Every finding on record at The Pavilion at Ocean Point

Based on interview and record review, the facility failed to report an injury of unknown source for one of three sampled residents (Resident 1) within 24 hours to the California Department of Public Health (CDPH, state survey agency that regulates nursing homes) and law enforcement as was mandated by law.As a result, investigation into the injury was delayed and placed Resident 1 and other residents at risk for further possible abuse. Findings:During a record review, the facility's undated Face Sheet indicated Resident 1 was admitted on [DATE] with diagnoses which included cognitive communication deficit (difficulty in thinking process involving communication), vascular dementia (a decline in thinking skills caused by reduced blood flow to the brain).During a record review, the Minimum Data Set (MDS- a federally mandated assessment tool) dated 4/26/26 indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool which assesses cognitive, or thinking, skills) of 06, which indicated Resident 1 had severe cognitive impairment. The MDS further indicated Resident 1 was dependent on staff on moving from a sitting position to a standing position, and for transfers from chair to bed, or vice versa.During an interview with Certified Nursing Assistant (CNA) 1 on 7/17/26 at 10:46 A.M., CNA 1 stated she had cared for Resident 1 in the past. CNA 1 stated Resident 1 had multiple behaviors related to dementia. CNA 1 stated Resident 1, yells a lot, she puts herself on the edge of the bed and is a fall risk. She stands up unassisted but she's not stable, she's very confused. CNA 1 stated on 6/7/26, a hematoma (a collection of blood outside the blood vessels) was found on the back of Resident 1's head. CNA stated, [The hematoma] looked pretty big, it had color to it. CNA 1 stated she was unsure how Resident 1 sustained the hematoma. CNA 1 stated CNA 2 was Resident 1's assigned CNA on 6/7/26.During a telephone interview with Certified Nursing Assistant (CNA) 2 on 7/21/26 at 12:18 P.M., CNA 2 stated on 6/7/26 while combing Resident 1's hair, Resident 1 made a sound and complained about pain at the back of her head. CNA 2 stated she observed a quarter sized bump on the back of Resident 1's head. CNA 2 stated the bump, was big and really bruised. CNA 2 stated Resident 1 was confused and could not tell her how she sustained the bump. CNA 2 stated, I asked around and nobody could tell me what happened to her. CNA 2 stated Resident 1 was able to propel her wheelchair, and would wander around the facility at times. During an interview with Licensed Nurse (LN) 1 on 7/28/26 at 8:41 A.M., LN 1 stated CNA 1 reported Resident 1's bump on the head to her on 6/7/26. LN 1 stated, Nobody knew what happened. The resident couldn't explain what happened because she's too confused. LN 1 stated she asked multiple staff members if they knew how Resident 1 sustained the bump on her head, but there were no witness to the incident. Per LN 1, Resident 1 had no noted falls.During an interview with the Director of Nursing (DON) on 7/28/26 at 11:16 A.M., the DON acknowledged Resident 1 could not verify what happened, and there were no witnesses to verify how Resident 1 sustained the injury to the right side of her head. The DON acknowledged Resident 1's injury was unwitnessed and unexplained, and stated it should have been reported to CDPH (California Department of Public Health) to rule out any abuse. The DON further stated, [Resident 1] has behaviors and it put her at risk for abuse.During an interview with the Administrator (ADMIN) on 8/11/26 at 11:55 AM, the ADMIN acknowledged Resident 1's bump on the back of her head was considered an injury of unknown origin. The ADMIN stated the injury should have been reported to protect Resident 1 from possible abuse.During a record review, the facility policy titled Abuse- Reporting and Investigations, revised March 2018 indicated, To protect the health, safety, and welfare of Facility residents by ensuring that all reports of resident abuse, mistreatment, neglect, exploitation or injuries of unknown source and suspicion of crimes are promptly reported and thoroughly investigated.

