstructive and reflux uropathy (urine blocked from leaving the body that flows backwards into the kidney) per the facility face sheet. A review of Resident 1's change in condition form, signed 8/3/25 at 12:37 P.M., by licensed nurse (LN) 1, indicated, .Swollen head of penis caused by double briefing of resident by CNA on NOC shift. A small hole was cut into secondary brief and penis pulled through. Upon changing resident CNA day Shift alerted this writer and assessed that the hole was too tight for proper circulation. A review of Resident 1's clinical notes, dated 8/3/25, indicated Resident 1 was found double briefed by the day shift which caused pain and swelling of the meatus of the penis and was subsequently sent to the emergency room via ambulance at 1:10 P.M. A review of the hospital after visit summary, dated 8/3/25, indicated Resident 1 was diagnosed with Paraphimosis (a medical emergency where the foreskin becomes stuck behind the penis head leading to swelling, pain and tissue death if not corrected). During an observation and interview on 8/14/25 at 11:33 A.M., Resident 1 was lying in bed with eyes open and was oriented to person and place. A call bell was on the bed beside Resident 1's left arm. Resident 1's left hand and wrist appeared stiff and contracted. Resident 1 stated he had little movement on his left side, and he was unable to reach the call bell. Resident 1 stated he wore briefs and was unable to control his urine but knew when he was wet. Resident 1 looked away and did not respond when asked if staff had ever provided improper incontinence care or applied briefs incorrectly. Resident 1 stated the facility used a lot of registry staff when they were short-staffed and that the care during the day was acceptable, but it was not as good at night. Resident 1 stated if the call bell was out of reach, he just waited for staff to come into the room. Resident 1 declined to provide additional information. During an interview on 8/14/25 at 1:16 P.M., certified nursing assistant (CNA) 1 stated Resident 1 usually communicated well, but on the morning of 8/3/25 was less talkative than usual. CNA 1 stated as she was performing incontinence care for Resident 1, she found a second brief underneath the outer brief. CNA 1 stated the outer brief was applied normally , while the inner brief was still folded like it just came out of the package, with a hole cut through the center and the resident's penis protruding through the opening. CNA 1 stated the top of the penis appeared swollen and red, and that Resident 1 reported it was painful. CNA 1 stated she immediately notified the charge nurse (LN 1) who came to assess Resident 1. CNA 1 stated the folded brief was removed but the penis was still swollen. CNA 1 stated Resident 1 stated he was upset with her for informing the charge nurse. CNA 1 stated Resident 1 appeared embarrassed and did not want to talk about who put the briefs on that way. During an interview on 9/3/25 at 11:05 A.M., LN 1 stated on the morning of 8/3/25 CNA 1 notified him she was concerned about Resident 1's brief placement. LN 1 stated he observed CNA 1 remove Resident 1's outer brief and saw a folded brief with a hole cut through the middle and Resident 1's meatus sticking through the hole. LN 1 stated Resident 1's penis appeared swollen and discolored and the opening was so tight it was acting like a rubber band. Resident 1 was guarded during the physical assessment. LN 1 stated the practice of putting a resident in two briefs was not acceptable and was considered a form of neglect. LN 1 stated there was visible skin breakdown where the brief was restricting the tip of the penis. LN 1 stated the person who placed Resident 1 in the briefs was identified as the overnight (NOC) CNA from registry (a staffing agency). During an interview on 9/4/25 at 4:20 P.M., the nurse administrator (NA) stated she had completed the internal investigation of the alleged abuse involving Resident 1 and found that NOC CNA was responsible for double briefing the resident. NA stated double briefing should never be done because it increases the risk of skin breakdown. NA stated it was the facility's policy to never double brief residents and all CNAs were expected to be competent and implement best practices. The NA stated registry staff should complete their competencies before coming to work on the floor. NA stated she was unable to find any type of documentation that verified NOC CNA's competencies were completed before working at the facility. NA acknowledged Resident 1 experienced psychosocial harm from embarrassment and reported pain as well as potential for injury because NOC CNA applied two briefs in an unsafe manner. NA stated the facility was unable to guarantee the safety of their residents if standards of care were not being met. A review of the facility document titled, Allegation of Abuse - 5 day summary report, dated 8/7/25, indicated .Summary of Incident: On August 3, 2025, at approximately 11:45 AM, Charge RN [CN] was notified by CNA [1] that Resident [1] was found to be double briefed during routine morning care. One brief was placed correctly, while the second had a hole cut in the center through which the penis was pulled, causing constriction. This resulted in swelling and discoloration of the meatus, and the resident reported discomfort. Follow up investigation. August 5, 2025. CNA [NOC CNA] (Night Shift, Registry) was interviewed. He admitted to applying two briefs in the described manner and stated that this was part of his routine practice with residents he considered heavy wetters. He acknowledged having used this technique in other faculties. The facility's investigation substantiated that improper continence care had occurred, constituting neglect. The CNA's actions resulted in physical harm to the resident and were inconsistent with regulatory standards, resident rights, and facility protocols.the deviation from accepted practices posed a risk to resident safety and dignity. Conclusion: After a thorough investigation was conducted, it was determined to be a substantiated case of neglect based on deviation from standard care practice. A review of the facility policy titled, Abuse and Neglect - Clinical Protocol, approved March 2025, indicated, Policy Statement. 2. Neglect, as defined at 483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. 5. Along with staff and management, the physician will help identify situations that might constitute or could be construed as neglect; for example. failure to provide incontinence care Cross Reference: see F726

