Every finding on record at The Grove Post-Acute

Based on observation, interview, and record review, the facility failed to ensure professional standards for food service safety was maintained for a census of 123, when:Inside the walk-in refrigerator and reach-in freezer were unlabeled and undated food; Multiple food spices containers had cracked lids and with whitish-brownish-dust-like substances; and, Spoiled bananas were found inside the dry storage area. Two kitchen trash bin lids had scattered brownish-sticky-substances; The can opener blades had orange-color-substances; Inside the walk-in refrigerator: the floor and the metal food shelves had brownish-blackish-sticky-substances;The juice dispenser spouts and connection tubing had scattered sticky-brownish-substances;Several pots and pans were stored under the working table and were exposed to kitchen dusts and debris particles; Multiple baking sheet pans were worn out and the inner rims had rust-stained-like color; Cooking hood range had dust-oil-like-substances; Two soiled wiping cloths were left on top of the food preparation area;Twelve pieces of dish-racks had grayish-blackish-sticky substances, chipped, old, and worn out; and,Six movable dry goods container bins and sidings had scattered fluid-like-brownish-and blackish-colored substances. These failures had the potential to result in foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages) cross contamination (means the transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, cloth towels, or utensils which are not cleaned after touching raw food, and then touch ready-to-eat foods), bacteria, pathogens, and pests to thrive.Findings:1.During a kitchen observation on 5/5/26 at 8:14 a.m., with the Dietary and Nutrition Supervisor (DNS) and the Director of Dietary and Nutrition (DDN), the following were found: 1.1. Inside the reach-in freezer were undated/unlabeled: 1 box of brussels sprout;1 box of beef strips;1 box of egg roll;1 box of meatless meat balls;1 box of lima beans;1 box of wheat roll; and1 box of tofu. 1.2. Inside the walk-in refrigerator were undated/unlabeled: 1 box of sliced turkey; 1 box of fish cod fillet;1 container with sliced lettuce; and 3 trays of vanilla-flavored ice cream. 2.Multiple containers of food spices had cracked lids and whitish-brownish-dust-like substances; and, 3. Inside the dry storage area were several pieces of spoiled bananas. During a concurrent observation and interview on 5/5/26 at 8:14 a.m. with DDN in the kitchen, the DDN confirmed the findings. The DDN stated everything should be dated, labeled, clean and in sanitary condition to prevent food spoilage, cross contamination, and foodborne illnesses. The DDN also stated undated and unlabeled food especially prepared and perishable food could present a significant risk of foodborne illness. During a kitchen observation on 5/5/26 at 8:14 a.m., with the Dietary and Nutrition Supervisor (DNS) and the Director of Dietary and Nutrition (DDN), the following were found: 4.Two kitchen trash bin lids had scattered brownish-sticky-substances; 5.The kitchen can opener blades had orange-color-substances; and, 6. Inside the walk-in refrigerator, the floor and the metal shelves had brownish-blackish-sticky-substances.During a concurrent observation and interview on 5/5/26 at 8:14 a.m. with the DDN, the DDN confirmed the findings in the kitchen. The DDN stated everything should be cleaned to prevent cross contamination and foodborne illnesses and eliminate breeding grounds for bacteria.On 5/6/26 at 8:18 a.m., with the DDN, the following were found: 7.The juice dispenser spouts and connection tubing had scattered sticky-brownish-substances;8.Several pots and pans were stored under the working table and were exposed to kitchen dusts and debris particles; 9.Multiple baking sheet pans were worn out and the inner rims had rust-stained-like color; and, 10.The kitchen cooking-hood-range had dust-oil-like-substances.During a concurrent observation and interview on 5/6/26 at 8:18 a.m. with the DDN, the DDN confirmed the findings in the kitchen. The DDN stated keeping the equipment clean and organized was crucial for food safety, prevention of foodborne diseases and bacteria build-up, extended life of the kitchen equipment and maximized equipment efficiency. On 5/7/26 at 1:05 p.m., with the Registered Dietician (RD), the following were found: 11.Two soiled wiping cloths were left on top of the food preparation area;12.Twelve pieces of dish-racks had grayish-blackish-sticky substances, chipped, old, and worn out; and13. Six movable dry goods container bins and sidings had scattered fluid-like-brownish-and blackish-colored substances;During a concurrent observation and interview on 5/7/26 at 1:05 p.m. with RD, the RD confirmed all the findings in the kitchen. The RD stated those soiled cloth should be inside the sanitized bucket to disinfect between used, to prevent the growth of bacteria and reduced the risk of cross-contamination in food service area. The RD confirmed a wet, dirty cloth used to wipe food surfaces can quickly breed bacteria. The RD also stated dirty dish rack ruined the effort of washing dishes, transferred bacteria and pathogens to clean plates, cups and cutlery. The RD stated dirty dry goods bins trapped food particles and moisture could attract insects to the kitchen. During a review of the facility's Policy and Procedure (P&P), titled, SANITIZATION, revised 11/22, the P&P indicated, The food service area is maintained in a clean and sanitary manner: 1. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. 2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair. 3. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. 9. Service area wiping cloths are cleaned and dried or placed in a chemical sanitizing solution of appropriate concentration. 12. Plastic ware, china and glassware that cannot be sanitized or are hazardous because of chips, cracks or loss of glaze are discarded. Damaged or broken equipment that cannot be repaired is discarded. 14. Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids (or otherwise covered). 15. Areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pests.During a review of the facility's undated Policy and Procedure (P&P) titled, LABELING AND DATING OF FOODS, the P/P indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated .Produce is to be dated with received date .

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were maintained for a census of 123, when: The staff failed to remove PPE (Personal Protective Equipment) inside an enhanced barrier precaution (EBP - a patient's room where staff must take extra steps to prevent the spread of hard-to-treat germs) and after handling dirty laundry;Staff reused contaminated PPE and touched clean items after contact with soiled equipment;The CK, with her gloved hands, kept pulling the lower back portion of her clothes, touched the side rim of the food tray-line area; touched the moving trays parked near her; side-touched her apron to remove food dripped on her gloves; and, The outside dumpster side-mounted opening was uncovered, garbage were dumped inside and flies flew around the dumpster. These failures had the potential to result in food cross-contamination, foodborne illness and transmission of infectious pathogens to residents, staff, equipment, and clean linens. Findings: 1.During a concurrent observation and interview on 05/05/2026 at 10:30 AM with Laundry Staff (LS 3), LS 3 exited an EBP room wearing a blue PPE gown. LS 3 removed the blue PPE gown in the hallway and carried the gown under their arm down the hallway. LS 3 stated PPE should be kept away from their clothing and should be taken off and disposed of inside the room to avoid contamination. During an interview on 05/06/2026 at 11:50 AM with Certified Nursing Assistant (CNA 6), CNA 6 stated staff should wear PPE items inside an EBP and do not come out with PPE items before leaving the room.to prevent infections to getting to other residents. During a concurrent observation and interview on 05/08/2026 at 8:45 AM with Laundry Staff (LS 3) in the laundry room, LS 3 acknowledged they touched a dirty washer and then obtained clean gloves, placing the clean gloves into their back pocket. LS 3 acknowledged it was an infection control risk. During a concurrent observation and interview on 05/08/2026 at 8:46 AM with Laundry Staff (LS 1) in the laundry room, LS 1 removed a reused cotton PPE gown after washing clothes and placed the gown on a hanger. The gown touched a trash can, and the dirty gown was placed in a holding area on a hook instead of being discarded. LS 1 did not perform hand hygiene after touching the gown and stated the gown was washed after every few washes. During an interview on 05/08/2026 with the Housekeeping Supervisor (HS), HS acknowledged LS 3 did not perform hand hygiene after touching the washing equipment and acknowledged LS 1 reused a cotton gown and confirmed it had touched the trash. HS stated personal clothing should not be contaminated and staff should follow PPE and EHB procedures when handling personal clothing or items. 2.During an observation on 05/08/2026 at 2:30 PM, a staff member was handling clean laundry while wearing the same clothing worn earlier during soiled laundry handling. During an interview on 05/08/2026 at 1:42 PM with the Infection Prevention Nurse (IPN), IPN stated staff were expected to remove gowns and gloves without touching contaminated surfaces and perform hand hygiene immediately. IPN stated PPE was not expected to be reused after handling dirty laundry. IPN stated reusing or touching contaminated PPE after exposure to soiled items could transfer pathogens to clean linens, equipment, and individuals, increasing the risk of illness. The Centers for Disease Control and Prevention (CDC) stated, soiled textiles and linens should be handled with minimal agitation to avoid contamination of air, surfaces, and persons, and staff must remove gloves and perform hand hygiene after handling contaminated laundry. gowns and gloves used under Enhanced Barrier Precautions should not be worn outside the resident's room, and must be removed and discarded prior to exiting to prevent transmission of multidrug resistant organisms. 3.During a kitchen tray-line observation on 5/7/26 at 11:30 a.m. through 12:45 p.m., the [NAME] (CK), with her gloved hands and in between tray-line service, also did the following: Kept pulling the lower back portion of her clothes, touched the side rim of the service tray-line area, touched the moving trays parked near her, and, side-touched her apron to remove food dripped on her gloves. The CK did not change her gloves. During a concurrent observation and interview on 5/7/26 at 12:45 p.m., the CK acknowledged all the findings. The CK confirmed she did not change her gloves during the entire tray-line service. The CK stated she should have safely handled food during tray-line to prevent cross contamination and germ transmission. During an interview on 5/7/26 at 1:15 p.m. with Registered Dietician (RD), the RD stated the contaminated gloves should have been changed and discarded immediately to prevent cross-contamination. During a review of the facility's Policy and Procedure (P&P) titled, FOOD PREPARATION AND SERVICE, dated 11/22, the P&P indicated, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. 2. Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned. Cross-contamination can also occur when raw food touches or drips onto cooked or ready-to-eat foods. 3. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. During a review of the facility's document titled, JOB DESCRIPTION: DIETARY COOK, undated, the document indicated, The primary purpose of your job position is to prepare food in accordance with current applicable federal, state, and local standards, guidelines and regulations, with our established policies and procedures .to assure that quality food service is provided at all times .you are delegated .the accountability necessary for carrying out your assigned duties. Safety and Sanitation: Perform duties in accordance with regulations and established policies and procedures .Follow established Infection Control and Universal Precautions policies and procedures when performing daily tasks . 4. On 5/8/26 at 12:55 p.m. with the Maintenance Director (MD) and the Regional Operations Director (ROD), the following were found: The outside dumpster side-mounted opening was uncovered, no functional lid; garbage were dumped inside; and flies flew around the dumpster. During a concurrent observation and interview, on 5/8/26 at 12:55 p.m., with the MD, the MD confirmed the dumpster side-mounted opening was uncovered and had no functional lid, garbage were dumped inside and flies flew around the dumpster. The MD stated flies spread bacteria from garbage. During a review of the facility's Policy and Procedure (P&P), titled, SANITIZATION, revised 11/22, the P&P indicated, Damaged or broken equipment that cannot be repaired is discarded. 14. Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids (or otherwise covered). 15. Areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pests.