Based on observations, interviews, and record review the facility failed to provide meatal care (cleaning the area where a urinary catheter [a flexible tube inserted into the bladder to drain urine] enters the body [the meatus] daily using mild soap and water to prevent infections) for four (Resident 3, Resident 4, Resident 6, & Resident 12) of five sampled residents with urinary catheters.This failure had the potential for residents with urinary catheters to not to get assessed and/or cleaned appropriately and could lead to nonfunctional catheters and/or urinary tract infections (an infection caused by bacteria entering the kidneys, bladder, ureters, and urethra) and/or sepsis (your body's extreme, life-threatening response to an infection). Findings:On 6/9/26 at 10:20 A.M., an interview with Registered Nurse 1(RN 1-the charge nurse on the unit) was conducted. RN 1 stated that Certified Nursing Assistants (CNAs) were responsible for the care of urinary catheters. RN 1 stated that Licensed Nurses (LNs) .measure urine output, flush the catheter if it is clogged, and perform no daily maintenance. RN 1 was not aware of who was responsible for meatal care of urinary catheter residents.On 6/9/26 at 10:35 A.M., an interview with RN 2, a medication nurse, was conducted. RN 2 stated that her process for residents with urinary catheters was to observe urinary output and to flush catheter if catheter is clogged. RN 2 was not aware of who was responsible for meatal care of urinary catheter residents. RN 2 stated I think the nurse.to prevent infections.Record review of the Face Sheet for Resident 3 indicated that he was admitted on [DATE] for diagnoses which included: Malignant Neoplasm (medical term for cancer) of Prostate (a small gland in the male reproductive system), Benign Prostatic Hyperplasia (medical term for an enlarged prostate gland) with lower urinary symptoms.Record review of Minimum Data Set (MDS- federally mandated clinical assessment tool used in all Medicare- or Medicaid-certified nursing homes) section C-Cognitive(thinking) Patterns, dated 5/2/26, for Resident 3 indicated resident with Brief Interview for Mental Status (BIMs- standardized assessment used by healthcare professionals to quickly screen a patient's cognitive function, particularly their memory, attention, and orientation) of 12 which indicated moderate cognitive impairment.Record review of MDS section GG Functional Abilities, dated 5/2/26, indicated Resident 3 was coded as Partial/Moderate assistance-Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort for Toileting Hygiene. The ability to maintain perineal (anything pertaining to the region of the body located between the pubic bone and the tailbone) hygiene, adjust clothes before and after voiding or having a bowel movement.Review of Resident 3's Physician (MD) Orders dated 6/3/26 indicated Change Foley catheter as needed for leaking, contamination, occlusion, dislodgement. No other catheter care orders were made day of the initial catheter orders.Review of Resident 3's MD Orders, dated 6/9/26, indicated telephone order Foley/SP catheter care to be provided. Cleanse the meatus with soap and water every shift. Monitor for s/sx (signs and symptoms) of infection and report to MD if noted. No prior orders for cleansing and assessing Resident 3's meatus were found despite orders for changing foley catheter on 6/3/26.On 6/9/26 at 11:05 A.M., a concurrent observation and interview with Resident 3 was conducted. Resident 3 was observed in bed resting, urinary catheter bag hanging on bed frame with privacy attachment (a piece of plastic that covers urine bag). Resident 3 was resting on a low air loss mattress (mattress to prevent bed sores) and had fall mats bedside. Resident 3 was alert, oriented, and agreeable to interview. Resident 3 stated he could not remember the last time someone cleaned his meatus or provided him with catheter care as it had not been for a while.Review of Resident 3's Treatment Administration Record (TAR-record of treatments provided by nurses) indicated the order Foley/SP(status post, catheter that resident had) catheter care to be provided. Cleanse the meatus with soap and water every shift. Monitor for s/sx (signs and symptoms) of infection and report to MD if noted was initiated on the evening of 6/9/26 after the investigation was started at the facility.Record review of Face Sheet for Resident 4 indicated he was admitted on [DATE] for diagnoses which included: Urinary Tract Infections, Chronic Obstructive Pulmonary Disease (progressive, long-term lung diseases that cause obstructed airflow and make it difficult to breathe).Record review of MDS section C-Cognitive Patterns, dated 5/2/26, for Resident 4 indicated resident with BIMS of 7 which indicated severe cognitive impairment.Record review of MDS section GG Functional Abilities, dated 5/2/26, indicated Resident 4 was coded as Dependent-Helper does ALL the effort. Resident does none of the effort to complete the activity. for Toileting Hygiene. The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement.Record review for MD orders for Resident 4 from 4/21/26 indicated Indwelling S/P Catheter size 18Fr with balloon 5 ml via gravity drainage for Obstructive Uropathy. No orders for cleansing meatus or catheter care were ordered with initial orders.Record review of MD orders from 6/9/26 for Resident 4, indicated Foley/SP catheter care to be provided. Cleanse the meatus with soap and water every shift. Monitor for s/sx (signs and symptoms) of infection and report to MD if noted. Order was placed day of the investigation.On 6/9/26 at 11:10 A.M., a concurrent observation and interview with Resident 4 was conducted. Resident 4 was observed in bed resting, urinary catheter bag hanging on bed frame with privacy attachment. Resident 4 was alert and agreeable to interview. Resident 4 stated he did not remember the last time someone cleaned his meatus or did catheter care on him.Record review of the TAR for Resident 4 indicated: Foley/SP catheter care to be provided. Cleanse the meatus with soap and water every shift. Monitor for s/sx (signs and symptoms) of infection and report to MD if noted was started on the evening of 6/9/26 after the investigation was started at the facility.On 6/9/26 at 11:15 A.M., an interview with RN 4 was conducted. RN 4 stated that the LN's responsibility was to check the urinary catheter every shift, and the CNA cleans and reports any problems with the catheter to the nurse. RN 4 stated the nurse can flush the catheter if clogged. RN 4 stated I will use an alcohol pad to clean the connection. RN 4 was unable to say whose responsibility it was to clean and assess resident's meatus.Record review of Face Sheet for Resident 6 indicated he was admitted on [DATE] for diagnoses which included: Urinary Tract Infections.Record review of MDS section C-Cognitive Patterns, dated 5/5/26, for Resident 6 indicated resident with BIMs of 10 which indicated moderate cognitive impairment.Record review of MDS section GG Functional Abilities, dated 5/5/26, indicated Resident 6 was coded as Dependent-Helper does ALL the effort. Resident does none of the effort to complete the activity. for Toileting Hygiene. The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement.Review of MD orders for Resident 6, dated 4/30/26 indicated FOLEY CATHETER TO BE CHANGED EVERY 2 WEEKS as needed for CLOGGED, DISLODGED. No other catheter care orders were found with initial catheter orders.Review of MD orders for Resident 6 dated 6/9/26 indicated Foley catheter care to be provided every shift written on day of the investigation.On 6/9/26 at 11:30 A.M., a concurrent observation and interview with Resident 6 was conducted. Resident 6 was observed in bed resting, urinary catheter bag hanging on bed frame with privacy attachment. Resident 6 was on low air loss mattress and had fall mats bedside. Resident 6 was alert and oriented and agreeable to interview. Resident 6 stated that the nurses don't clean his urethral meatus every shift. Resident 6 stated Sometimes the nurses come to clean it, but not every shift.Review of Resident 6's TAR indicated Foley catheter care is to be provided every shift was started on the evening shift on the day of the investigation 6/9/26.On 6/9/26 at 11:45 an interview with CNA 2 was conducted. CNA 2 stated the CNAs clean the tubing but was not sure whose responsibility it was to clean the resident's urinary meatus.On 6/9/26 at 11:55 A.M. a concurrent interview with LN 2 and record review of Resident 6's TAR was conducted. LN 2 stated the nurse's responsibility for catheter care was to change the catheter as needed and assess and clean the Resident's meatus every shift. LN 2 stated the importance of assessing and cleaning the resident's meatus every shift was to make sure catheter is working and to prevent infections. Record review of Resident 6's TAR at the time of interview indicated that there was nowhere to document the cleansing and assessing of resident's catheter every shift as claimed. LN 2 stated that if the care was not documented then it was not done.On 6/9/26 at 12:15 P.M., an interview with CNA 3 was conducted. CNA 3 stated she thought that the CNAs clean the tubing and urinary meatus but unsure if the nurse should be assessing the meatus. `Record review of Resident 12's Face Sheet indicated that he was admitted on [DATE] for diagnoses which included: acute respiratory failure( a critical, life-threatening condition that happens when your respiratory system suddenly cannot get enough oxygen into your blood or remove enough carbon dioxide from your body) and edema (swelling caused by excess fluid trapped in your body's tissues).Review of Resident 12's MD orders from 6/26//25 indicated Change urinary catheter bag per schedule when foley is changed and as needed. No other orders for catheter care were placed with original catheter orders.Review of Resident 12's MD orders from 6/15/26 indicated S/P catheter care to be provided. Cleanse the insertion site with mild soap and water, pat dry. Every shift monitor for s/sx fo infection and report to MD if noted. Orders were placed six days after initial investigation and almost a year after initial catheter orders.On 6/9/26 at 12:50 P.M. a concurrent interview with LN 3 and record review of Resident 12's treatment administration record (TAR) was conducted with LN 3. LN 3 stated the nurse's responsibility for catheter care was to change the catheter as needed and assess and clean the resident's meatus every shift. LN 3 stated the importance of assessing and cleaning the resident's meatus every shift was to make sure catheter is working and to prevent infections. Record review of Resident 12's TAR indicated that there was nowhere to document cleansing and assessing of resident's catheter in the TAR. LN 3 stated that if the care was not documented then it was not done.Review of Resident 12's TAR indicated that S/P catheter care to be provided. Cleanse the insertion site with mild soap and water, pat dry. Every shift monitor for s/sx fo infection and report to MD if noted.Start date 6/15/26 1500(3 P.M.) Treatment was charted six days after start of investigation and almost a year after initial catheter orders.On 6/9/26 at 1 P.M. an interview with the ADON was conducted. The ADON stated the expectations for catheter care was for the medication nurse to assess and clean resident's catheter and meatus with soap and water every shift to prevent infection. The ADON stated that if catheter care and assesments were not charted, they are not considered done.On 6/23/26 at 10 A.M., a concurrent interview with the Director of Nursing (DON) and record review of competencies of the nurses interviewed during the investigation was conducted. Review of facility document Indwelling Catheter Care Competency Validation' for nurses: RN 1, RN 2, RN 3, RN 4, LN 2, and LN 3 indicated that all competencies were signed off as Met with Return Demonstration (An instructor or doctor first shows a patient or student how to do a health skill. Then, the learner repeats the skill back). The DON stated that .Nurses who passed the competency should be able to describe the process of catheter care that they were taught, to show that they are actually competent with catheter care. The DON stated she felt that the nurses needed to have their competencies rechecked to make sure they were competent with urinary catheters. The DON stated the expectation for urinary catheter care was that nurses should monitor, assess, and clean the resident's meatus with soap and water every shift to prevent UTI and sepsis. The DON stated the TAR should reflect treatments being done, and if it was not charted it was not done.On 6/23/26 at 10:15 A.M., a concurrent interview with the DON and record review of facility policy titled BB03 Indwelling Catheter dated 2025 was conducted. Policy indicated that .2. Only properly trained licensed and care staff who know the correct aseptic catheter insertion and maintenance will be responsible for the insertion and care of indwelling catheters. The DON stated that the facility policy for catheters did not address how the catheter care should be done, and should be more specific and detailed, so all nurses could follow the same policy and procedure and would know exactly what to do to prevent unnecessary urinary tract infections and related urinary problems.