Based on interview and record review, the facility failed to ensure nursing staff were competent to provide continence care for 1 of 1 sampled residents (1) when competency validation records were not maintained for a night shift (NOC) certified nursing assistant (NOC CNA) from registry (a staffing agency) who was identified in the facility's internal investigation as having improperly applied incontinence briefs. This failure resulted in registry staff providing care without verified competency, which contributed to improper continence care, swelling, pain and psychosocial harm requiring hospital evaluation for Resident 1. Resident 1 was admitted to the facility on [DATE] with diagnoses of prostatic hyperplasia with lower urinary tract symptoms (and enlarged prostate that can block urine flow) and obstructive and reflux uropathy (urine blocked from leaving the body that flows backwards into the kidney) per the facility face sheet.A review of Resident 1's change in condition form, signed 8/3/25 at 12:37 P.M., by licensed nurse (LN) 1, indicated, .Swollen head of penis caused by double briefing of resident by CNA on NOC shift. A small hole was cut into secondary brief and penis pulled through. Upon changing resident CNA day Shift alerted this writer and assessed that the hole was too tight for proper circulation.A review of Resident 1's clinical notes, dated 8/3/25, indicated Resident 1 was found double briefed by the day shift which caused pain and swelling of the penis and was subsequently sent to the emergency room via ambulance at 1:10 P.M.During an interview on 8/14/25 at 1:16 P.M., certified nursing assistant (CNA) 1 stated Resident 1 usually communicated well, but on the morning of 8/3/25 was less talkative than usual. CNA 1 stated as she was performing incontinence care for Resident 1 she found a second brief underneath the outer brief. CNA 1 stated the outer brief was applied normally , while the inner brief was still folded like it just came out of the package, with a hole cut through the center and the resident's penis protruding through the opening. During an interview on 9/3/25 at 11:05 A.M., licensed nurse (LN) 1 stated he was a registry nurse who had worked at the facility. LN 1 stated on the morning of 8/3/25 CNA 1 notified him she had found Resident 1 wearing 2 briefs. LN 1 stated on observation he found one brief placed over a second folded brief with a hole cut through the middle and the tip Resident 1's penis sticking through the hole. LN 1 stated Resident 1's penis appeared swollen and discolored and the opening was so tight it was acting like a rubber band. LN 1 stated upon investigation it was discovered a NOC CNA from registry had placed the two briefs on Resident 1. LN 1 stated he did not receive any formal orientation or training from the facility before working on the floor. LN 1 stated he did not receive any facility-specific policies and did not receive the facility's abuse prevention policy prior to starting shifts on the floor.During an interview on 9/4/25 at 1:47 P.M., CNA 2 stated she was a full-time staff at the facility. CNA 2 stated it was not a facility practice to have registry CNA's shadow a staff CNA before they worked on the floor.During an interview on 9/14/25 at 2:18 P.M., LN 2 stated she was a full-time staff at the facility. LN 2 stated when registry CNAs worked at the facility, they did not receive formal training or orientation from the charge nurses or nursing staff. During an interview on 9/4/25 at 3:08 P.M., registry CNA 3 stated the facility did not require him to complete any type of skills checklist before he began working on the floor. Registry CNA 3 stated he had not completed a facility-specific skills checklist through the registry company.During an interview on 9/4/25 at 4:20 P.M., the nurse administrator (NA) stated she completed the internal investigation of the alleged abuse involving Resident 1 and found that NOC CNA was responsible for double briefing the resident. The NA stated registry staff should complete their competencies before coming to work on the floor. NA stated she was unable to find any type of documentation that verified NOC CNA's competencies were completed before working at the facility. NA acknowledged Resident 1 experienced psychosocial harm from embarrassment and reported pain as well as potential for injury because NOC CNA applied two briefs in an unsafe manner. NA stated the facility was unable to guarantee the safety of their residents if standards of care were not being met. A record review of the facility submitted a skills checklist provided by the registry company from a different long-term care provider not connected to the facility. The skills check list was signed by the NOC CNA on 8/20/25, after the CNA had been terminated from the facility on 8/5/25. Additionally, the check list was incomplete and for an unrelated long-term care facility and provided no evidence of assessment or supervisory validation signatures for each competency. The facility did not provide a policy on the utilization of registry staff upon request.