Based on interview and record reviews, the facility failed to ensure two out of nine sampled Certified Nurse Assistant (CNA) employee personnel records were current in their annual Resident Abuse Prevention and Department of Justice (DOJ) trainings. This failure had the potential to result in staff not recognizing, preventing, and reporting any possible resident abuse for a census of 123 residents.Findings:During a concurrent interview and record review on 5//6/26 at 3:23 p.m., of nine sampled CNA employee personnel records with the Director of Staff Development (DSD), the CNAs personnel records were reviewed. The CNA personnel records were reviewed for the completion of the annual Abuse Prevention, and Department of Justice (DOJ) trainings.The following CNA employee records were reviewed for completion Abuse Prevention and DOJ trainings:CNA 1, Date of Hire 11/1/23 (DOH) - No Abuse Prevention and DOJ Training for 2025.CNA 3, DOH 8/21/06 - Training is currentCNA 4, DOH 9/4/24 - No Abuse Prevention and DOJ Training for 2025.CNA 5, DOH 2/7/24, Terminated 12/9/25 - Training is currentCNA 9, DOH 6/26/14 - Training is currentCNA 10, DOH 1/23/25 - Training is currentCNA 11, DOH 10/21/24 - Training is current.CNA 13, DOH 5/29/24 Terminated 4/8/26 - Training is CurrentCNA 16, DOH 12/20/23 - Training is current During a concurrent interview with the DSD she confirmed that the Abuse Prevention and DOJ Trainings are conducted annually. The expectations are employees must attend the provided trainings annually. The DSD after concurrent review of CNA 1, and CNA 10's employee files indicated CNA 1 and CNA 10 had not completed the annual Abuse Prevention and DOJ training for 2025. Review of a facility policy Abuse Prevention Program revised 12/16 indicated: .3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.4. Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse.

Based on interviews and record reviews the facility failed to ensure a safe and appropriate discharge for one of three sampled residents (Resident 58) when Resident 58 was discharged from the facility while an application for Medi-Cal (state run Medicaid program under federal guidelines) was still in process and without a discharge plan .This failure resulted in Resident 58's discharge to a hotel without appropriate resources or discharge instructions. Findings:A review of Resident 58's admission Record (AR) indicated Resident 58 had been admitted to the facility in December 2025 with diagnoses which included alcoholic hepatitis (severe liver inflammation and damage caused by long-term, heavy alcohol consumption) and cognitive communication deficit (a difficulty with verbal or nonverbal communication). The AR indicated Resident 58 was homeless.A review of Resident 58's 48 Hour Baseline Care Plan/Discharge Planning, dated 12/18/25, by Social Services Director (SSD) 1, SSD 1 indicated Resident 58's initial discharge goal was to return to the community. SSD 1 identified Resident 58's concern of not have any housing at this time. SSD 1 indicated she was unable to contact [Resident 58's] family.During a review of the Progress Note - Psych Provider Note (supportive psychotherapy visit) dated 1/15/26, the progress note indicated Resident 58 as homeless and experienced situational anxiety (an intense, temporary stress response triggered by a specific event) related to discharge planning and that collaboration with the interdisciplinary team (IDT, a team of physicians, nurses, social workers, and therapists who coordinate holistic care plans for residents) to ensure the continuity of discharge planning support was provided. The note indicated the following recommendations: continue supportive reassurance and orientation related to discharge planning and encourage resident engagement with SS for discharge coordination.During a review of the Minimum Data Set (MDS, an assessment tool) dated 3/16/26, the MDS indicated there was not an active discharge plan for Resident 58 to return to the community. A review of the Order Summary Report (OSR, physician orders) dated 4/29/26, the OSR indicated Resident 58 may discharge home with a home health registered nurse (HH RN, a registered nurse who provides in-home care to individuals receiving services under a plan of care established and periodically reviewed by a physician). A review of the IDT Discharge Summary (IDT DCS) finalized on 4/30/26, the IDT DCS indicated due to insurance pending status a primary care physician for Resident 58's transfer of care was unattainable. During a concurrent interview and record review on 5/7/26 at 11:44 p.m. with SSD 1, the MDS Coordinator and the Social Services Assistant (SSA), Resident 58's medical record was reviewed. SSD 1 stated, Discharge planning starts upon the first meeting with the resident. SSD 1 confirmed Resident 58 was homeless and a current application for Medi-Cal was pending at the time of Resident 58's discharge from the facility. SSD 1 was unable to provide documentation regarding ongoing discharge planning for Resident 58. During a telephone interview on 5/8/26 at 9:50 a.m. with the Home Health Agency (HHA), Resident 58's HHA referral, received on 4/29/26, was reviewed. The HHA stated, There were different discharge addresses provided, one address only identified the city, and we don't have staff to send to that area. The HHA verified Resident 58's insurance information provided by the facility and stated, We were not informed of [Resident 58's] insurance or that an application [Medi-Cal] was pending, that wasn't provided to us at the time of discharge, [Resident 58] wouldn't qualify for HH RN services with the insurance information provided. During a concurrent interview and record review on 5/8/26 at 11:44 a.m. with the Business Office Manager (BOM) Resident 58's insurance status was reviewed. The BOM confirmed Resident 58's application for Medi-Cal was still pending at the time of discharge. A review of the facility's policy and procedure (P&P) titled Transfer or Discharge Notices revised March 2025, the P&P indicated, Residents (or resident representatives) are notified of an impending transfer or discharge and the reasons for the move in writing and in a language and manner they understand. A copy of this notice is sent to the Office of the State Long-Term Care Ombudsman. Notice of Transfer or Discharge (Anticipated): 1. Except as specified below, the resident and his or her representative are provided with a written notice of an impending transfer or discharge at least 30 days prior to the transfer or discharge. 3. The resident and representative are notified in writing of the following information: a. The specific reason for the transfer or discharge, including the basis under 483.15(c)(1)(i)(A)-(F); b. The effective date of the transfer or discharge; c. The specific location (such as the name of the new provider, description, and/or address if the location is a residence) to which the resident is being transferred or discharged ; d. An explanation of the resident's rights to appeal the transfer or discharge to the state, including: (1) the name, address, email, and telephone number of the entity which receives such appeal hearing requests; (2) information about how to obtain an appeal form; and (3) how to get assistance in completing and submitting the appeal hearing request; e. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman; 5. Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge.

Based on observation, interview, and record review, the facility failed to maintain a comfortable room temperature for one out of 30 sampled residents (Resident 57) when Resident 57's room temperature was below 71 degrees Fahrenheit (*F). This failure negatively impacted Resident 57's comfort, and created an environment that was not homelike. Findings: A review of Resident 57's admission Record, indicated that Resident 57 was admitted to the facility on [DATE] with diagnoses which included kidney disease. A review of the Resident 57's MDS, dated [DATE], the MDS indicated Resident 57 had a BIMS score of 11 out of 15, suggestive of moderate cognitive impairment.During a concurrent observation and interview on 5/5/26 at 10 a.m. with Resident 57 in her room, Resident 57 was fully covered with multiple blankets in bed. Resident 57 stated room always felt cold, was discussed in resident council, had not noticed any changes yet. Resident pointed to a folded towel placed over the floor vent, by the staff, to prevent cold air from entering room. Resident stated had shivering anxiety. There is no thermometer temperature dial in room. During a concurrent observation and interview on 5/5/26 at 11 a.m., standing at Unit 3's nursing station, with Certified Nursing Assistant 14 (CNA 14) and Licensed Nurse 16 (LN 16) who stated they felt cold on the unit. CNA 14 stated it was usually cold on the floor, and needed to wear an extra jacket. LN 16 stated the facility had one blanket warmer machine for the residents, which was being repaired. CNA 14 and LN 16 acknowledged they had heard complaints from residents that their rooms were cold, and staff had placed towels over the floor vents to prevent cold air flow. CNA 14 and LN 16 stated staff were expected to notify maintenance for temperature adjustments in residents' rooms. CNA 14 and LN 16 stated it was important for residents' comfort and quality of life. During an interview on 5/5/26 at 11:40 a.m., on hallway Unit 3 with Maintenance Director (MD), MD stated building felt cold when he arrived at work this morning, and that he had closed approximately five of the resident's windows on Unit 2. MD acknowledged towels were placed over floor vents in residents' rooms. MD stated he would remove the towels, and instructed residents to notify maintenance staff for temperature adjustments. MD did not have a room temperature check routine for the residents. During a concurrent observation and interview on 5/6/26 at 12:30 p.m. with Resident 57 in her room, Resident 57 stated her room was cold overnight, cold air currently felt from floor vent. Resident 57 stated it was okay if the MD came to room for a temperature check. During a concurrent observation and interview on 5/6/26 at 12:40 p.m. with MD in Resident 57's room, MD used a hand-held laser temperature gun, and measured several areas of the room: mid-room showed 69*F, floor showed 67*F, ceiling showed 69*F. MD acknowledged room temperatures were below the recommended 71-81*F. MD stated the entire building was set with the air conditioner, in anticipation of the warmer weather this week. Resident 57 stated felt cold, I'm not very comfortable right now. During an interview on 5/8/26 at 1 p.m., in the social service's office with MD, MD stated it was important that residents' rooms had comfortable temperature levels.their [residents] rights, this is where they [residents] live. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised 12/2023, the P&P indicated, .comfortable and safe temperatures (71*F - 81*F).