Based on observation, interview and record review, the facility failed to monitor intake, initiate weekly weights and implement timely interventions to address significant weight loss for 1 of 3 residents (116) reviewed for nutritional status.This failure resulted in a significant decline in Resident 116's weight from 141.8 pounds (lbs.) in December 2025 to 112.6 lbs. by February 2026.Findings:Resident 116 was admitted to the facility on [DATE] with a diagnosis of dysphagia (difficulty swallowing) and major depression per the facility admission record.Facility weight records indicated Resident 116 weighed 153.8 pounds (lbs.) on 7/27/25.The nutritional risk assessment (NRA), dated 7/31/25, indicated a goal weight range (GWR) of 145 to 165 lbs. and recommended a regular diet with mechanical soft texture and standard portions.Facility weight records indicated Resident 116 weighed 156.4 lbs. on 9/1/25 and 148.8lbs on 10/6/25.The NRA, dated 10/9/25, indicated registered dietitian (RD) 1 reviewed Resident 116's recent weight measurements and identified a 7.6 lb. weight loss over approximately one month, calculated as 4.9% of the resident's body weight. The RD noted the weight loss was just below the 5 percent threshold for significant weight loss and was potentially related to inadequate energy intake. The RD recommended increasing the meal portion size to large to prevent further fluctuation. The NRA did not recommend initiating weekly weights.Physician's orders, active as of 12/1/25, indicated Resident 116's order had been updated to minced and moist, but the portion size remained a regular standard portion.Facility weight records indicated Resident 116 weighed 141.8 lbs. on 12/1/25.The change of condition (COC) report, dated 12/5/25, indicated licensed nurse (LN) 3 documented Resident 116 experienced significant weight loss of 14.6 lbs. over the previous three months.A record review indicated the facility did not complete a NRA for Resident 116 in November 2025 or December 2025.Resident 116's Nutrition - Amount Eaten flow sheet for December 2025 indicated staff did not document intake for 16 meals and documented less than 50% intake for 38 meals.Physician's orders, active as of 1/1/26, indicated Resident 116 continued to have an active diet order of minced and moist with standard portion size.Facility weight records indicated Resident 116 weighed 127.2 lbs. on 1/6/26.The NRA, dated 1/13/26, indicated RD 1 reviewed Resident 116's weight history and documented continued weight decline as follows:1. One month weight loss: 127.2 lbs. on 1/6/26 compared to 141.8 lbs. on 12/1/25 (-10.3% weight loss).2. Three-month weight loss: 127.2 lbs. on 1/6/26 compared to 148.8 lbs. on 10/13/25 (14.5% weight loss).3. Six-month weight loss: 127.2 lbs. on 1/6/26 compared to 153.8 lbs. on 7/27/25 (17.3% weight loss).RD 1 documented the continued weight loss was likely due to inadequate intake related to decreased ability to consume sufficient energy. The RD noted Resident 116 was no longer attending meals in the dining room and there was a noticeable decrease in intake. The RD documented Resident 116 would benefit from assistance and encouragement with meals. The RD recommended one magic cup daily at lunch and a fortified diet. The NRA did not recommend starting weekly weights.Resident 116's Nutrition - Amount Eaten flow sheet for January 2026 indicated staff did not document intake for nine meals, 50 meals were documented with less than 50 percent of the meal consumed, and two meals were documented as refused.Physician's orders, active as of 2/1/26, indicated there were no orders for weekly weights.Facility weight records indicated Resident 116 weighed 119.4 lbs. on 2/2/26.The NRA, dated 2/5/26, indicated the RD 1 reviewed Resident 116's last weight of 119.4 lbs. on 2/2/26 and recommended weekly weights be implemented.Facility weight records indicated the next documented weight of 112.6 lbs. was obtained on 2/19/26.Interdisciplinary team (IDT) meeting notes indicated, the first documented IDT team meeting notes addressing Resident 116's weight loss occurred on 2/6/26.The care plan addressing Resident 116's nutritional status, initiated on 8/1/25, indicated the resident had a nutritional problem or potential nutritional problem related to multiple medical conditions including dysphagia and major depressive disorder (MDD). The care plan established goals for the resident to maintain oral intake at 75% of most meals and maintain weight within the goal weight range without unintended weight change.The care plan directed staff to weigh Resident 116 at the same time of day monthly and as needed (PRN). The intervention for monthly weight monitoring was initiated on 10/20/25 and last revised on 10/23/25.The care plan directed staff to provide and serve the diet as ordered. This intervention was initiated on 10/20/25 and was not revised to reflect the fortified diet order until 2/24/26.The care plan did not include an intervention directing staff to monitor or document Resident 116's oral intake or provide staff assistance or supervision during meals.During an interview and record review on 2/24/26 at 11:17 A.M., Certified Nursing Assistant (CNA) 1 stated she was assigned to care for Resident 116. CNA 1 stated the facility did not have dedicatedfeeding assistants and that CNAs or restorative nursing assistants (RNAs) supervised and assisted residents with meals as needed. Review of the daily assignment sheet with CNA 1 indicated Resident 116 was not listed as requiring feeding assistance. CNA 1 stated Resident 116 did not eat much of her breakfast that day.Resident 116's Nutrition - Amount Eaten flow sheet entry for 8 A.M. on 2/24/26 indicated CNA 1 documented Resident 116 ate 0-25% of the breakfast meal.During an observation on 2/24/26 at 1:03 P.M., Resident 116 was lying in bed with a lunch tray placed in front of her. The meal on her plate appeared partially eaten with only a few bites consumed. No staff were observed in the room assisting Resident 116 with the meal at the time of the observation.Resident 116's Nutrition - Amount Eaten flow sheet entry for 12 PM on 2/24/26 indicated CNA 1 documented Resident 116 ate 0-25% of the lunch meal.The Nutrition - Amount Eaten flow sheet indicated staff did not document meal intake entries for 8 A.M. and 12 P.M. on 2/25/26.During an interview on 02/26/2026 at 12:05 PM Resident 116 stated she had eaten a little of her breakfast meal that morning but did not provide additional information regarding her food intake.During an interview on 2/26/26 at 12:12 PM, CNA 2 stated Resident 116 did not eat much and had just been placed on the feeding assistant list that day. CNA 2 stated staff were required to document the percentage of food consumed for every meal in the electronic health record. CNA 2 stated Resident 116 had eaten about 25% of her breakfast. During an interview on 2/26/26 at 4:30 P.M., licensed nurse (LN) 1 stated she was serving as the charge nurse and familiar with Resident 116's care. LN 1 stated Resident 116 did not have problems eating and was not on the list of residents requiring supervised or assisted eating.During an observation and interview on 2/27/26 at 9:39 A.M., CNA 3 stated CNAs are required to chart amount of each meal eaten in the EHR. CNA 3 demonstrated how to enter meal percentage eaten into the EHR. CNA 3 stated if a resident continues to have below 50% meal intake the nurse should be notified.During an interview on 2/27/26 at 9:48 A.M., LN 2 stated CNAs are required to chart the percentage of each meal eaten in nutritional task in the EHR and notify the nurse of any refused meals. LN 2 stated it is important CNA's chart every meal to make sure the facility stays on top of residents at risk for weight loss. LN 2 stated if a Resident ate less than 25% of any meal the nurse should be notified to ensure weight is monitored.During an interview and record review on 2/27/26 at 9:58 A.M., Registered Dietician (RD) 2 stated residents with weight variances should be discussed in weekly interdisciplinary team (IDT) weight meetings and that Certified Nursing Assistants (CNAs) were expected to document the percentage of food consumed for each meal in the EHR flowsheet for nutrition intake. RD 2 stated oral intake documentation and resident weights were objective measures used to evaluate nutritional status and determine the need for dietary interventions. RD 2 stated significant weight loss was defined as 5% loss in one month, 7.5% loss in three months, and 10 percent loss in six months. RD 2 stated if significant weight loss was identified it should trigger weekly weight monitoring and an IDT review.During a review of Resident 116's NRAs, intake documentation, and weight records, RD 2 stated nursing documented a change of condition for significant weight loss on 12/5/25 but a nutritional assessment was not completed until a month later on 1/6/26. RD2 acknowledged meal intake documentation contained multiple entries of less than 50% intake and had multiple missing entries. RD 2 acknowledged an NRA should have been completed following the identification of a significant weight loss.RD 2 stated weekly weight monitoring should have been initiated when the significant weight loss was first identified, and acknowledged weekly weights were not recommended until the NRA on 2/5/26 and were not obtained until two weeks later on 2/19/26.RD 2 stated when staff did not document meal intake the facility could not determine whether nutritional interventions were effective. RD 2 stated weekly weight monitoring and meal intake documentation were important data to identify continued weight loss and implement timely interventions.During an interview and record review on 2/27/26 at 2:06 P.M., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) stated residents were weighed monthly and that weight variances of 5% or 5 lbs loss in one month, 7.5% loss in three months, 10% loss in six months, or a 2% loss in one week required nursing to complete a COC report and notify the RD.The DON and ADON stated CNAs were required to document the percentage of food consumed for each meal in the EHR flow sheets and report meals with intake below 50% to the nurse. The DON and ADON stated nursing should review intake documentation and follow up when intake was low or documentation was missing. The DON and ADON further stated significant weight loss should trigger weekly weight monitoring, weekly IDT weight meetings, and care plans should be updated based on interventions discussed during IDT review.During the record review of Resident 116's chart, the DON stated the significant weight loss documented in the nurses COC on 12/5/26 should have triggered weekly weight monitoring. The DON further stated the continued significant weight loss identified on 1/6/26 in the NRA should also have triggered weekly weights, an IDT review, and updated care plan interventions reflecting IDT recommendations.A review of the facility policy, titled, Evaluation of Weight and Nutritional Status, revised 1/30/25, indicated, .Policy: 1. The facility will maintain an acceptable nutritional status for residents per professional standards by:. b. Analyzing the assessment information to identify the medical conditions, causes and/or problems. c. Implementing interventions for maintaining or improving nutritional status. e. Monitoring and evaluating the resident's response, or lack of response to interventions. Clinical Evaluation:. b. Any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days, 10% in 180 days. will be evaluated by the IDT to determine the cause of the weight loss/gain and the interventions required. Once weight gain or loss as describe above is identified, the IDT will: 1. Identify and implement appropriate interventions; 2. Update and revise the Care Plan. d. Any resident meeting the criteria for physician prescribed weight loss and any resident at risk for weight loss or gain will be weighed and documented weekly. Weekly weights will be reviewed by the IDT. Resident's at risk who should be weighed weekly include. 2. Significant weight loss or gain identified in a 30, 90, 180-day period. Monthly evaluation will continue for all residents.

Based on interview and record review, the facility failed to ensure that sufficient staff were available to provide care and services to the residents in a timely manner. As a result, there was a delay in the staff's ability to provide care and services to the resident.Findings:Per the PBJ Staffing Data Report CASPER Report 1705D FY Quarter 4 2025 (July 1 -September 30), the report indicated the facility had a one star staffing rating and excessively low weekend staffing.During an interview on 2/25/2026 at 10:00 A.M. with Resident 13, Resident 13 stated there are times when I wait a long time for help, but I can do most things on my own. So that's good. Others can't, I feel bad for them when they have to wait. I get frustrated when I have to wait .During an interview on 2/25/2026 at 10:10 A.M. with Resident 11, Resident 11 stated that he has had to wait for help and he feels bad.I wish I didn't have to rely on the nurses, but I do. I think nights and weekends are when I wait the longest.During an interview on 2/26/2026 at 2:24 P.M. with Certified Nursing Assistant 31(CNA31), CNA31 stated we need more care staff, we are often short of CNAs and that impacts resident care, they may not get the help they need or have to wait a long time.During an interview on 2/26/2026 at 2:32 P.M. with Licensed Nurse 31 (LN31), LN31 stated We need more staff .well, nurses for all shifts and all days, not just the weekends. Resident care is definitely impacted, mainly by delays in care.During an interview on 3/2/2026 at 9:00 A.M. with Housekeeper 1 (HSK1), HSK1 stated .This weekend was bad, but the CNAs work hard. But I think they need more. Especially on the weekends .During an interview on 3/2/2026 at 9:55 A.M. with Housekeeper 2 (HSK2), HSK2 stated .I do work on Saturdays. They can definitely use more staff. On the weekends, I do not know about the night shift.During an interview on 3/2/2026 at 11:30 A.M. with the Director of Nursing (DON), the DON stated I am aware of the staffing issues. The facility had been using registry a lot. The data comes from PBJ, we are working on improving it.