Based on interview and record review the facility failed to identify and to report an allegation of verbal abuse to the California Department of Public Health (CDPH) when: an incident between Resident 1 and Resident 2 was not identified as a verbal abuse allegation or reported timely per Federal regulations.This failure resulted in the Department being unaware of the abuse allegation between Resident 1 and Resident 2 and, had the potential for Resident 1 to be continually subjected to verbal abuse by Resident 2, who was not separated from Resident 1.During a review of Resident 1's Minimum Data Set (MDS: federally mandated assessment) Section C dated 3/16/26, MDS-C indicated Resident 1 had a Brief Interview for Mental status (BIMS: a standardized assessment used by healthcare professionals to evaluate cognitive function, with a score 13-15: indicating Intact cognition) score of 13. This indicated Resident 1's cognition (ability to think and rationalize) was intact.During a review of Resident 1's Order Review History Report dated 3/2/26-4/2/26, report indicated, Resident 1 had an order indicating Resident is capable of making her own health decisions. Order start date 11/18/23.During an interview on 4/2/26, at 8:05 a.m., with Licensed Nurse (LN 1), LN 1 stated, Resident 1 told her recently that she has been unable to sleep due to her roommate, and that she notified the Provider who increased some of her medication to let her sleep better. LN 1 stated, Resident 1 told her yesterday (4/1/26) that her roommate (Resident 2) called her a f . c . [a delegatory and offensive insult].During an interview on 4/2/26, at 8:46 a.m., with Resident 1, in Resident 1's room, Resident 1 stated, she had not been getting along with her roommate (Resident 2). Resident 1 stated, for several weeks her T.V. has been too loud, and she curses at me every day. Resident 1 stated she was told by staff there is nothing they can do, and they cannot force Resident 2 to move rooms and that she can move if she doesn't get along with her roommate. Resident 1 stated, she should not have to move rooms when she's been in this room for years and has not had any issues before her current roommate. Resident 1 stated, her roommate (Resident 2) moved to this room around 2 months ago. Resident 1 stated, she feels like she is less than a person, because the staff won't move her roommate who has been cursing at her and making her feel uncomfortable.During an interview on 4/2/26, at 8:58 a.m., with Resident 2, Resident 2 stated, in an aggressive tone I liked my old room better, the staff were better over there. Resident 2 stated, she did not like her current roommate (Resident 1).During an interview on 4/2/26, at 10:09 a.m., with Social Services Director (SSD), SSD stated, they changed the process for grievances recently. SSD stated, she was informed the new process for grievances is, if a family member or resident has a grievance they will complete a form, and the form will go to the department involved in the grievance, they will then investigate the concern and fill in the outcome on the form. SSD stated, regarding room changes, if a resident has a concern with their roommate we will usually move the roommate who has the concern, unless it's a safety concern then we will move the other resident. SSD stated, she had a care conference with Resident 1's family member (FM) on 3/18/26. SSD stated, she was informed by FM that Resident 1 and Resident 2 were not getting along. SSD stated, yesterday (4/1/26) we were notified by LN 1 that Resident 2 used curse words towards Resident 1. SSD stated, FM filed a grievance regarding the curse words on 4/1/26 around 3 p.m. SSD stated, she reviewed the incident of the curse words with the Administrator who is the abuse coordinator. SSD stated, she believes verbal abuse can only occur in residents who are cognizant (having knowledge or being aware of) or if they were cognitively intact and saying the words purposefully. SSD stated, if she saw or heard of residents verbally abusing one another she would separate them immediately for their safety. SSD stated, neither of the residents have any disease which cause them to say things out loud uncontrollably (like Tourette's Syndrome: a nervous system disorder characterized by involuntary, repetitive movements and sounds). SSD stated, both residents are capable of making their own medical decisions. SSD stated, she did not report this incident as abuse because she did think it constituted abuse.During a review of Resident Grievance/Complaint Form dated 4/1/26, form indicated a grievance was made by FM regarding Resident 1, the form indicated, [Resident 1's] roommate was upset her T.V. was not working. It was after hours & she asked her [Resident 1] for the remote to be turned on, [Resident 1] said no, the roommate called her a f . c .what actions or recommendations do you feel need to be taken? The roommate need to be changed to a room that she cannot abuse [Resident 1] or bully her.During a review of Resident 1's Nurses Notes, dated 4/1/26, notes indicated, Resident informed writer that her roommate called her a f . c . last night. Signed by LN 1.During an interview on 4/2/26 at 12:40 p.m., with LN 1, LN 1 stated, she had noticed issues between Resident 1 and Resident 2 for a while. LN 1 stated, I don't think its appropriate the words Resident 2 stated to Resident 1 yesterday. LN 1, stated, I guess it is abuse, verbal abuse is yelling or saying bad words.During an interview on 4/2/26, at 12:53 p.m., with MDS Nurse, MDS Nurse stated, she was aware of the incident between Resident 1 and Resident 2 sometime around noon yesterday 4/1/26. MDS Nurse stated, we had a care conference with FM about the issues of a room change for Resident 2, but since then, they were still having issues. We let FM know she can file a grievance regarding the words Resident 2 stated to Resident 1. MDS Nurse stated, she had LN 1 put in the chat for their charting system to notify management about the incident, the administrator is in that chat so he can see it. MDS Nurse stated, It would constitute abuse the cursing of Resident 2 to Resident 1.During an interview on 4/2/26, at 1:17 p.m., with Administrator (ADM), ADM stated, he was notified of the incident between Resident 1 and Resident 2 yesterday from the SSD. ADM stated, the incident was not an allegation of verbal abuse because Resident 2 did not have intent.During a concurrent interview and record review on 4/2/26, at 1:19 pm, with ADM, the facility's Policy and Procedure (P&P) titled, Abuse Prevention Policy dated, 2024 was reviewed. The P&P indicated, [facility name] will prohibit abuse.for all residents.Verbal Abuse: Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory [expressions intended to insult, belittle, or diminish a person or group, expressing a low opinion or disrespect] terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend or disability.if the suspected abuse is patient to patient, the patient who has in any way threatened or attacked another will be removed from the setting. Immediately means as soon as possible but ought not exceed 2 hours after discovery of the incident, the facility administrator or designee will report the immediate allegations to the California Department of Health using the SOC 341 form . Staff will identify events - such as suspicious bruising of patients, occurrences, patterns, and trends that may constitute abuse - and determine the direction of the investigation. This also includes patient to patient abuse.Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect. the ED or designee will perform the following: a. Report allegation not later than two hours after the allegation is made. The ADM stated, there was no intent so we did not consider this an allegation of abuse, which is why it was not reported. ADM was unable to point out where in the abuse policy the word intent was stated. ADM stated, I'm not sure, it depends whether it was okay for residents to use derogatory remarks to one another. ADM stated, Yes it is the facility's policy to protect residents from verbal abuse. ADM further stated, I think I've already said what I need to say in this particular case, there is a differentiation of understanding of what abuse is, our understanding may differ. ADM was not willing to explain the incident further.

Based on interview and record review the facility failed to protect one of three sampled residents (Resident 1) from verbal abuse when Resident 2 made derogatory remarks toward Resident 1.This failure had the potential to negatively affect Residents 1's mental health.During a review of Resident 1's Minimum Data Set (MDS: federally mandated assessment) Section C dated 3/16/26, MDS-C indicated Resident 1 had a Brief Interview for Mental status (BIMS: a standardized assessment used by healthcare professionals to evaluate cognitive function, with a score 13-15: indicating Intact cognition) score of 13. This indicated Resident 1's cognition (ability to think and rationalize) was intact.During a review of Resident 1's Order Review History Report dated 3/2/26-4/2/26, report indicated, Resident 1 had an order indicating Resident is capable of making her own health decisions. Order start date 11/18/23.During an interview on 4/2/26, at 8:05 a.m., with Licensed Nurse (LN 1), LN 1 stated, Resident 1 told her recently that she has been unable to sleep due to her roommate, and that she notified the Provider who increased some of her medication to let her sleep better. LN 1 stated, Resident 1 told her yesterday (4/1/26) that her roommate (Resident 2) called her a f . c . [a delegatory and offensive insult] .During an interview on 4/2/26, at 8:46 a.m., with Resident 1, in Resident 1's room, Resident 1 stated, she had not been getting along with her roommate (Resident 2). Resident 1 stated, for several weeks her T.V. has been too loud, and she curses at me every day. Resident 1 stated she was told by staff there is nothing they can do, and they cannot force Resident 2 to move rooms and that she can move if she doesn't get along with her roommate. Resident 1 stated, she should not have to move rooms when she's been in this room for years and has not had any issues before her current roommate. Resident 1 stated, her roommate (Resident 2) moved to this room around 2 months ago. Resident 1 stated, she feels like she is less than a person, because the staff won't move her roommate who has been cursing at her and making her feel uncomfortable.During an interview on 4/2/26, at 8:58 a.m., with Resident 2, Resident 2 stated, in an aggressive tone I liked my old room better, the staff were better over there. Resident 2 stated, she did not like her current roommate (Resident 1).During an interview on 4/2/26, at 10:09 a.m., with Social Services Director (SSD), SSD stated, they changed the process for grievances recently. SSD stated, she was informed the new process for grievances is, if a family member or resident has a grievance they will complete a form, and the form will go to the department involved in the grievance, they will then investigate the concern and fill in the outcome on the form. SSD stated, regarding room changes, if a resident has a concern with their roommate we will usually move the roommate who has the concern, unless it's a safety concern then we will move the other resident. SSD stated, she had a care conference with Resident 1's family member (FM) on 3/18/26. SSD stated, she was informed by FM that Resident 1 and Resident 2 were not getting along. SSD stated, yesterday (4/1/26) we were notified by LN 1 that Resident 2 used curse words towards Resident 1. SSD stated, FM filed a grievance regarding the curse words on 4/1/26 around 3 p.m. SSD stated, she reviewed the incident of the curse words with the Administrator who is the abuse coordinator. SSD stated, she believes verbal abuse can only occur in residents who are cognizant (having knowledge or being aware of) or if they were cognitively intact and saying the words purposefully. SSD stated, if she saw or heard of residents verbally abusing one another she would separate them immediately for their safety. SSD stated, neither of the residents have any disease which cause them to say things out loud uncontrollably ( like Tourette's Syndrome: a nervous system disorder characterized by involuntary, repetitive movements and sounds). SSD stated, both residents are capable of making their own medical decisions.During a review of Resident Grievance/Complaint Form dated 4/1/26, form indicated a grievance was made by FM regarding Resident 1, the form indicated, [Resident 1's] roommate was upset her T.V. was not working. It was after hours & she asked her [Resident 1] for the remote to be turned on, [Resident 1] said no, the roommate called her a f . c .what actions or recommendations do you feel need to be taken? The roommate need to be changed to a room that she cannot abuse [Resident 1] or bully her.During a review of Resident 1's Nurses Notes, dated 4/1/26, notes indicated, Resident informed writer that her roommate called her a f . c . last night. Signed by LN 1.During an interview on 4/2/26 at 12:40 p.m., with LN 1, LN 1 stated, she had noticed issues between Resident 1 and Resident 2 for a while. LN 1 stated, I don't think its appropriate the words Resident 2 stated to Resident 1 yesterday. LN 1, stated, I guess it is abuse, verbal abuse is yelling or saying bad words.During an interview on 4/2/26, at 12:53 p.m., with MDS Nurse, MDS Nurse stated, she was aware of the incident between Resident 1 and Resident 2 sometime around noon yesterday 4/1/26. MDS Nurse stated, we had a care conference with FM about the issues of a room change for Resident 2, but since then, they were still having issues. We let FM know she can file a grievance regarding the words Resident 2 stated to Resident 1. MDS stated, she had LN 1 put in the chat for their charting system to notify management about the incident, the administrator is in that chat so he can see it. MDS Nurse stated, It would constitute abuse the cursing of Resident 2 to Resident 1.During an interview on 4/2/26, at 1:17 p.m., with Administrator (ADM), ADM stated, he was notified of the incident between Resident 1 and Resident 2 yesterday from the SSD. ADM stated, the incident was not an allegation of verbal abuse because Resident 2 did not have intent.During a concurrent interview and record review on 4/2/26, at 1:19 pm, with ADM, the facility's Policy and Procedure (P&P) titled, Abuse Prevention Policy dated, 2024 was reviewed. The P&P indicated, [facility name] will prohibit abuse.for all residents.Verbal Abuse: Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory [expressions intended to insult, belittle, or diminish a person or group, expressing a low opinion or disrespect] terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend or disability. if the suspected abuse is patient to patient, the patient who has in any way threatened or attacked another will be removed from the setting. The ADM stated, there was no intent so we did not consider this an allegation of abuse. ADM was unable to point out where in the abuse policy the word intent was stated. ADM stated, I'm not sure, it depends whether it was okay for residents to use derogatory remarks to one another. ADM stated, Yes it is the facility's policy to protect residents from verbal abuse. ADM further stated, I think I've already said what I need to say in this particular case, there is a differentiation of understanding of what abuse is, our understanding may differ. ADM was not willing to explain the incident further.