Based on interview and record review the facility's Quality Assessment and Assurance Committee (QAA-facility group that monitors concerning trends in a facility) failed to identify areas of improvement and include in the facility's Quality Assurance Performance Improvement plan (QAPI-plan developed by QAA to help improve conditions in the facility), the facility's staffing needs identified during the facility's recertification survey and in the Payroll-Based Journal (PBJ- a mandatory , electronic reporting system which tracked hours worked, staff turnover, tenure and census data for long-term care facilities).Cross reference F725 This failure had the potential to affect resident care.Findings: During a review of the facility's PBJ Staffing Data Report, Quarter four 2025 (July 1- September 30), the PBJ indicated, Excessively Low Weekend Staffing. A QAPI meeting on 3/2/26 at 12:09 P.M. was conducted with the facility's Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and a charge nurse. The DON stated the areas of concern identified by the QAA committee included call light response, falls, skin/wounds, infection control, weight loss/nutrition, hygiene care, change in condition and care conference scheduling. The DON stated staffing has not been addressed by QAA committee. The Administrator stated it was important to address areas of concern in the QAPI meeting because those areas affect resident safety and well-being. A review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance Improvement [QAPI] Program, revised on 3/28/24 was conducted. The P&P indicated, The facility implements and maintains an ongoing, facility-wide Quality Assurance and Performance Improvement [QAPI] Program designed to monitor and evaluate the quality of resident care, pursue methods to improve quality of care, and resolve identified issues.

Based on observation, interview and record review, the facility failed to use professional nursing standards using when licensed nurse (LN) 23 did not administer Resident 10's medication via gastronomy tube (G-tube - a soft, flexible tube placed directly into the stomach through a small opening in the belly) by gravity (a technique where liquid medication is allowed to flow solely by the force of gravity and not by a syringe plunger or a pump).This failure had the potential to increase the risk of tube clogging, dislodgement, and medication reflux for Resident 10. Per the admission record, Resident 10's was admitted to the facility on [DATE] with diagnoses that included gastrostomy status (means a person has a G-tube placed directly into their stomach through the skin of the belly, creating a permanent or temporary opening for feeding, fluids, and medicine). On 2/26/26 at 8:30 A.M., an observation and interview were conducted with LN 23 during a medication administration observation. LN 23 administered the following medications to Resident 10 via G-tube: -Aspirin 162mg [medication for stroke prophylaxis (steps to prevent a stroke before it happens)-Bupropion HCL 50mg (medication to treat depression)LN 23 was observed to administer the medications by flushing with a syringe plunger. On 2/27/26 at 9:00 A.M., an interview was conducted with LN 23. LN 23 stated he did use gravity when administering medications to Resident 10 because the G-tube has issues when administering via gravity. LN 23 stated there was not a doctor's order but there should have been for flushing medications with a syringe. On 3/2/26 at 9:00 A.M., an interview was conducted with the director of nursing (DON). The DON stated it was her expectation that nurses are to follow professional nursing standards and doctor's orders when administering medications. A review of the facility policy titled Feeding Tube - Administration of Medication, dated 6/12/24, indicated that nursing staff are to .administer medications by syringe via gravity into the feeding tube.A review of the facility policy titled Medication - Administration, dated 8/19/25, indicated that All medications shall be administered by licensed nursing staff according to physician orders, current best practices and federal and state regulations.

Based on observation, interview and record review, the facility failed to assess, care plan, and implement interventions to address severe hair matting and hygiene refusals for 1 of 2 sampled residents (116).This failure resulted in Resident 116 having severely matted hair with scalp irritation and had the potential to result in further skin breakdown and infection. Resident 116 was admitted to the facility on [DATE] with a diagnosis of anxiety and major depression per the facility admission record.During an observation and interview on 2/24/26 at 10:12 A.M., Resident 116 was observed sitting up in bed. The resident's gray hair was tightly matted across the top and back of the scalp. Yellow crusted material and flaking were present on the right forehead at the hairline. Skin discoloration and red splotching were present on the right and left cheeks.During the interview, Resident 116 stated, What do you mean? when the condition of the resident's hair was discussed. The resident then stated, Is there something wrong with my hair? Resident 116 patted the top of her head, removed a large [NAME] pin and adjusted the matted hair before replacing the pin. After adjusting the hair, Resident 116 stated, Does it look OK? Review of the nursing clinical admission assessment, dated 7/24/25 indicated Resident 116 underwent a :comprehensive nursing assessment upon admission. The assessment did not document matted hair, scalp irritation, or other concerns related to the residents' hair or scalp condition. Review of the history and physical (H&P) examination, dated 7/25/25, indicated Resident 116 was admitted to the facility from the hospital for rehabilitation following a urinary tract infection due to suspected elder neglect. The physical examination did not document matted hair, scalp irritation, or concerns related to hair hygiene. Review of the initial psychiatric evaluation, dated 7/31/25, indicated the resident appeared well-groomed with mild distress related to anxiety and low mood. The evaluation did not document matted hair or scalp irritation.During an interview on 2/26/26 at 12:12 P.M., certified nursing assistant (CNA) 2 stated Resident 116 had matted hair. CNA 2 stated Resident 116 did not allow staff to brush her hair. CNA 2 stated staff attempted to address the resident's hair during showers. CNA 2 stated attempts to brush the resident's hair were not documented.During an interview on 2/26/26 at 12:24 P.M., certified nursing assistant (CNA) 3 stated Resident 116 frequently refused showers and did not like to get her hair wet. CNA 3 stated the resident often declined hair care. CNA 3 stated the facility did not have specific interventions in place to address the resident's hair matting. CNA 3 stated refusals of showers and hair care were documented on the shower sheets. Record review of shower sheets and electronic flow charts for bathing from December 2025 through January 2026 was conducted. Resident 116 was scheduled to receive showers twice weekly on Tuesdays and Fridays. The December 2025 shower and bathing records indicated Resident 116 was scheduled to receive nine showers during the month. Shower sheets and electronic flowsheets for bathing indicated Resident 116 refused showers six times (12/2, 12/5, 12/9, 12/12, 12/16, 12/23). Neither the shower sheets nor the electronic flowsheets indicated refusals of hair care or attempts to address the resident's matted hair. The January 2026 shower and bathing records indicated Resident 116 was available at the facility for eight scheduled showers during the month. Shower sheets and electronic flowsheets for bathing indicated Resident 116 refused showers five times (1/2, 1/9, 1/13, 1/23, 1/27). Neither the shower sheets nor the electronic flowsheets indicated refusals of hair care or attempts to address the resident's matted hair.During an interview and record review on 2/26/26 at 4:30 P.M., Licensed Nurse (LN) 1 stated Resident 116 had matted hair since she was admitted to the facility the previous year on 7/24/25. LN 1 stated the resident would not allow staff to brush her hair. Review of Resident 116's progress notes with LN 1 indicated the only documentation referencing the resident's hair or scalp condition was in a skin check note, dated 2/19/26, that indicated the resident's hair was extremely matted with dry flaked areas to top of head. LN 1 acknowledged no other documentation of matted hair was in Resident 116's health record. LN 1 stated if Resident 116 refused a shower and hair care, the refusal should be documented and the clinical team should be informed.Review of Resident 116's care plans with LN 1 indicated the only care plan addressing hair care was initiated on 2/26/26. LN 1 acknowledged Resident 116 did not have a care plan in place prior to that day. LN 1 stated Resident 116's hair matting had been an ongoing issue since admission on [DATE] and a care plan should have been implemented prior to 2/26/26.Review of physician orders, active 2/1/26, did not identify orders related to hair care or treatment of the resident's scalp condition. Review of the care plan, initiated on 8/1/25, indicated Resident 116 had a problem of activities of daily living (ADL) self-care performance deficit related to multiple diagnoses including, major depressive disorder (MDD) and anxiety. The care plan did not include interventions related to hair care or management of hygiene refusals.During an interview on 2/27/26 at 2:16 P.M., with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON and ADON stated Resident 116 did not want staff to touch her hair and was sensitive about how her hair was styled. The DON and ADON stated Resident 116's matted hair had been a long-standing issue known to the facility. The DON and ADON acknowledged the facility did not have a care plan in place prior to 2/26/26 to address the resident's matted hair. The DON and ADON stated when the facility identifies a problem with resident care needs the issue should be care planned and appropriate interventions implemented and monitored.The facility did not provide a policy regarding monitoring activities of daily living upon request.