Based on observations, interviews, and record review, the facility failed to protect one of five sampled residents' (Resident 1) right to be free from physical/mental abuse by Resident 2 when Resident 2 shoved a walker into Resident 1's legs.As a result of this failure, Resident 1 experienced a skin tear in the left knee. Findings:Resident 1 was admitted to the facility in March of 2025 with diagnoses that included chronic respiratory failure and adult failure to thrive.A review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool used in nursing homes), dated 7/16/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 13 of 15 indicating Resident 1 was cognitively intact.Resident 2 was admitted to the facility in December of 2023 with diagnoses that included dementia (a decline in cognitive abilities, such as memory, thinking, and reasoning).During a review of the facility's document titled, Event Statement Form, dated 8/19/25, the document indicated that Certified Nursing Assistant 1 (CNA 1) gave the following statement after the incident between Resident 1 and 2 had occurred, I heard [Resident 1] and [Resident 2] arguing from the hallway over their curtain. I rushed over there and witnessed [Resident 1] standing above [Resident 2] who was seated in his wheelchair. [Resident 1's] walker was in front of [Resident 2], and [Resident 2] pushed the walker into [Resident 1] right as I walked into the room.During a review of Resident 1's SBAR [situation, background, assessment, and recommendation] & INITIAL COC [change in condition]/ALERT CHARTING & SKILLED DOCUMENTATION, dated 8/19/25, the document indicated, Describe the problem/symptom: Verbal Disagreement with roommate resulting in ST [skin tear] to L [left]. knee.Other things that have occurred with this problem/symptom are: ST 0.9x0.2x.0.1 cm [centimeters] to Right (sic) front knee, with scant bleeding, controlled and stopped.During an interview on 9/2/25 at 10:28 a.m. with CNA 1, CNA 1 confirmed that she witnessed Resident 2 shove a walker into Resident 1's legs during her shift on 8/19/25 at approximately 6:20 p.m. CNA 1 indicated that, as a result of the incident, Resident 1 ended up with a skin tear to his left knee.During a concurrent observation and interview on 9/2/25 at 11:02 a.m. with Resident 1, Resident 1's left anterior knee had a circular scab of approximately 1 inch diameter. Resident 1's knee also had purplish and reddish bruising to the medial aspect of his left knee. Resident 1 indicated that, on 8/19/25, Resident 2 shoved a walker into his knees and stated, I was surprised he did what he did.I put my hands up in fear during the incident.During an interview on 9/2/25 at 11:47 a.m. with the Social Services Director Assistant (SSDA), the SSDA indicated that a resident using a walker to strike another resident would be considered physical abuse.During an interview on 9/2/25 at 1:03 p.m. with Licensed Nurse 2 (LN 2), LN 2 indicated she assessed Resident 1 immediately after the incident between Resident 1 and Resident 2. LN 2 indicated Resident 1 sustained a skin tear to his left knee that was bleeding, so she proceeded to bandage it. LN 2 further indicated that, after a short time after applying the dressing, the wound had bled through the dressing and required a new dressing.During a review of the facility's policy and procedure (P&P) titled Abuse Prevention Policy, revised 3/24, the P&P indicated, Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff off other agencies serving the resident, family member(s) or legal guardian, friend(s), or other individuals.

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the kitchen for a census of 132 when: 1. Unsanitary conditions were observed in the kitchen's dry storage area; and, 2. Expired items were found in the walk-in refrigerator. These failures had the potential to cause food borne illnesses. Findings: 1. During a concurrent observation and interview on [DATE] at 8:19 a.m. with the Dietary Manager (DM), the dry storage area located in the kitchen was observed. A blue used cookie wrapper was observed on silver rack on shelf next to condiment sauce bottles. The DM stated, . I don't know how it got there and that should not have been there . During a continued concurrent observation and interview on [DATE] at 8:19 a.m. with the DM in the dry storage area located in the kitchen, a thickener container was observed open and exposed to air with a piece of yellow cereal and silver foil piece inside. DM stated that the container would be removed and confirmed the area was not in sanitary conditions. 2. During a continued concurrent observation and interview on [DATE] at 8:22 a.m. with the DM in the walk in refrigeration area in the kitchen, a plastic container with diced apples with an open date of [DATE] and expiration date of [DATE] were observed. The DM confirmed the diced apples were expired. During a continued concurrent observation and interview on [DATE] at 8:26 a.m. with the DM in the walk in refrigeration area in the kitchen, a plastic container of expired boiled eggs was found with an expiration date of [DATE]. The DM confirmed the boiled eggs were expired. During a review of facility policy and procedure (P&P) titled Storage of Food and Supplies dated 2023, the P&P indicated, Routine cleaning . should be developed and followed . Dry bulk food .thickener . should be stored in seamless metal or plastic container with tight covers .All food products will be used per the times specified . During a review of the United States (US) FDA (Food and Drug Administration) 2022 Food Code, section ,d+[DATE].11 titled Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, the document indicated, (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch (C) Non-food-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris .

Based on observation, interview, and record review, the facility failed to ensure call lights were accessible and in good repair for three of 32 sampled residents (Resident 16, Resident 24, and Resident 1). This failure had the potential to jeopardize the safety of these residents and limited accessibility for them to call for help. Findings: 1a. A review of Resident 16's Admission Record indicated Resident 16 was admitted to the facility in December 2024 with multiple diagnoses including heart failure and encephalopathy (a medical condition characterized by general dysfunction of the brain). A review of Resident 16's Minimum Data Set (MDS- a federally mandated assessment tool), Cognitive Patterns, dated 12/19/24, indicated Resident 16 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 9 out of 15 that indicated Resident 16 was moderately cognitively impaired. Resident 16's Functional Abilities indicated he required substantial maximum assistance for toileting, bathing, dressing, and hygiene and dependent on staff for bed mobility and transfers. During an observation on 3/4/25 at 8:31 a.m. in Resident 16's room, Resident 16 was observed with a call light hanging next to resident right side of bed, pinned in between bed rail without a red button to push to call for help. During a review of Resident 16's undated care plan titled, . at risks for falls ., the care plan indicated, . Resident's call light is [placed] within reach and encouraged resident to use it for assistance . During an interview on 3/4/25 at 10:32 a.m. in Resident 16's room, Certified Nursing Assistant 1 (CNA 1) confirmed call light button was not within easy reach for the resident. Resident 16's call light was observed with no red button to call for help and the CNA 1 stated this can prevent resident from calling for help and it was a safety risk. During a follow up observation on 3/5/25 at 8:53 a.m., in Resident 16's room, Resident 16 was observed sitting up in bed. The call light for Resident 16 was observed hanging out of reach with no red button to press and call for help. During a follow up observation on 3/6/25 at 7:15 a.m. in Resident 16's room, Resident 16 was observed lying in bed, call light was out of reach on right side of resident bed with no red button to press for help. 1b. A review of Resident 24's Admission Record indicated Resident 24 was admitted to the facility in March 2022 with multiple diagnoses including muscle weakness. A review of Resident 24's MDS Cognitive Patterns, dated 2/19/25 indicated a BIMS score of 0 out of 15 indicating severe cognitive impairment. Resident 24's Functional Abilities indicated, he required substantial maximum assistance for toileting, and dependent on staff for transferring, bathing, and hygiene. During an observation on 3/4/25 at 10:24 a.m. in Resident 24's room, Resident 24 was observed sitting up in bed and call light was hanging on the left side of bed, out of resident's reach, with no red button to press to call for help when needed. During a review of Resident 24's undated care plan titled, Potential alteration in comfort ., the care plan indicated, .Ensure call light is within reach and encourage [Resident 24] to use it for assistance as needed . During an interview on 3/4/25 at 10:32 a.m. in Resident 24's room, CNA 1 confirmed call light button not placed within reach for resident and no red button to push. CNA 1 stated this can prevent the resident from calling for help and was a safety risk. During a follow up observation on 3/5/25 at 8:53 a.m., in Resident 24's room, Resident 24 was observed sitting up in bed. Resident 24's call light was observed pinned between the mattress and side rail on left side with no button to press for assistance. During a concurrent observation and interview on 3/6/25 at 7:19 a.m. with CNA 2, CNA 2 confirmed Resident 16 and Resident 24's call light was out of reach and Resident 16 had no red button to press and call for help. CNA 2 was asked the process regarding reporting repairs of equipment and CNA 2 stated the process was to report repairs needed by entering the information in maintenance binder. The surveyor reviewed the maintenance binder with CNA 2 and confirmed there was no previous report of call light button missing the press buttons for Resident 16 and Resident 24. 1c. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility in March 2018 with multiple diagnoses including Muscle weakness and difficulty in walking. A review of Resident 1's MDS, Cognitive Patterns, dated 12/10/24, indicated Resident 1's BIMS score was 3 out of 15 that indicated Resident 1 was severely cognitively impaired. Resident 1's Functional Abilities, indicated Resident 1 required substantial maximum assistance for toileting, bathing, dressing, bed mobility, and personal hygiene. During a concurrent observation and interview on 3/5/25 at 8:55 a.m. in Resident 1's room, Resident 1 was observed with call light out of reach, Resident 1 asked surveyor for help, resident stated he could not reach the call light. CNA 3 stated, . I can't find the call light . CNA 3 confirmed the call light was under a urinal, spirometer, and black bag and it was out of resident's reach. CNA 3 stated Resident 1 cannot call for help without the call light and can result in harm if Resident 1 tried to get out of their bed. During a review of Resident 1's undated care plan titled, Resident found ., the care plan indicated, . keep call light within reach and answer promptly . maintain a hazard free environment . During a concurrent interview and record review on 3/6/25 starting at 10:49 a.m., with Maintenance Director (MD) at the Hall 5 nursing station, MD stated the process for repairs was the facility had a maintenance log at each nursing station that was checked 3 times a day. The staff are supposed to write in the log, concern, room number, and which patient. Reviewed maintenance binder with MD, the MD confirmed there was a report dated 3/6/25 of Resident 24's call light and no previous report for Resident 16's call light. MD confirmed call light without button for Resident 16 via photograph taken by surveyor, MD stated, . it should have been reported, we have extras and could have fixed the call light right away . During an interview and record review on 3/7/25 at 9:44 a.m. with Central Supply (CS), the CS stated, for room rounds generally goes early in the morning. CS further stated Resident 16's call light was missed. CS stated aware of missed call light for Resident 16. Reviewed photograph of Resident 16's call light with CS. CS confirmed call light had no red button and Resident 16 would be unable to call for help. Reviewed room rounds paperwork with CS, confirmed call light marked not accessible for Resident 24. During an interview on 3/7/25 at 9:53 a.m. with Director of Staff Development (DSD), the DSD stated the expectations for CNAs were to answer call lights in timely fashion. Staff should report any repairs needed with call lights to maintenance immediately and they should be adding any equipment concerns in the maintenance binder. During an interview on 3/7/25 at 1:17 p.m. with Administrator (ADM), the ADM confirmed resident call light was out of reach for Resident 1, Resident 16, and Resident 24. ADM stated the resident could not call for help and it should have been reported to maintenance immediately. During a review of facility policy and procedure (P&P) titled, Answering the Call light dated September 2022, the P&P directed, . Ensure that the call light is accessible to the resident when in bed . Report all defective call lights to the nurse supervisor promptly . Answer the resident call system immediately .

Based on observation, interview, and record review the facility failed to ensure the medication error rate was less than five percent (5%) for a census of 132 when: 1. Licensed Nurse 1 (LN 1) did not follow the physician's order in administering Resident 13's prescribed medication; 2. Resident 115 was given another resident's supply of insulin glargine (long-acting insulin); and 3. Three of Resident 83's morning medication were combined and administered at the same time through the feeding tube with no regard for medication reactions (therapeutic response). These failures resulted in a medication error rate of 23.08% for the facility. Findings: 1. A review of an admission record for Resident 13 indicated he was admitted to the facility in December 2009 with diagnoses including hyperlipidemia (high cholesterol, too much fat in the blood). In an observation on 3/4/25 at 8:50 a.m., during Medication Administration with LN 1, LN 1 was observed preparing Resident 13's morning medications, LN 1 scooped a teaspoon (tsp., unit of measurement) of psyllium powder (used for constipation) and stirred it with 5 ounces (oz., unit of measurement) of water. LN 1 stated Resident 13 drinks the mixture without difficulty. A review of Resident 13's Order Summary Report (OSR) dated 12/30/22 indicated an order for Resident 13 to receive a tablespoon (tbsp., unit of measurement) of psyllium powder mixed in 8 oz. [ounce,unit of volume measurement] water daily in the morning. In a concurrent interview and record review on 3/7/25 at 8:05 a.m., with LN 1 Resident 13's OSR was reviewed. LN 1 confirmed that on 3/4/25, she did not administer the right dosage of psyllium powder to Resident 13, instead of giving 1 tbsp. LN 1 gave 1 tsp. of psyllium mixed in 5 oz. of water. 2. A review of Resident 115's Admission Record indicated he was admitted in January 2025 with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 115's OSR dated 2/27/25 indicated an order for insulin glargine (long acting insulin), inject 22 units subcutaneously (SQ, under the skin) daily in the morning. On 3/4/25 the following concurrent observations and interviews were conducted with LN 2: - At 9:45 a.m., LN 2 checked Resident 115's blood sugar level, LN stated it was 375; - At 9:50 a.m., LN 2 took one vial of insulin glargine (long-acting insulin) without inspecting the label properly from the medication cart then withdrew 22 units in a syringe, LN 2 used another resident's supply of the same insulin, LN 2 stated she was in a hurry and did not check the name on the insulin vial. - At 9:55 a.m. LN 2 injected 22 units of insulin glargine to Resident 115's abdomen taken from another resident's vial. 3. A review of the admission record for Resident 83 indicated he was admitted to the facility in December 2023 with diagnoses including anoxic brain damage (irreversible brain damage caused by an interrupted oxygen supply to the brain). A review of Resident 83's OSR dated 12/8/23 indicated Resident 83 took nothing by mouth, received nutrition and medication through the feeding tube. A review of Resident 83's OSR dated 12/13/23 indicated to flush feeding tube with 60 ml. (milliliter, volume measurement) of water before and after medication administration. In an observation on 3/4/25/at 10 a.m., during Medication Administration with LN 2, LN 2 was observed preparing all medications for Resident 83. LN 2 crushed two 100 milligram (mg., unit of measurement) tablets of docusate sodium (stool softener), one tablet of multi-vitamin with minerals, opened two soft gel capsules of ultimate omega, and six capsules of herbal supplements. During a continued Medication Administration observation on 3/4/25 starting at 10 a.m., LN 2 combined all crushed and opened medications then mixed it with water in a 5 oz cup. LN 2 flushed Resident 83's feeding tube with 40 ml.,of warm water then poured the medication mixture right after. Resident 83's feeding tube stopped draining after a few minutes, and the Assistant Director of Nursing (ADON) went inside Resident 83's room to assist LN 2. The ADON confirmed the feeding tube was plugged up because of the medication mixture. The ADON stated the medications should have been administered one at a time with water flushes in between to keep the feeding tube patent and prevent it from getting blocked and as per policy. In an interview on 3/7/25 at 8:35 a.m. with the Director of Nursing (DON) the DON stated all the nurses had undergone skills training in medication administration including administration through a feeding tube. DON expected all nurses to be able to utilize what they've learned in training to be able to properly care for the residents and prevent errors when giving medications that can lead to complications. A review of the facility's policy titled Administering Medications Through an Enteral Tube revised in 2018 indicated .safe administration of medications through an enteral tube .Administer each medication separately .If administering more than one medication, flush with 15 ml warm purified water between medications. A review of the facility's policy titled Administering Medications revised in 2019 indicated Medications are administered in a safe .manner .The individual administering the medication checks the label to verify the right resident, right medication, right dose, right time and right method (route) of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to promote safety measures for one of 32 sampled residents (Resident 50) when Resident 50's order for the use of wander guard (a device that allows sensors on doors to alarm to keep track of wandering residents) was not followed as ordered. This failure increased Resident 50's risk for elopement. Findings: A review of an admission record for Resident 50 indicated she was admitted in November 2024 with diagnoses including vascular dementia (a type of dementia caused by problems with blood flow to the brain affecting thinking, memory, and behavior). A review of Resident 50's Order Summary Report (OSR) dated 11/10/24 indicated an order to apply wander guard to the left arm/wrist and check placement every shift due to episodes of going out of the facility unassisted. During observations on 3/4/25 at 11:50 a.m., 3/5/25 at 1:45 p.m., and 3/6/25 at 9 a.m., Resident 50 was observed not wearing a wander guard. During a concurrent observation, interview, and record review on 3/6/25 at 10:28 a.m., with the Assistant Director of Nursing (ADON), Resident 50's OSR, and Medication Administration Record (MAR) were reviewed. ADON confirmed Resident 50 was not wearing a wander guard to the left arm or to any of Resident 50's upper/lower extremities, but the order was still active due to Resident 50's history of wandering. During an interview on 3/7/25 at 8:35 a.m., with the Director of Nursing (DON) the DON acknowledged that Resident 50 should always wear the wander guard as ordered to maintain resident's safety with proper supervision and prevent wandering that may lead to accidents. A review of the facility's policy titled Wandering and Elopements revised in 2019 indicated The facility will identify residents who are at risk for unsafe wandering . care plan .will include strategies and interventions to maintain resident's safety.

Based on observation, interview, and record review, the facility failed to notify the RP (Responsible Party) of the transfer and the reason for the transfer for one resident (Resident 132) out of 32 sampled residents. This failure increased the risk for Resident 132's RP not be informed of the resident's discharge rights. Findings: Review of Resident 132's admission record indicated Resident 132 was admitted in December 2024 with several diagnoses including memory deficit following other cerebral vascular disease (memory problems caused by inadequate blood flow in parts of the brain) and dementia (a progressive decline in mental abilities). Review of Resident 132's Minimum Data Set (MDS, a federally mandated assessment tool) dated 12/13/24, indicated Resident 132 had severely impaired cognition. Review of Resident 132's Nurse's Notes dated 12/13/24, indicated, Resident sent to ER [emergency room ] due to disturbing behaviors. During a concurrent observation and interview on 3/7/25 at 9:02 a.m. with the Director of Nursing (DON), the DON confirmed that there was no documentation that Resident 132's RP was notified of resident's transfer to an acute care hospital. The DON stated that her expectation was that the RP be notified by the Licensed Nurse before a resident is transferred. Review of the facility's Policy and Procedure (P&P) dated October 2022, and titled, Transfer or Discharge, Facility Initiated. The P&P indicated, When a resident is transferred or discharged from the facility, the following information is documented in the medical records .That an appropriate notice was provided to the resident and/or legal representative .

Based on interview and record review, the facility failed to timely submit a Minimum Data Set (MDS, a federally mandated resident assessment tool) for one of 32 sampled residents (Resident 119) when the discharge assessment was not completed and transmitted according to the required regulatory time frame. This failure had the potential to result in incomplete information being submitted to Centers for Medicare and Medicaid Services (CMS). Findings: A review of Resident 119's admission record indicated she was admitted to the facility on ,d+[DATE] and discharged on [DATE]. In a concurrent interview and record review on 3/6/25 at 11:08 a.m., with the MDS Coordinator 1 (MDSC 1), Resident 119's MDS assessments were reviewed. MDSC 1 confirmed Resident 119's discharge assessment was completed and transmitted more than 14 days from the date of discharge. In an interview on 3/7/25 at 8:35 a.m. with the Director of Nursing (DON), the DON stated she expected the MDSC 1 to follow the required timeframes for MDS submission. A review of the facility's policy titled MDS Completion and Submission Timeframes revised in 2023 stipulated the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. A review of a document titled Assessments for the RAI [Resident Assessment Instrument], dated 10/23, indicated MDS completion date for discharge assessment must be completed no later than the discharge date plus 14 calendar days.

Based on interview and record review, the facility failed to ensure one of 32 sampled residents (Resident 125) had a PASARR (Pre admission Screening and Resident Review, a federal requirement to ensure individuals with serious mental illness, intellectual disability, or other related conditions are not inappropriately placed in nursing homes for long term care and receive services in the most integrated setting) completed. This failure had the potential for the facility not to provide or seek appropriate mental health services for Resident 125. Findings: A review of Resident 125's Admission Record indicated Resident 125 was admitted to the facility in December 2024 with multiple diagnoses including Major Depressive Disorder ( a common and serious condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life). During a review of Resident 125's medical record, under PASARR, the document titled DHCS[Department of Health Care Services], dated 12/13/2024 indicated, . If the individual remains in the NF[Nursing Facility] longer than 30 days, the facility must resubmit a new Level 1 [a screening used to determine if an individual has or is suspected of having a PASARR condition ]Screening as a Resident Review on the 31st day, During a concurrent interview and record review on 3/7/25 at 1:56 p.m. with Director of Nursing (DON) and Administrator (ADM), the DON and ADM reviewed the PASARR document provided by the facility located in Resident 33's medical record. The DON and ADM confirmed there should be an additional PASARR to be completed for Resident 125. DON and ADM stated this was missed and it should have been done. A request was made to the Administrator(ADM) on 3/7/25 at 2:53 p.m. for additional PASARR documentation for Resident 125 and facility PASARR policy and there was no documentation provided.