Based on interview and record review, the facility failed to provide necessary care and services in accordance with professional standards of practice when: 1. Insulin injection sites were not rotated for two of six residents (Resident 7 and Resident 16), 2. The facility failed to reassess the vital signs of one of eight sampled residents (Resident 126). This deficient practice had the potential for residents to develop complications such as hardened, scarred skin and unpredictable insulin absorption. In addition, this failure had the potential for Resident 126's condition to decline without proper interventions. Findings: 1a. Resident 16 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with hyperglycemia (high blood sugar levels) according to the facility's admission Record. During an observation and interview on [DATE] at 8:05 A.M., Resident 16 was sitting up in a wheelchair in his room. Resident 16 stated the facility staff administered insulin (medication that helps regulate blood sugar levels) for him. An interview and joint record review on [DATE] at 10:26 A.M. was conducted with Licensed Nurse (LN) 11. LN 11 reviewed the February 2026 Medication Administration Record (MAR) in Resident 16's electronic health record (EHR). LN 11 stated Resident 16 had been receiving insulin glargine (a long-acting insulin). LN 11 stated the injection sites on Resident 16 were not rotated. The MAR indicated insulin gargline was administered to Resident 16 on the following sites: [DATE] at 12 P.M.- right arm [DATE] at 12 P.M.- right arm [DATE] at 11:54 A.M.- abdomen-left upper quadrant [DATE] at 12:59 P.M.- abdomen-left upper quadrant [DATE] at 12 P.M.- left arm [DATE] at 12:43 P.M.- left arm [DATE] at 12:42 P.M.- abdomen-left lower quadrant [DATE] at 2:20 P.M.- abdomen-left lower quadrant [DATE] at12:29 P.M.- left arm [DATE] at 12:14 P.M.- left arm [DATE] at 11:58 A.M.- left arm 1b. Resident 7 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar) and muscle weakness according to the facility's admission Record. During an observation and interview on [DATE] at 10:19 A.M., Resident 7 stated she was on insulin and the nurses administered the injection for her. During a review on [DATE] at 2:52 P.M. of physician's orders (PO) in the electronic health record (EHR) for Resident 7, the PO indicated, Insulin Lispro [a fast acting insulin] Inject as per sliding scale [method of insulin administration where the dose is base on the pre-meal blood sugar result] and Insulin Glargine.inject 10 unit subcutaneously [fatty tissue, just under the skin] at bedtime for diabetes rotate sites. An interview and joint record review on [DATE] at 10:37 A.M. was conducted with Licensed Nurse (LN) 11. LN 11 reviewed the February 2026 Medication Administration Record (MAR) in Resident 7's EHR. LN 11 stated Resident 7 had been receiving insulins. The MAR indicated insulin gargline was administered to Resident 7 on the following sites: [DATE] at 9:04 P.M. - right arm [DATE] at 9:25 P.M. - right arm [DATE] at 9:50 P.M. - Abdomen-RUQ (right upper quadrant) [DATE] at 10:03 P.M. -Abdomen-RUQ [DATE] at 8:45 P.M. - left arm [DATE] at 9:25 P.M. - left arm [DATE] at 9:38 P.M. - rear upper arm [DATE] at 9:29 P.M. - rear upper arm The MAR indicated insulin lispro was administered to Resident 7 on: [DATE] at 6:35 A.M. – right arm [DATE] at 8:08 A.M. – right arm [DATE] at 12:57 P.M. – right arm [DATE] at 5:26 P.M. – right arm LN 11 stated insulin injection sites should be rotated to prevent bruising or hardening of the skin. An interview on [DATE] at 10:15 A.M. was conducted with the facility's consultant pharmacist (CP). The CP stated he reviewed residents' MARs monthly to check if medications were administered but did not check the rotation injection sites for insulin. The CP stated it was standard of practice to rotate sites because redness and skin discoloration can occur if sites were not rotated. An interview on [DATE] at 2:59 P.M was conducted with the Director of Nurses (DON). The DON stated insulin injection sites should be rotated to prevent side effects, tissue damage and allow sites a chance to heal. A review of the facility's policy and procedure (P&P) titled, Medication Administration, with revision date of [DATE] was reviewed. The P&P indicated, All medications shall be administered by licensed nursing staff according to physician orders, current best practices, and federal and stated regulations. During a review of the facility's P&P titled, Diabetic Care, revised on [DATE], the P&P indicated, The Facility will provide the necessary care and services to permit each diabetic resident to attain or maintain optimal well-being while monitoring their care in accordance with their individualized Comprehensive Assessment and Care Plan. The P&P did not address guidance regarding rotation of insulin administration sites. 2.Per the facility's admission record, Resident 126 was admitted on [DATE] with a diagnosis of metabolic encephalopathy (a brain dysfunction caused by an illness, such as diabetes, liver failure, or kidney disease, rather than structural brain damage). Resident 126 died at the facility on [DATE]. During an interview on [DATE] at 2:24 P.M. with Certified Nursing Assistant 31(CNA31), CNA31 stated I take the resident vitals. There is a normal range and if something was out of that range, we would tell the med nurse and the charge nurse. CNA31 further stated .for temperature below 97 or above 101 we will tell the nurses. If we did not tell the nurses something bad could happen to the resident. During an interview on [DATE] at 2:32 P.M. with Licensed Nurse 31 (LN31), LN31 stated The CNAs take the resident vitals. There are normal ranges for each one. If they have a reading out of range, the expectation is that they would retake the vital and if still out of range they would tell me and the medication nurse. LN31 continued If an out of range vital was recorded and not addressed, the resident could be really sick and we would not know. During a concurrent interview and record review on [DATE] at 11:35 A.M. with the Director of Nursing (DON), Resident 126's recorded vital signs were reviewed. The record indicated that on [DATE] at 5:22 p.m. Resident 126's temperature was 72 degrees Fahrenheit and that this temperature was taken orally. The record further indicates that on [DATE] at 12:13 a.m. resident 126's temperature was again 72 degrees Fahrenheit and that this temperature was a tympanic (through the ear) temperature. The DON stated If a vital sign is out of normal range, the measurement should be repeated, if it remains out of range then it needs to be reported and a change of condition initiated. The DON continued .for this case, I would expect this to have been re-evaluated at the early reading. The expectations are not being met here. During a review of the facility's policy and procedure titled Obtaining Vital Signs date [DATE], the policy indicated that vital signs are .clinical measurements that indicate the state of a resident's basic body functions. and .Vital signs will be taken . F. When there is a change in the resident's condition.

Based on observation, interview, and record review, the facility failed to assess, document, and implement interventions to address contractures affecting the left index and left little fingers for 1 of 2 residents (17) reviewed for mobility limitations.This failure had the potential to result in worsening contractures decreased functional use of Resident 17's left hand.Resident 17 was admitted to the facility on [DATE] with a diagnosis Parkinson's disease (progressive movement disorder of nervous system that causes stiffness and tremors) per the facility admission record.During an observation and interview on 2/24/26 at 11:27 A.M., Resident 17 was observed seated in a wheelchair, propelling down the hallway with his feet. The resident's right hand appeared severely contracted at the wrist. The resident's left index finger and left little finger appeared contracted and positioned in flexion (condition of being bent). The resident was unable to provide additional information regarding the condition of his hands upon questioning. Review of history and physical (H&P) note, dated 2/5/19, indicated Resident 17 had bilateral hand contractions. Review of nurse practitioner progress note dated 11/12/20, reconfirmed Resident 17 had bilateral hand contractures. Review of physician progress note, dated 10/25/21, indicated Resident 17 had a contracture of the right hand and a small contracture of the left fingers. During an observation and interview on 2/26/26 at 10:29 A.M., certified nursing assistant (CNA) 4 stated Resident 17 was supposed to have a hand splint for his right-hand contracture but was not aware of anything for the residents left hand. CNA 4 stated restorative nursing assistants (RNA) were responsible for putting the splint on the resident's right hand.During an interview on 2/26/26 at 10:43 A.M., restorative nursing assistants (RNA) 1 and 2, stated Resident 17 wore a splint on his right arm daily and performed sit-to-stand style exercises for balance five days a week. RNA 1 and 2, stated the resident had no ordered RNA interventions for the left hand. Review of the physician orders, active 3/1/26, indicated Resident 17 had orders for passive range of motion (ROM) exercises for the RUE with splint and sit to stand exercises for balance. There were no active orders for ROM exercises to the left hand or fingers. During an interview on 2/26/26 at 10:52 A.M., Occupational Therapist (OT) 1 stated Resident 17 had functional limitations and wore a splint on the right hand while continuing active range of motion exercises. OT 1 stated she was not aware of contractures affecting the left-hand fingers.During a subsequent observation and interview on 2/26/26 at 11:02 A.M., with OT 1, Resident 17's left index finger and left little finger appeared contracted. OT 1 sated the resident's fingers had been positioned that way previously and did not consider the condition to be a contracture.An OT evaluation dated 10/20/25 indicated Resident 17 had limitations related to a RUE contracture but did not identify contractures affecting the left-hand fingers. During an observation, interview and record review on 3/2/26 at 11:46 A.M., the Director of Rehabilitation (DOR) attempted to have Resident 17 extend fingers on the left hand. Resident 17 was unable to extend his fingers upon request. The DOR attempted passive range of motion on the left-hand fingers and was unable to fully extend the resident's left index finger and left little finger. The DOR stated Resident 17's left index and little finger should be documented and assessed as contractures and the resident should receive stretching and range of motion (ROM) exercises to prevent worsening of the contractures.Review of Resident 17's care plan with the DOR indicated interventions addressing RNA sit to stand exercises and right wrist flexion contracture ROM exercises, including splinting. The care plan did not include goals or interventions addressing contractures of the left index or left little finger.During an interview on 3/2/26 at 3:55 P.M., the Director of Nursing (DON) stated if a contracture is identified it should be documented and referred to the DOR for assessment and preventative exercises. DON stated it is important to identify and treat early to make sure the contracture does not worsen. DON stated all contractures should be monitored and reassessed. A review of the facility policy titled, Rehab Rounding and Screening, revised 8/28/25, indicated, POLICY: To identify residents with potential functional changes and allow those residents to receive therapy services if possible functional declines or improvements are present and skilled services are required. PURPOSE: To ensure timely identification of residents experiencing possible functional changes whether decline or improvement, to facilitate appropriate assessment and provision of skilled therapy services as clinically indicated.