Based on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for four residents (Resident 13, Resident 83 Resident 115 and Resident 33) of 32 sampled residents, when: 1. Licensed Nurse 1 (LN 1) did not follow the physician's order in administering Resident 13's prescribed medication; 2. Three of Resident 83's morning medication were combined and administered at the same time through the feeding tube; 3a. Resident 115 was given another resident's supply of insulin glargine (long-acting insulin); and, 3b. Resident 115's order for compression socks was not followed as ordered. 3c. Resident 33's physician order to flush an indwelling Foley catheter (a thin flexible tube inserted into the urinary bladder to drain urine) was not followed as ordered. These failures increased the resident's potential to have unmet health needs and decreased the facility's potential to provide a responsible and accurate care for residents. Findings: 1. A review of an admission record for Resident 13 indicated he was admitted to the facility in December 2009 with diagnoses including hyperlipidemia (high cholesterol, too much fat in the blood). In an observation on 3/4/25 at 8:50 a.m., during medication pass with LN 1, LN 1 was observed preparing Resident 13's morning medications, LN 1 scooped a teaspoon (tsp., unit of measurement) of psyllium powder (used for constipation) and stirred it with 5 ounces (oz., unit of measurement) of water. LN 1 stated Resident 13 drinks the mixture without difficulty. A review of Resident 13's Order Summary Report (OSR) dated 12/30/22 indicated an order for Resident 13 to receive a tablespoon (tbsp., unit of measurement) of psyllium powder mixed in 8 oz. of water daily in the morning. In a concurrent interview and record review on 3/7/25 at 8:05 a.m., with LN 1 Resident 13's OSR was reviewed. LN 1 confirmed that on 3/4/25, she did not administer the right dosage of psyllium powder to Resident 13, instead of giving 1 tbsp. LN 1 gave 1 tsp. of psyllium mixed in 5 oz. of water. 2. A review of an admission record for Resident 83 indicated he was admitted to the facility in December 2023 with diagnoses including anoxic brain damage (irreversible brain damage caused by an interrupted oxygen supply to the brain). A review of Resident 83's OSR dated 12/8/23 indicated Resident 83 takes nothing by mouth, receives nutrition and medication through the feeding tube. A review of Resident 83's OSR dated 12/13/23 indicated to flush feeding tube with 60 ml.[ml, milliliter is a unit of measurement] of water before and after medication administration. In an observation on 3/4/25 at 10 a.m., during medication administration with LN 2, LN 2 was observed preparing medications for Resident 83. LN 2 crushed two 100 milligram (mg., unit of measurement) tablets of docusate sodium (stool softener), one tablet of multi-vitamin with minerals, opened two soft gel capsules of ultimate omega, and six capsules of herbal supplements. During a continued medication administration observation on 3/4/25 starting at 10 a.m., LN 2 combined all crushed and opened medications and mixed it with water in a 5 oz cup. LN 2 flushed Resident 83's feeding tube with 40 ml., of warm water then poured the medication mixture right after. Resident 83's feeding tube stopped draining after a few minutes, and the Assistant Director of Nursing (ADON) came in Resident 83's room to assist LN 2. The ADON confirmed the feeding tube was plugged up because of the medication mixture. The ADON stated the medications should have been administered one at a time with water flushes in between to keep the feeding tube patent and prevent it from getting blocked. 3a. A review of Resident 115's Admission Record indicated he was admitted in January 2025 with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 115's OSR dated 2/27/25 indicated an order for insulin glargine (long acting insulin, a medication used to manage diabetes), inject 22 units subcutaneously (SQ, under the skin) daily in the morning. On 3/4/25 the following concurrent observations and interviews were conducted with LN 2: - At 9:45 a.m., LN 2 checked Resident 115's blood sugar level, LN 2 stated it was 375; - At 9:50 a.m., LN 2 took one vial of insulin glargine (long-acting insulin) from the medication cart without checking the label and withdrew 22 units in a syringe, LN 2 used another resident's supply of the same insulin, LN 2 stated she was in a hurry and did not check the name on the insulin vial; and, - At 9:55 a.m. LN 2 injected the 22 units of insulin glargine to Resident 115's abdomen, insulin that belonged to another resident. In an interview on 3/7/25 at 8:35 a.m. with the Director of Nursing (DON) the DON stated all the nurses had undergone skills training in medication administration including administration through a feeding tube. The DON stated she expected all nurses to be able to utilize what they had learned in training to be able to properly care for the residents and prevent errors when giving medications that can lead to complications. A review of the facility's policy titled Administering Medications Through an Enteral Tube revised in 2018 indicated .safe administration of medications through an enteral tube .Administer each medication separately .If administering more than one medication, flush with 15 ml warm purified water between medications. A review of the facility's policy titled Administering Medications revised in 2019 indicated Medications are administered in a safe .manner .The individual administering the medication checks the label to verify the right resident, right medication, right dose, right time and right method (route) of administration before giving the medication. 36681 3b. A review of the Admission Record indicated Resident 115 was initially admitted [DATE] and recently admitted [DATE]. with diagnoses including Diabetes mellitus with diabetic neuropathy (nerve damage caused by high blood sugar levels). A review of Resident 115's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 1/17/25 indicated Resident 115 had moderate cognitive impairment with a score of 12 out of 15 in the Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident). A review of Resident 115's physician order dated 1/13/25 indicated, COMPRESSION SOCKS: CNA [Certified Nursing Assistant] to apply COMPRESSION SOCKS to BLE [bilateral lower extremities] during the day and remove at bedtime as tolerated . Further review of Resident 115's clinical records indicated the following: - Admission H & P [History & Physical] dated 1/10/25 indicated, .Edema [swelling caused by excess fluid buildup] of lower extremity due to peripheral venous insufficiency [veins in the legs have trouble returning blood to the heart] .chronic, continue compression stocking daily; - the Medication Administration Record (MAR) from 1/13/25 to 3/4/25 had no documentation of Resident 115's refusal to use the compression socks. The MAR was signed by LNs all shifts; and, - there was no care plan initiated for Resident 115's use of compression socks from 1/13/25 to 3/4/25. In a concurrent observation and interview on 3/4/25 at 9:08 a.m., Resident 115 was up in his wheelchair inside his room and had socks and shoes on. Resident 115 stated he had been in the facility for a couple of weeks and he was ready to go home. A concurrent observation and interview was conducted on 3/5/25 at 2:15 p.m.,inside Resident 115's room with his wife at bedside. Resident 115 and his wife stated he was wearing regular socks. Resident 115's wife further stated [Resident 115] had not been using the compression socks for 6 weeks and resident just quit using it. A concurrent interview and record review was conducted on 3/5/25 at 2:20 p.m. in the nurses' station with LN 5. The LN 5 confirmed Resident 115 had an order for compression socks dated 1/13/25. The LN 5 stated she had not checked if resident was wearing the compression socks and she did not get a report from the CNA of resident refusing to wear the compression socks. A subsequent observation and interview was conducted on 3/5/25 at 2:22 p.m., inside Resident's 115 room with his wife at bedside. The LN 5 checked Resident 115's socks and confirmed he was using non skid socks and not compression socks. A concurrent observation and interview was conducted on 3/6/25 at 10:06 a.m., inside Resident 115's room with CNA 4. The CNA 4 confirmed Resident 115 was using his own socks provided by his wife and it was not compression socks. The CNA 4 stated she did not know if Resident 115 should wear compression socks. The CNA 4 further stated LN 5 did not inform her Resident 115 had to use compression socks. The CNA 4 added she had worked with Resident 115 three weeks ago and resident was using the socks provided by his wife. In a concurrent interview and record review on 3/7/25 at 10:43 a.m., the DON stated Resident 115 had episodes of refusing the compression socks. The DON further stated she confirmed with one of the CNAs Resident 115 sometimes wears his compression socks and sometimes he does not. The DON said her expectation was for LNs to document resident refusal either in the MAR or TAR [Treatment Administration Record] since the resident has the right to refuse. The DON confirmed the care plan for the use of compression socks was initiated on 3/6/25 and there was no documented refusals in the MAR from 1/13/25 to 3/4/25. A review of the facility's policy and procedure revised October 2010 and titled, Applying Anti-Emboli Stockings (TED Hose) indicated, The purpose of this procedure is to improve venous return to the heart, to improve arterial circulation to the feet, to minimize edema to the legs and feet .The following information should be recorded in the resident's medical record .If the resident refused the treatment, the reason(s) why and the intervention taken .Notify the supervisor if the resident refuses the procedure. 50351 3c. A review of Resident 33's Admission Record indicated Resident 33 was admitted to the facility in November 2024 with multiple diagnoses including history of urinary tract infection and diabetes. During a review of Resident 33's Physician order, dated 11/21/24, the order directed, . Catheter: irrigated with 60 mL[milliliters, a unit of measurement] of Normal Saline [a sterile solution] PRN [as needed] (Clogging) . During an observation on 3/4/25 at 9:41 a.m. in Resident 33's room, Resident 33 was observed resting in bed with catheter tubing noted with cloudy yellow urine. During a follow up observation on 3/7/25 at 7:17 a.m. in Resident 33's room, Resident 33 was observed sitting up in bed. The catheter tubing was noted with yellow thick sediments and dark cloudy urine. During a concurrent observation and interview on 3/7/25 at 7:33 a.m. with CNA 5 in Resident 33's room, Resident 33's catheter tubing was observed with thick yellow sediment, was cloudy and yellow in color. CNA 5 confirmed the observation of thick yellow sediment and she stated [the observation] should be reported to the nurse. During an interview on 3/7/25 at 9:21 a.m. at nursing station 1 next to the administration office with Treatment Nurse (TN), the TN stated, catheter care can be completed by the treatment nurse and shift nurses. TN further stated the catheter tubing flush for Resident 33 was ordered as needed. The TN confirmed there were sediments in Resident 33's catheter tubing via photo images taken by surveyor and should be flushed. During a review of Resident 33's progress note dated 2/9/25, the progress note indicated, . Family member concerned with cath [catheter] bag containing light sediment with dark urine in part of tubing and requested to change cath out. Checked order with last change 1/18/25 per Q30 [every 30] days schedule order for patient. Flushed cath . During a review of Resident 33's care plan titled Resident has altered elimination due to use of indwelling catheter . dated 11/21/24 indicated, . Change FC [Foley catheter] . per facility protocol . Check urine for any significant change in color, odor, amount, and Notify MD [Medical Doctor, physician] . During a review of Resident 33's Treatment Administration Record (TAR), the TAR indicated order dated 11/21/24 to . Observe for s/s [signs and symptoms] of infexn [sic, infection] & complications r/t [related to] use . Thick/cloudy urine . Excessive sediments . early detection of possible infection for use of indwelling catheter . On 3/5/25 TAR documentation indicated there was thick cloudy urine noted. There was no documentation the resident's physician was notified of the s/s of infection. During a concurrent interview and record review on 3/7/25 at 1:24 p.m. with DON, the DON stated her expectation for catheter care and flushes was the nursing staff to follow physician's orders, if they are monitoring it daily, it should be documented according to what they observed. DON confirmed sediment in catheter tubing via photograph image and confirmed monitoring order for catheter for Resident 33. During a review of policy and procedure titled, Catheter Care, Urinary, dated August 2022, indicated, . change catheters and drainage bags based on clinical indication such as infection, obstruction . Residents who form encrustations can quickly lead to an obstruction need more frequent catheter changes Report unusual findings to Physician or supervisor . if urine has an unusual appearance . color . if signs of symptoms of urinary traction infections .occur The following information should be recorded in the resident's medical record . character of urine such as color .

Based on interview and record review, the facility failed to ensure the pharmacy recommendations for one of 32 sampled residents (Resident 54) during a Medication Regimen Review (MRR) was communicated to the physician. This failure had the potential for Resident 54 to experience adverse effects from the medication. Findings: A review of the Admission Record indicated Resident 54 was admitted [DATE] with multiple diagnoses including insomnia (trouble falling asleep or staying asleep). A review of Resident 54's Medication Administration Record (MAR, daily documentation record used by a licensed nurse to document medication and treatment given to a resident) included the following orders: -an order dated 4/4/24 for Melatonin (used to treat insomnia) 3 mg (milligram, unit of measurement) give 1 tablet by mouth for insomnia; -an order dated 4/4/24 for Melatonin 3 mg give 1 tablet by mouth as needed for insomnia. May give one additional tablet at bedtime, total of 6 mg per day; and, -an order dated 6/1/24 for Melatonin 3 mg give 1 tablet by mouth as needed at bedtime for circadian rhythm (internal clock in the brain that regulates cycles of alertness and sleepiness). A review of the MRR from the Consultant Pharmacist created between 1/1/25 and 1/26/25 for Resident 54 indicated, There are two PRN [given as needed or requested] orders for Melatonin. One of these should be discontinued. In a concurrent interview and record review on 3/6/25 starting at 3:33 p.m., the Director of Nursing (DON) stated the facility communicates the pharmacy recommendations to the physician. The DON confirmed Resident 54 had 2 PRN orders for Melatonin and a scheduled Melatonin 3 mg at bedtime for insomnia. The DON further stated the additional Melatonin PRN order should have been discontinued since Resident 54 was on routine Melatonin. In a follow up interview on 3/7/25 at 10:54 a.m., the DON stated she had a conversation with the physician regarding Resident 54's Melatonin orders and she was not sure if the conversation was documented. The DON further stated she will check with medical records. In a concurrent interview and record review on 3/7/25 at 2:52 p.m., the Medical Records Director (MRD) stated she could not find documented evidence the physician was notified of the pharmacy recommendations for Resident 54's PRN Melatonin orders. A review of the facility's policy and procedure revised May 2019 and titled, Medication Regimen Reviews indicated, .The consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility .The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems .and other irregularities, for example .duplicative therapies .Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physician for each resident identified as having a non-life threatening medication irregularity .The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) was taken to address it.

Based on observation, interview, and record review the facility failed to ensure one resident (Resident 115) for a census of 132 was free from significant medication error when Resident 115 was administered another resident's insulin. This failure increased Resident 115's risk for receiving the wrong medication and complications of diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) including diabetic coma. Findings: A review of Resident 115's Admission Record indicated he was admitted in January 2025 with diagnoses including Type 1 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of an Order Summary Report (OSR) for Resident 115 dated 2/27/25 indicated an order for insulin glargine, inject 22 units subcutaneously (SQ, under the skin) daily in the morning. On 3/4/25 the following concurrent observations and interviews were conducted with Licensed Nurse 2 (LN 2): - At 9:45 a.m., LN 2 checked Resident 115's blood sugar level, LN 2 stated it was 375; - At 9:50 a.m., LN 2 took one vial of insulin glargine (long-acting insulin) without checking the label properly from the medication cart then withdrew 22 units in a syringe, LN 2 used another resident's supply of the same insulin, LN 2 stated she was in a hurry and did not check the name in the insulin vial. - At 9:55 a.m. LN 2 injected 22 units of insulin glargine to Resident 115's abdomen taken from another resident's vial. In an interview on 3/7/25 at 8:35 a.m. with the Director of Nursing (DON) the DON stated all the nurses had undergone skills training in proper medication administration, she expected nurses to use what they've learned and should follow the seven rights of medication when administering medications to prevent errors from occurring. A review of the facility's policy titled Administering Medications revised in 2019 indicated Medications are administered in a safe .manner .The individual administering the medication checks the label to verify the right resident, right medication, right dose, right time and right method (route) of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to update the medication label for one (Resident 115) out of a census of 132 when Resident 115's insulin glargine (long-acting insulin) order was changed. This failure increased the potential for unsafe administration of medication to residents. Findings: A review of Resident 115's Admission Record indicated he was admitted in January 2025 with diagnoses including Type 1 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of an Order Summary Report (OSR) for Resident 115 dated 2/27/25 indicated an order for insulin glargine, inject 22 units subcutaneously (SQ, under the skin) daily in the morning. In a concurrent observation and interview on 3/4/25 at 9:50 a.m., during Medication Administration with Licensed Nurse 2 (LN 2), LN 2 withdrew 22 units of insulin glargine from the vial, LN 2 stated the order for Resident 115 had been changed to 22 units daily in the morning . LN 2 confirmed the dosage [27 units] written on the label in the insulin vial was incorrect. In a concurrent interview and record review on 3/7//25 at 11:45 a.m., with the Assistant Director of Nursing (ADON), Resident 115's OSR and insulin vial were reviewed, ADON confirmed the label on the insulin vial for Resident 115 stored in the cart was not updated per order. The ADON stated Resident 115's insulin glargine order had been changed from 27 units to 22 units on 2/27/25. ADON added the nurse who changed the order should have updated the label on Resident 115's insulin vial and should have attached an order sticker to alert the nurses that the order had been changed to prevent errors in the administration of the medication. A review of the facility's policy titled Administering Medications revised in 2019 indicated Medications are administered in a safe .manner .and as prescribed. The individual administering the medication checks the label to verify .the right dose .before giving the medication.

Based on interview and record review, the facility failed to ensure services furnished by outside resources had written agreements when two of 32 sampled residents' (Resident 56 and Resident 96) dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) services were provided without existing agreements with dialysis clinic. This failure had the potential to result in the lack of responsibility and accountability in the dialysis services received by Resident 56 and Resident 96. Findings: 1a. A review of the Admission Record indicated Resident 56 was initially admitted [DATE] with diagnoses including end stage renal disease (ESRD, irreversible kidney failure) and dependence on renal dialysis. A review of Resident 56's physician order dated 12/3/24 indicated, DIALYSIS: Hemodialysis [Dialysis company name and address] .Schedule: (Monday, Wednesday, Friday) . 2a. A review of the Admission Record indicated Resident 96 was initially admitted [DATE] with diagnoses including end stage renal disease and dependence on renal dialysis. A review of Resident 96's physician order dated 8/22/23 indicated, DIALYSIS M-W-F [Monday-Wednesday-Friday] AT [Dialysis company name] . A review of Resident 96's undated care plan indicated, .needs hemodialysis r/t [related to] ESRD A review of the clinical records indicated Resident 56 and Resident 96 go to the same dialysis clinic. In an interview on 3/6/25 at 11:30 a.m., the Administrator (ADM) stated he was waiting for the contract from the Dialysis clinic. In a follow up interview on 3/7/25 at 11:53 a.m., the ADM confirmed the Dialysis contract was not available for review. A review of the facility's policy and procedure (P & P) revised September 2010 and titled, End Stage Renal Disease, Care of a Resident with indicated, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care .Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: .how the care plan will be developed and implemented .how information will be exchanged between the facilities . A review of the facility's P & P revised October 2008 and titled, Referral Agreements indicated, The facility shall maintain written agreements with agencies providing services to our residents .To facilitate referrals, the facility has entered into referral agreements with agencies that will provide services to residents. The scope of agencies and the agreements are consistent with the needs of the facility's resident population. When appropriate, the agreements will be reviewed and approved by other departments or disciplines (e.g., the medical director should review agreements to provide medical .as well as specialized services such as dialysis .

Based on observation, interview, and record review, the facility failed to establish and implement an effective screening process, for all individuals entering the building, to prevent the introduction and spread of COVID-19 infection (a contagious respiratory and vascular disease caused by severe acute respiratory syndrome coronavirus) to 39 of 87 Residents when the facility did not have designated screeners on the morning and night shifts to identify symptomatic individuals entering the building. The facility's current screening tool, used for identifying symptomatic (having symptoms of COVID-19) individuals, did not contain all current signs and symptoms of COVID-19 per Centers for Disease Control (CDC) guidelines. These failures resulted in an increased potential for introduction and spread of COVID-19 into the building due to ineffective identification of individuals with potential symptoms of COVID-19 which had the potential to result in serious harm or possible death as a result of possible exposure to COVID-19 for 39 of 87 residents in the facility. Based on the above failure, an Immediate Jeopardy (IJ) was called on [DATE] at 3:13 p.m. On [DATE] at 3:13 p.m., the Administrator was informed of the IJ situation which had the potential to result in serious infection or death when facility staff performed self-screenings of themselves with an incomplete COVID-19 screening tool. This placed 39 of 87 residents in serious jeopardy due to the increased potential of transmitting COVID-19 to non-infected residents. The Administrator presented a Plan of Correction (POC) on [DATE] at 6:26 p.m. which was accepted by the Department. In an interview with the Administrator (ADM) on [DATE] at 6:30 p.m., the ADM stated the facility will follow the POC immediately, which included assigning trained staff as screeners upon entry on each shift to actively screen oncoming individuals entering the building; completion and implementation of a revised screening tool with current signs and symptoms of COVID-19 per CDC guidelines; and, providing a plan for scheduled in-services to all staff regarding implementation of screeners and the new screening tool. The Administrator was informed the immediacy of the IJ had been removed on [DATE] at 6:30 p.m. by the Department's surveyor who remained onsite during the IJ and confirmed the IJ was removed onsite. Findings: Review of the facility's COVID-19 Mitigation Attestation, signed by the ADM and dated [DATE] indicated, The [facility] screens and documents every individual entering the facility (including staff) for COVID-19 symptoms. Proper screening includes temperature checks . A review of the complaint incident, dated [DATE] to the Department, indicated an allegation that the facility was not screening staff appropriately and allowing them to work with symptoms of COVID-19 (fever or chills, cough, shortness of breath or difficulty breathing, fatigue muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea). Upon entrance to the facility on [DATE] at 12:42 p.m., the facility was noted to have a census of 87 as confirmed with the Administrator. The facility had 48 COVID-19 positive residents, 2 COVID-19 positive residents in the general acute care hospital, 4 COVID-19 positive residents who expired, 39 COVID-19 negative residents, and 9 COVID-19 positive facility staff between [DATE] and [DATE]. Review of the facility's COVID-19 screening tool titled Daily Staff Screening Form, dated [DATE], indicated Staff Name .Temp [temperature] .Difficulty Breathing .New Cough .Sore Throat .Chills .New loss of taste or smell . A concurrent observation and interview regarding the facility's screening process was conducted on [DATE] at 12:42 p.m. with The Licensed Nurse (LN). The LN performed the screening process on the Department's surveyor by taking the temperature and asking about signs and symptoms of COVID-19 per the facility screening tool. The LN stated she is not an assigned screener and there is normally someone always at the front entrance to screen visitors. An observation of the employee's entrance in the back of the facility located near the staff break room was conducted on [DATE] at 12:58 p.m. The staff break room, designated for the non-COVID-19 unit, was located near the back entrance across the entrance to the kitchen with the door closed. The inside of the break room included a table with several screening forms, thermometer and sanitizer. There was no written instruction on how to perform the screening or how to sanitize the equipment. During a subsequent observation on [DATE] at 1:01 p.m., 2 staff observed inside the break room exited the room and another 2 staff entered the room. In an interview with the Certified Nurse Assistant 2 (CNA 2 works the AM shift) on [DATE] at 1:16 p.m., the CNA 2 stated employees enter through the back entrance and self-screen (staff screen themselves for signs and symptoms of COVID-19 and take their own temperatures) for symptoms of COVID-19. The CNA 2 further stated the process is to enter through the back entrance, sign in at the breakroom and screen self. In an interview with the LN on [DATE] at 1:23 p.m., the LN stated employees enter through the back entrance and self-screen by answering the screening tool and taking their own temperature. The LN further stated someone from the Activities Department screens staff for the p.m. (evening) shift, and no one screens staff for the a.m. (morning) shift. In an interview with the Housekeeper (HSKP works the AM shift) on [DATE] at 1:33 p.m., the HSKP stated, we enter through the back-room entrance, sign in and take our own temperature. In an interview with the CNA 3 (works on the AM shift) on [DATE] at 1:43 p.m., the CNA 3 stated she enters through the back-room entrance, screens herself in the break room, and takes her own temperature. In an interview with the Central Supply Coordinator (CSC) on [DATE] at 1:55 p.m., the CSC (works the AM shift) stated she screens visitors at the front desk and that there is always someone in the front to screen visitors. The CSC further stated staff use the back entrance and usually there is someone from the Activities Department to screen in the afternoon. In an interview with the Activities Director (AD) on [DATE] at 2 p.m., the AD stated she screens incoming staff for the p.m. shift. The AD stated she takes the temperatures and makes sure the screening forms are completed. The AD further stated she was not sure who conducts the screening for the morning and night shifts. In an interview with the Administrator (ADM) on [DATE] at 2:06 p.m., the ADM stated employees get screened at the back entrance. The ADM further stated there is no schedule of screeners, and on occasion employees must screen themselves before entering the units. The ADM stated there are no specific screeners assigned for the morning and night shifts. The ADM further stated the CNA 1 was the first individual to test positive for COVID-19. The ADM stated the CNA 1's last work shift was on [DATE] on the night shift, and first reported symptom of muscle ache began on [DATE]. The ADM further stated the CNA 1 received a COVID-19 test on [DATE] with a positive result on [DATE]. The ADM stated another staff member tested positive three days later and it further spread to the residents. A review of the CDC guidelines titled, Symptoms of Coronavirus [COVID-19] updated [DATE] at https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html indicated, watch for symptoms .fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting [and] diarrhea . Review of the facility's COVID-19 screening tool titled Daily Staff Screening Form, dated [DATE], indicated [CNA 1] .Temp .98.6 .Difficulty Breathing .no .New Cough .no .Sore Throat .no .Chills .no .New loss of taste or smell .no . There was no documented evidence CNA 1 was screened for muscle or body aches. In a subsequent interview with the ADM on [DATE] at 5:56 p.m., the ADM stated even though the screening tool was dated [DATE], the CNA 1's last day was still [DATE] because the CNA 1 began work on the night shift of [DATE]. Review of a facility document titled, COVID-19 dated [DATE] indicated, All HCP [healthcare personnel] must be screened upon entry to the facility (fever, cough, sore throat). As COVID-19 is circulating in our communities, it is important to screen all HCP upon entry to your building . Review of an undated facility document titled, All Staff to Check Temperature Prior to Shift indicated, 0600 (AM shift) - NOC [night] shift CNA will be stationed to temp [temperatures] oncoming staff .1400 [2 p.m.] (PM shift) - Activity staff will be stationed to temp oncoming staff .2200 [10 p.m.] (NOC shift) - PM shift CNA will be stationed to temp oncoming staff .Licensed Nurses, CNA's and Ancillary staff reporting for work at times other than as stated above .will check temperature independently upon arrival . A review of the CDC guidelines titled, Operational Considerations for the Identification of Healthcare Workers and Inpatients with Suspected COVID-19 in non-US Healthcare Settings updated [DATE] https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/guidance-identify-hcw-patients.html indicated, .facilities should define a standardized set of signs and symptoms (e.g., fever and/or cough/shortness of breath) to screen healthcare workers and patients for suspected COVID-19. A high level of suspicion is critical to ensure cases do not go unrecognized due to a substantial proportion of patients and healthcare workers presenting with atypical or minimal symptoms . Review of CNA 1's laboratory test result, dated [DATE], indicated CNA 1 received a COVID-19 test on [DATE] with results of positive on [DATE]. Review of facility documents titled, Daily Staff Screening Form dated between [DATE] to [DATE] indicated licensed nurses, CNAs, kitchen staff, housekeepers, laundry staff, maintenance staff, restorative nurse aids (RNAs), physical therapy and administrative staff were screened for COVID-19 on each day. The documents further indicated recorded staff temperatures and symptom screenings for difficulty breathing, new cough, sore throat, chills and new loss of taste or smell. Review of facility documents titled, Visitor Screening Log dated between [DATE] to [DATE] indicated visitors recorded their names and temperatures and were screened for difficulty breathing, new cough, sore throat, chills and new loss of taste or smell. The facility's Visitor Screening Log did not include all of the current CDC guidelines to monitor staff and visitors for (fever or chills, cough, shortness of breath or difficulty breathing, fatigue muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea). In an interview with the ADM on [DATE] at 3:13 p.m., the ADM confirmed the screening tool did not have all the current signs and symptoms of COVID-19. The ADM further stated the tool would be modified. Review of the facility's Infection Control Plan revised [DATE] indicated, The primary goal is the protection of residents, families/visitors and personnel from acquiring community and nosocomial [health-care associated] disease .the facility performs [sic] ongoing assessment to identify its risks for the acquisition and transmission of infectious agents . Review of the facility's Designation of COVID-19 Unit Policy dated [DATE] indicated, When pandemic is detected in the geographic region of the facility, aggressive infection control measures will be implemented to prevent introduction of the Covid-19 virus to residents, staff and visitors. Isolation of infected residents in the Covid-19 Unit will be implemented .