Based on observation, interview and record review, the facility failed to ensure one of one resident (Resident 15) reviewed for dialysis (the process of removing toxic substances from the blood via machine when a person's kidneys no long function adequately) care, received care and treatment that followed the physician's orders and/or the residents' plan of care when fluid restriction was not followed. This deficient practice placed Resident 15 at risk for fluid overload (excessive accumulation of fluid in the body's tissues) which may cause shortness of breath, swelling, rapid weight gain, high blood pressure, fatigue and heart failure.Findings: Resident 15 was re-admitted to the facility on [DATE] with diagnoses including end stage renal [kidney] disease and dependence on renal dialysis (process of removing excess water and toxins from the blood in people whose kidneys can no longer perform these functions naturally). During an observation and interview on 2/25/26 at 9:06 A.M. with Resident 15, Resident 15 was in bed with a blanket covered up to his head. Resident 15 stated he went for dialysis treatments but did not know the schedule. An interview on 2/26/26 at 8:15 A.M. was conducted with Certified Nurse Assistant (CNA) 14. CNA 14 stated Resident 15 was confused and went out for dialysis treatments. CNA 14 stated Resident 15 ate well and was not on fluid restriction. An interview on 2/26/26 a 9:13 A.M was conducted with CNA 16. CNA 16 stated she was assigned to Resident 15. CNA 16 stated Resident 15 had episodes of agitation and screaming. CNA 16 stated she provided a snack to calm Resident 15. CNA 16 stated Resident 15 went out for dialysis and was not on fluid restriction. During an observation on 2/26/26 at 9:22 A.M., Resident was wheeled out of the room by staff. Resident 15's overbed table in the room was observed with a pitcher that was 3/4 full of fluid. An interview and joint record review on 2/26/26 at 9:39 A.M. was conducted with Licensed Nurse (LN) 11. LN 11 reviewed physician's orders for Resident 15. LN 11 stated there was a physician's order for 1200 ml [milliliter] fluid restriction per day. LN 11 stated the physician's order indicated, dietary: 600 ml, night shift: 100 ml, morning shift: 300ml and afternoon shift: 200 ml. LN 11 reviewed Resident 15's fluid intake in the Medication Administration Record (MAR). LN 11 stated Resident 15 received 480 ml of fluids during morning shift on 2/1/26, 2/3/26, 2/13/26, 2/17/26, 2/22/6, 2/23/26 and on 2/24/26. LN 11 stated Resident 15 received 300 ml of fluid during afternoon shift on 2/20/26. LN 11 stated Resident 15 received 240 ml of fluid during night shift on 2/1/26, 2/2/26, 2/14/26, 2/24/26 and 2/25/26. LN 11 stated Resident 15 received more than the fluid restriction. LN 11 further stated the medication nurses and CNAs should know that Resident 15 was on fluid restriction. During an another observation on 2/27/26 at 7:55 A.M., Resident 15 was observed sitting at the edge of the bed with breakfast tray being served. A water pitcher with 3/4 full of fluid was on the overbed table. During an interview on 2/27/26 at 9:07 A.M with LN12, LN 12 stated residents on dialysis and on fluid restriction should not have a water pitcher because drinking too much fluid can cause water retention and fluid overload. An interview on 3/2/26 at 2:59 P.M. was conducted with the Director of Nursing (DON). The DON stated residents on dialysis were on fluid restriction to prevent fluid overload and staff had to monitor how much fluid was being provided to the resident. A review of the facility's policies and procedures (P&P) titled, Dialysis Management, dated 1/25/24 was conducted. The P&P indicated, A pre and post dialysis evaluation will be completed by the licensed nurse.Diet and fluid restrictions will be followed as ordered.

Based on observations, interviews and record reviews, the facility failed to ensure two of two residents (Resident 16 and 1) reviewed for Trauma Informed Care (TIC - an intervention and organization approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health), received care and services in accordance with professional standards when Resident 16 and Resident 1's diagnosis of post-traumatic stress disorder (PTSD- a disorder that may occur in people who have experienced or witnessed a traumatic event) was not identified and addressed by the healthcare providers. This failure resulted in the facility's inability to identify Resident 16's and Resident 1's possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past traumatic experience).Findings: 1. Resident 16 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder and acute pain due to trauma according to the facility's admission Record. During an observation and interview on 2/24/26 at 8:05 A.M. Resident 16 was sitting up at the edge of his bed in his room. Resident 16 stated he had PTSD because he was raped at the age of five and was beaten until the age of 17. Resident 16 stated he saw a psychologist in the facility but hearing residents screaming made him anxious. Resident 16 stated he did not want to close his room door. During a review of the facility's Trauma Informed Care Screening, for Resident 16 dated 9/16/24, the Trauma Informed Care Screening indicated, No traumatic event. Score: 0. An interview on 2/26/26 at 8:38 A.M. was conducted with Certified Nurse Assistant (CNA)13. CNA 13 stated Resident 16 had complained about noise and other residents yelling. CNA 13 stated she offered to close the door or earplugs but Resident 16 declined. CNA 13 stated she was not sure if Resident 16 had a diagnosis of PTSD. During an interview on 2/26/26 at 10:26 A.M. with Licensed Nurse (LN) 11, LN 11 stated she was unsure if Resident 16 had PTSD. An interview and joint record review on 2/26/26 at 12:26 P.M. was conducted with the Minimum Data Set nurse (MDSN- a nurse who assessed and evaluated the quality of care being given to residents). The MDSN stated the quarterly Minimum Data Set (MDS-a clinical assessment tool) For Resident 16, dated 12/21/25 indicated PTSD. The MDSN stated all staff should know if a resident had PTSD to prevent triggering the experience. A review of a follow up psychology note (PN) dated 2/18/26, the PN indicated, Pt [patient] appears in mild distress, discussing past physical and emotional trauma.Cognition: Pt [patient] exhibits normal alertness and attention with some difficulty concentration due to PTSD symptoms, but maintains memory and knowledge appropriate for age. 2. Resident 1 was re-admitted to the facility on [DATE] with diagnoses including post traumatic disorder, major depressive disorder and anxiety according to the facility's admission Record. During an observation and interview on 2/24/26 at 12:47 P.M., Resident 1 was sitting in a wheelchair in his room. Resident 1 stated he had a diagnosis of PTSD due to work history of being a firefighter for 20 years. Resident 1 stated as a firefighter he had seen multiple traumatic events such as people burning and suicides. Resident 1 stated he had seen it all and was often feeling anxious. An interview on 2/26/26 at 9:04 A.M. was conducted with Certified Nurse Assistant (CNA) 15. CNA 15 stated Resident 1 was compliant with care but did not know that Resident 1 had a diagnosis of PTSD. CNA 15 stated it was important to know Resident 1's diagnosis because certain things can be triggered from Resident 1's past experience. An interview and joint record review on 2/26/26 at 10:44 A.M. was conducted with Licensed Nurse (LN) 11. LN 11 stated she did not know if Resident 1 had a diagnosis of PTSD. LN 11 reviewed Resident 1's care plans in Resident 1's electronic medical record and stated Resident 1 had a care plan which indicated mood problem related to PTSD. LN 11 stated staff should know if a resident had PTSD to know how to care for the resident. During an interview on 2/26/26 at 12:41 P.M. with the Social Service Director (SSD), the SSD stated staff should be aware of residents' PTSD to know the trauma experienced by the resident and to try not to recreate the experience. A review of a follow up psychology note (PN) dated 1/21/26 for Resident 1 was conducted. The PN indicated, Cognition: Pt [patient] is alert and oriented x3 [name, time, place] .ASSESSMENT/Diagnosis.PTSD. Patient described experiencing persistent nightmares related to past military and firefighting trauma.Patient described constant anxiety from waking up until the end of the day. During an interview on 3/2/26 at 2:59 P.M. with the Director of Nursing (DON), the DON stated it was important for staff to know which residents had the diagnosis of PTSD and be aware of the triggers to prevent re-traumatization. A review of the facility's policies and procedures (P&P) titled, Trauma Informed Care-Screening, Training and Care Integration Program, revised 2/27/25 was conducted. The P&P indicated, A [traumatic event] can involve interpersonal events.Trauma may also be described as [individual trauma resulting from an event, series of events, or circumstances that an individual experiences that has a lasting adverse effects on the person's physical functioning, and mental, social, emotional and/or spiritual well-being].The IDT [Interdisciplinary Team- team members with various areas of expertise who work together toward the goals of their residents] will meet to discuss the Trauma Informed Screen and implement a plan of care to address potential Trauma Triggers and prevent re-traumatization.