Based on interview and record review, the facility failed to protect 1 of 2 sampled residents (Resident 2) from sexual abuse when Resident 1 touched her inappropriately in her vaginal area while she was sleeping. This failure caused Resident 2 psychosocial distress (the way situations affect a person's interaction with others). Findings: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool), dated 3/4/16, indicated Resident 1 had no memory problems or disorganized thinking. Resident 1 was independent in all of his self-care needs, including walking. Resident 1 had a care plan, dated 3/25/14, that indicated he was at risk for developing an alteration in mood/behavior as a result of his [DIAGNOSES REDACTED]. The interventions included encourage resident to express feelings, administer medications as ordered, calm resident down when he gets verbally aggressive, speak slowly and clearly, intervene when needed, have social service staff speak with resident if behaviors continue to be offensive, notify physician if behaviors worsen, and provide 1 to 1 attention if needed. Resident 1's care plan was not updated until 3/29/16, three days after the incident with Resident 2. Resident 1 had a physician order, dated 7/14/15, that directed licensed nurses to administer 1 milligram of [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION]) each evening. The targeted behavior for the [MEDICATION NAME] was impulsivity sexual disinhibition and verbal aggression/yelling out. Resident 1's Medication Administration Record [REDACTED]. Resident 1's MAR for August 2015 noted 2 episodes of sexual disinhibition that month. Resident 1's MAR for September 2015 noted 3 episodes of sexual disinhibition that month. Resident 1's MAR for October 2015 noted 6 episodes of sexual disinhibition that month. Resident 1's MAR for November 2015 noted 0 episodes of sexual disinhibition that month. Resident 1's MAR for December 2015 noted 13 episodes of sexual disinhibition that month. Resident 1's MAR for January 2016 noted 33 episodes of sexual disinhibition that month. Resident 1's MAR for February 2016 noted 25 episodes of sexual disinhibition between 2/1/16 and 2/21/16. The monthly total of sexual disinhibition behaviors was 45. A nursing note, dated 2/21/16 and written by Licensed Nurse (LN) 2, indicated a Nurse Supervisor had approached LN 2 to inform the LN that Resident 1 had exposed himself outside the facility. The LN noted he spoke with Resident 1 about the incident and Resident 1 had told him he was sorry and would not do it again. LN 2 noted he would continue to monitor Resident 1's behavior. There were no additional nursing notes to demonstrate facility staff in general were aware of a need to monitor Resident 1 after he exposed himself outside. A Social Service Director (SSD) note, dated 2/22/16, indicated the SSD had spoken to Resident 1 about an inappropriate sexual behavior that occurred outside of the facility. The SSD note indicated Resident 1 stated, He couldn't quite explain why he did what he did, but that 'there's something that just builds up inside of me and before I know it, I'm already unable to control myself.' The SSD indicated Resident 1 was apologetic and agreed to not go outside anymore. Resident 1 would limit his walking to inside the facility. The SSD further indicated he explained to Resident 1 that he could be arrested for indecent exposure if neighbors called the police. The SSD reminded Resident 1 not to make unnecessary stops in front of other resident rooms, so as not to appear intrusive. The SSD indicated he would continue to monitor and outside mental health services would follow up with Resident 1's case. There was no other documentation demonstrating Resident 1's plan of care had been updated as a result of the escalated sexual behaviors and the reported indecent exposure incident of 2/21/16. Resident 1's Annual Activity Note, dated 3/4/16 and written by the Activity Director (AD), indicated, When the weather is nice he sits outside . ambulates and is able to know when his programs take place. An Annual Social Service Review, dated 3/9/16, indicated Resident 1 had a history of [REDACTED]. There was no indication in the note that the SSD had identified an escalating pattern of sexual disinhibition as evidenced by the 25 incidents that occurred in February prior to his exposing himself outside of the building. There was no indication in the SSD note that alternate interventions had been put into place when it was identified that Resident 1's behaviors had escalated when he exposed himself outside the facility and the resident himself reported his behaviors were beyond his own control. Resident 1's care plans were updated on 3/29/16 to include a care plan for Alterations in behavior related to [MEDICAL CONDITION] disorder. The care plan indicated Resident 1's behaviors included standing in front of his open window while stroking his penis and pulling down his pants, exposing his penis, to allow staff to administer insulin injections. The care plan also indicated Resident 1 removed pants and underwear while in his room and would watch to see who was looking at him and made inappropriate comments to staff, such as, I'm the best (offensive description of female anatomy and action) around here . I want you to see me get hard, while wiggling his penis with his hand. The care plan identified Resident 1 would open privacy curtains while masturbating, with sexually inappropriate touching of others without consent. The updated interventions included offer stimulating activities in room if resident refuses to socialize outside of room and notify social services for intervention if escalation of behaviors occur. Resident 2 was admitted to the facility in 2014 and her [DIAGNOSES REDACTED]. Resident 2's MDS, dated [DATE], indicated she had no memory problems or disorganized thinking. Resident 2 had a care plan, dated 3/26/16, that identified Resident 2's potential for psychosocial distress related to being touched on her private parts without her consent. The care plan further identified this issue was compounded by Resident 2's [DIAGNOSES REDACTED]. A Social Service Note, dated 3/28/16, indicated Resident 2 was upset that a male was able to go into her room. On 4/1/16 the facility provided an investigation summary of an incident that occurred between two residents on 3/26/16. The summary indicated Resident 2 had notified staff on 3/26/16 at 9:50 p.m., that a man walked into her room while she was sleeping and woke her up when he touched her vagina. Resident 2 was found frantic and upset. Resident 2 reported she recognized the man who had touched her as being the man who came to her room several times a week to deliver empty soda cans to her roommate. Resident 2 expressed a desire to press legal charges. The summary indicated the staff had confirmed Resident 1 had been the only man seen walking through the facility that night and Resident 1 admitted touching Resident 2's vaginal area. An interview was conducted with Licensed Nurse (LN) 1 on 4/12/16 at 11:20 p.m. He stated he was one of the nurses that monitored Resident 1's sexually inappropriate behaviors. LN 1 stated Resident 1 would walk around naked and masturbate in his room. LN 1 stated this was something Resident 1 did in front of nursing staff, but he was unaware of Resident 1 exhibiting this behavior in front of other people. An interview was conducted with Resident 2 on 4/12/16 at 11:45 p.m. Resident 2 stated she was traumatized by the incident perpetrated by Resident 1, but stated, I don't want to go over it again. She stated she generally stayed in her room, but the prior day she had to leave the facility for a doctor visit and she saw Resident 1 sitting outside as she left the building. She stated it was very distressing to her that he appeared to be free to walk around the facility and she wished she never had to see him again. An interview was conducted with the SSD on 6/27/16 at 12:30 p.m. He reported the facility learned about the 2/21/16 indecent exposure incident when a neighbor reported to a staff member he had seen Resident 1 expose himself at the perimeter of the building property. The neighbor had reported there was a children's party going on at the time and he was concerned about Resident 1's indecent exposure. The SSD reported there were no other witnesses to the event. An interview was conducted with the SSD on 7/12/16 at approximately 11 a.m. The SSD stated there were no additional care plan interventions put into place at the time Resident 1's behaviors escalated in number and severity on 2/21/16. The SSD reviewed the annual note he wrote on 3/9/16. The SSD confirmed the annual review did not demonstrate facility staff had used the behavior monitoring records to identify or address the escalation of behaviors by Resident 1 to prevent the abuse of Resident 2, when Resident 1 had himself stated the behaviors were beyond his control.