Based on observation, interview and record review, the facility failed to follow a physician's order when licensed nurse (LN) 22 failed to administer a medication as ordered by a physician for a resident (98). This failure had the potential for ineffective medication efficacy (the ability to produce a desired or intended result).Per the admission Record, Resident 98 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disorder (COPD - a treatable lung disease that makes it difficult to breathe).A review of Resident 22's physician's orders indicated an order for Tiotropium Bromide inhaler (medication to treat COPD) - inhale 1 puff daily for COPD. On 2/26/26 at 11:40 A.M., a concurrent observation and interview was conducted with LN 22 during an inspection of medication storage cart (Med cart 5). During the inspection, a single and unopened package of a Tiotropium Bromide was found for Resident 98. LN 22 stated he forgot to administer the medication and that the resident should have received it between 8:00 A.M. and 10:00 A.M. as ordered by the physician. LN 22 stated it is important to administer medication as ordered by a physician to ensure the medication's effectiveness. According to LN 22, Resident 22's unopened Tiotropium Bromide inhaler was intended to be administered on 2/26/26 and there was not another opened Tiotropium Bromide inhaler for Resident 22 available in the med cart. On 3/2/26 at 9:00 A.M., an interview was conducted with the director of nursing (DON). The DON stated it was her expectation that nurses administer all medications as ordered by the physician. A review of the facility policy titled Medication - Administration, dated 8/19/25, indicated that All medications shall be administered by licensed nursing staff according to physician orders, current best practices and federal and state regulations.

Based on observation, interview record review, the facility failed to ensure food items were stored and labeled with contents, received dates, and use-by or expiration dates in the walk-in refrigerator, freezer, and dry storage areas for food prepared and served to residents. This failure had the potential to result in residents consuming expired or unidentified food products, increasing the risk of foodborne illness. During a kitchen observation on 2/24/26 at 8 A.M., the facility's walk in refrigerator was inspected.The following items in the refrigerator were found unlabeled with contents, a received date, or a use-by or expiration date: A. One small metal container covered in foil filled with a browned ground meat, unlabeled and undated. B. One small metal container covered in foil filled with a gelatinous tan substance, unlabeled and undated. C. Three large boxes of whole leaf lettuce with a use-by date of 2/20/26. D. One plastic container labeled lettuce with six large bags of chopped lettuce labeled with a use-by date of 2/20/26. E. One large whole ham stored in a plastic container with a use-by date of 2/22/26. F. Two extra-large casings of raw meat with no label identifying the contents and no use-by or expiration date.In addition one metal tumbler mug containing a brown liquid was stored on the food shelving next to resident food items.During an observation and interview on 2/24/26 at 8:30 A.M the facility cook (CK) observed the metal tumbler stored in the walk-in refrigerator next to resident food items and stated the tumbler was his personal mug containing coffee. The CK stated his personal beverages should not be stored with resident food because doing so creates an infection control risk and could cause cross contamination. The CK stated food items should be labeled with contents, date received, and use-by date, and that food items past expiration should be discarded. The CK stated the boxes of lettuce, unlabeled containers and meat products should be removed from use.During a kitchen observation and interview on 2/24/26 at 8:45 A.M., the facility's freezer was inspected with registered dietitian (RD) 3. Four boxes of ready to bake 10-inch apple pies were not labeled with a received on date and did not have an expiration date. RD 3 stated all food items should be labeled with the date received and use-by date. RD 3 stated items without an expiration date should not be used because they could create a foodborne illness risk.During a kitchen observation and interview on 2/24/26 at 9:00 A.M., with the registered dietician (RD) 2 and the Dietary Manger (DM) , the facility's dry storage room was inspected. The following items were unlabeled and undated: 1. Five racks, each with 10 loaves of bread each with no received on date, use-by date or expiration date. 2. One box of cornstarch opened and was not dated. 3. Ten 16 ounce (oz) containers of beef base with no expiration dates 4. Seven 16 oz. containers of chicken base with no expiration dates. DM and RD acknowledged the items without a label indicating received on, use by or expiration dates. The RD 2stated all items should be labeled with contents, date received, a use by date or expiration date. RD 2 stated if food items are not labeled residents are at risk of becoming ill from bad food.During an interview on 2/27/26 at 2:55 P.M. the director of nursing (DON) stated all resident food items should be labeled according to policy to prevent foodborne illnesses. A review of the facility policy titled, Food Storage and Handling, revised 2/29/24, indicated, 1. Raw Meat/Poultry/Seafood Storage.b. Raw meat, poultry and seafood should be labeled, dated. 7. Frozen Fruit Storage. b label and date all food items. d. use within 6 months. 9. Fresh Vegetable Storage. f. label and date all food items. 13. Dry Storage Area. Label and date all storage products.

Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS- a nursing assessment tool) for one of three sampled residents reviewed for MDS accuracy. (Resident 2) This deficient practice resulted in providing inaccurate information to the Federal database (information maintained by the federal government).Findings:Resident 2 was admitted to the facility on [DATE] with diagnoses including dysphasia (inability to communicate effectively) following cerebral infarction (stroke) according to the facility's admission Record. During a review Resident 2's Minimum Data Set (MDS-a clinical assessment tool) dated 8/25/25, section I5600 indicated an x next to malnutrition. An interview and joint record review was conducted on 9/17/25 at 10:41 A.M. with the Minimum Data Set Nurse (MDSN- a nurse who assessed and evaluated the quality of care being given to residents). The MDSN reviewed Resident 2's MDS. The MDSN stated physician documentation was required to code malnutrition in section I5600. The MDSN stated she provided a query titled, ICD-10-CM MD QUERY for the physician to sign. The MDSN stated the form served as supporting documentation to code malnutrition in the MDS. The MDSN further stated the query for Resident 2 had not been signed by the physician and she coded malnutrition in Resident 2's MDS. An interview was conducted on 9/22/25 at 9:12 A.M. with the Director of Nursing (DON). The DON stated physician documentation was needed to accurately code the MDS because the MDS was sent to CMS (Center for Medicare and Medicaid Services- oversees the nation's health care system) for billing. A review of the facility's policy and procedure (P&P) titled, RAI [Resident Assessment Instrument- manual for completing the MDS] Process, revised on 10/4/16 was conducted. The P&P indicated, The Facility will utilize the Resident Assessment Instrument [RAI] process as the basis for the accurate assessment of each resident's functional capacity and health status, as outlined in the CMS RAI MDS 3.0 Manual. A review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023 was conducted. Chapter 1.2 page seven of the User's Manual indicated the Resident Assessment Instrument (RAI) consisted of the MDS. The User's Manual chapter 1.2, page eight indicated, .The RAI process has multiple regulatory requirement.Federal regulations.require that (1) the assessment accurately reflects the resident's status. Furthermore chapter 5.5, page 668 of the User's Manual indicated, .the MDS must be accurate as of the ARD [Assessment Reference Date]. Minor changes in the resident's status should be noted in the resident's record.in accordance with standards of practice and documentation.

Based on observation, interview, and record review the facility failed to ensure four of seven residents were provided care in a manner that promoted dignity and respect when: 1. Staff did not answer Resident 1's call bell for seven hours;2. Resident 2 waited one hour to have his brief changed; 3. Resident 3 waited all night to have his brief changed; 4. Resident 4 waited one and a half hours for call light to be answered;5. Call light response was an issue verbalized by residents at theResident Council meetings for three consecutive months.These failures resulted in not ensuring residents' rights to be treated with respect and dignity, with the potential to cause psychosocial harm to the involved residents. In addition, this failure had the potential for residents who remained wet for an extended period to develop or worsening of bedsores and infection.Findings:1. Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (disrupted blood flow to the brain) due to thrombosis (blood clot) according to the facility's admission Record. During a review of Resident 2's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 7/9/25, section C0500 indicated Resident 1's Brief Interview for Mental Status (BIMS- evaluates cognition, the ability to remember and think clearly) score was 13, intact cognition. During an observation and interview on 8/13/25 at 9:11 A.M. with Resident 1, Resident 1 was in bed and stated there was a power outage at the facility last week on 8/6/25. Resident 1 stated the electrical power was off from 10 P.M. until 6 A.M. Resident 1 stated he was provided with a call bell similar to the ones used at hotels. Resident 1 stated he pressed the call bell around 10 PM and staff did not come to his room until 5:30 A.M. Resident 1 stated he felt bad because his roommate needed assistance. Resident 1 stated he also waited two hours last week at night before anyone came to check on him. Resident 1 stated he felt frustrated having to wait so long for staff to assist him. 2. Resident 2 was admitted to facility on 8/7/25 with diagnoses including neurogenic bowel (nerve damage affecting signals between the brain and the bowel, leading to difficulties with bowel control and emptying) and pressure ulcer (bedsore) of sacral (the triangular shaped bone at the base of the back) region according to the facility's admission Record. An observation and interview was conducted on 8/13/25 at 9:39 A.M. with Resident 2. Resident 2 was in bed and stated he had been at the facility for almost one week and the call light response was too long. Resident 2 stated he needed his brief to be changed yesterday evening (8/12/25), but waited for one hour. Resident 2 stated he had no control of his bowels and had to call for assistance to be changed or repositioned. 3. Resident 3 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side according to the facility's admission Record. During a review of Resident 2's MDS dated [DATE], indicated BIMS score of 14, intact cognition. An observation and interview on 8/13/25 at 9:42 A.M. was conducted with Resident 3. Resident 3 was in a wheelchair in his room. Resident 3 had no right arm and Resident 3's left arm was on his lap. Resident 3 stated there was a facility power outage on 8/6/25. Resident 3 stated he was provided with a call bell, but he could not use it because he was not able to raise or reach using his left arm. Resident 3 stated he stayed wet until the electrical power turned on at 5:45 A.M. Resident 3 further stated he waited one hour yesterday (8/12/25) afternoon for someone to assist with the use of the urinal. Resident 3 stated he ended up being wet which made him angry and uncomfortable. During an interview on 8/13/25 at 10:10 A.M. with Certified Nurse Assistant (CNA) 1, CNA 1 stated residents' call lights should be answered immediately. CNA 1 stated residents have complained about the call light response and has been reported to the charge nurse. CNA 1 further stated if residents were left wet, they could develop rashes and bedsores. 4. Resident 4 was admitted to the facility on [DATE] with diagnoses including muscle weakness and acquired absence of right upper limb (arm) according to the facility's admission Record. During a review of Resident 2's MDS dated [DATE], indicated BIMS score of 14, intact cognition. An observation and interview on 8/13/25 at 10:27 A.M. was conducted with Resident 4. Resident 4 was in bed and stated she waited an hour and a half for brief change. Resident 4 stated she could not recall the date and time but felt helpless having to wait too long. An interview was conducted on 8/13/25 at 10:31 A.M. with Licensed Nurse (LN) 1. LN 1 stated call light response should be as soon as possible. During an interview on 8/13/25 at 19:39 A.M. with CNA 2, CNA 2 stated call lights should be answered as soon as possible, at least between 10 to 20 minutes. CNA 2 stated residents could develop a rash and skin redness if left wet too long. 5. A review of the facility's minutes for the Resident Council meeting titled, Quality of Life Questions [QOL] was conducted. The QOL dated 5/20/25 indicated, 8. Is your call light answered timely? Sometimes not during Noc [night]. The QOL dated 6/17/25 indicated, 8. Is your call light answered timely? No. The QOL dated 7/15/25 indicated, 8. Is your call light answered timely? No PM.An interview was conducted on 8/20/25 at 9:32 A.M. with the Director of Nursing (DON). The DON stated he expected staff to respond to residents' call lights as soon as possible. Stated he expected CNAs to conduct rounding on the floors, inquire what the resident's need was and address accordingly. Stated leaving a resident wet was unacceptable because the resident can develop moisture associated dermatitis (MASD- skin damage caused by prolonged exposure to moisture), excoriation and pressure injury (bedsore). The DON further stated it was very uncomfortable laying or sitting on something wet. A review of the facility's policy and procedure (P&P) titled, Resident Rights, dated January 1, 2012, was conducted. The P&P indicated, Residents have freedom of choice, as much as possible how they wish to live their everyday lives.Employees are to treat all residents with kindness, respect and dignity ad honor the exercise of residents' rights. A review of the facility's P&P titled, Communication-Call System, dated January 1, 2012, was conducted. The P&P indicated, Nursing Staff will answer call bells promptly.adaptive call bell will be provided to resident per resident's needs.

Based on interview and record review, the facility failed to ensure a care plan was implemented related to falls for one of two residents reviewed for falls (Resident 1).As a result, Resident 1 was at risk for additional falls.Findings:Resident 1 was admitted to the facility on [DATE] with diagnoses to include muscle weakness and dementia (a loss of thinking, remembering, and reasoning that interferes with daily living and activities), per the admission Record.An interview was conducted with the Administrator (ADM) on 7/31/25 at 10:30 A.M. The ADM stated Resident 1 had fallen from his wheelchair on 7/21/25, and this was the first time Resident 1 had sustained an injury. Per the ADM, Resident 1 had been in his room, seated in a wheelchair with no staff present when the fall occurred. The ADM stated Resident 1 had hit his head and was bleeding from his forehead, so he was sent to the hospital to be assessed.On 7/31/25 at 10:45 A.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated Resident 1 was often in her office, and enjoyed watching football on television and getting snacks. The DSD stated if Resident 1 wasn't in his bed, he was usually seated in his wheelchair at the nurses station. Per the DSD, Resident 1 enjoyed watching people walking by, and watching the nurses work. The DSD stated placing Resident 1 at the nurses station was also an intervention to prevent falls, since he could be seen by many staff members and assisted in the event he slid from his chair, or attempted to get up independently.On 7/31/25 at 1 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she was familiar with Resident 1, and provided care to him often. CNA 1 stated Resident 1 liked to sit by the nurses station and watch people, and this kept him safe from falls because staff could easily see him there. CNA 1 stated Resident 1 was only in his room when he wanted to take a nap or go to sleep for the night, otherwise he was at the nurses station or at an activity. CNA 1 stated Resident 1 was unable to use the call light to get assistance, and was unable to explain what he needed to staff. CNA 1 stated Resident 1 answered most questions with a Yes or No.On 7/31/25 at 1:15 P.M., an interview was conducted with CNA 2. CNA 2 stated she was aware of which residents were fall risk because the nursing station kept a binder with a list of resident names as a resource. CNA 2 stated Resident 1 was listed as a fall risk, but the binder did not advise staff on ways to prevent him from falling. CNA 2 stated she was aware a care plan was available for staff to use, and the care plan included interventions for fall prevention, but she had not used care plans to identify ways to keep Resident 1 from falling.A record review was conducted.On 5/28/25, Resident 1's Brief Interview for Mental Status (BIMS, an assessment of thinking and memory) score was six, indicating severe cognitive impairment.Resident 1's Fall Risk Assessment (a evaluation of risk factors for falls, including diagnoses, medications, and fall history) score at the time of the fall was 17, indicating high risk for falls.Resident 1's care plan indicated he was at risk for falls due to his diagnosis of dementia, and others. Interventions to prevent falls were to anticipate his needs, ensure his call light was within reach, and encourage/assist the resident promptly. On 7/31/25 at 1:30 P.M. an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated a Fall Risk score of 10 or higher indicated the resident was at high risk for falls, and the facility should implement strategies to prevent the falls from continuing. The ADON stated Resident 1 had care plan interventions for fall prevention, including anticipating his needs, and ensuring the call light was within reach. The ADON stated those interventions may not be effective as Resident 1 was unable to use the call light or communicate his needs. The ADON stated the care plan should have included not leaving the resident in a wheelchair unattended, but it did not. Per the ADON, the care plan did not address the specific care needs of Resident 1. The ADON stated, Care plans are for problems being addressed, and interventions and goals. Our care plan for (Resident 1) was not specific to his needs. The ADON stated a binder at the nurses station included a list of residents who were at risk for falls, but it did not include individualized interventions. Per a facility policy, revised 8/24/23 and titled Comprehensive Person-Centered Care Planning, Policy: The Facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to implement strategies to prevent a resident from falling (Resident 1).As a result, Resident 1 sustained a fall with injury.Findings:Resident 1 was admitted to the facility on [DATE] with diagnoses to include muscle weakness and dementia (a loss of thinking, remembering, and reasoning that interferes with daily living and activities), per the admission Record.An interview was conducted with the Administrator (ADM) on 7/31/25 at 10:30 A.M. The ADM stated Resident 1 had fallen from his wheelchair on 7/21/25, and this was the first time Resident 1 had sustained an injury. Per the ADM, Resident 1 had been in his room, seated in a wheelchair with no staff present when the fall occurred. The ADM stated Resident 1 had hit his head and was bleeding from his forehead, so he was sent to the hospital to be assessed.On 7/31/25 at 10:45 A.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated Resident 1 was often in her office, and enjoyed watching football on television and getting snacks. The DSD stated if Resident 1 wasn't in his bed, he was usually seated in his wheelchair at the nurses station. Per the DSD, Resident 1 enjoyed watching people walking by, and watching the nurses work/ The DSD stated placing Resident 1 at the nurses station was also an intervention to prevent falls, since he could be seen by many staff members and assisted in the event he slid from his chair, or attempted to get up independently.On 7/31/25 at 1 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she was familiar with Resident 1, and provided care to him often. CNA 1 stated Resident 1 liked to sit by the nurses station and watch people, and this kept him safe from falls because staff could easily see him there. CNA 1 stated Resident 1 was only in his room when he wanted to take a nap or go to sleep for the night, otherwise he was at the nurses station or at an activity. CNA 1 stated Resident 1 was unable to use the call light to get assistance, and was unable to explain what he needed to staff. CNA 1 stated Resident 1 answered most questions with a Yes or No.A record review was conducted.On 5/28/25, Resident 1's Brief Interview for Mental Status (BIMS, an assessment of thinking and memory) score was six, indicating severe cognitive impairment.Resident 1's care plan indicated he was at risk for falls. Interventions to prevent falls were to anticipate his needs, ensure his call light was within reach, and encourage/assist the resident as needed.Resident 1's Fall Risk Assessment (a evaluation of risk factors for falls, including diagnoses, medications, and fall history) score at the time of the fall was 17, indicating high risk for falls. On 7/31/25 at 1:30 P.M. an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated a Fall Risk score of 10 or higher indicated the resident was at high risk for falls, and the facility should implement strategies to prevent the falls from continuing. The ADON stated Resident 1 had many interventions for fall prevention, including anticipating his needs, and ensuring the call light was within reach. The ADON stated those interventions may not be effective as Resident 1 was unable to use the call light or communicate his needs. The ADON stated when Resident 1 was in his wheelchair, he was usually left at the nurses station so staff could monitor him for safety. Per the ADON, the fall occurred in Resident 1's room, and no staff had been present. The ADON stated, Staff should have left him where he could be monitored, instead of in his room.Per a facility policy, revised 8/24/23 and titled Fall Management Program, Purpose: To provide residents a sfe environment that minimizes complications associated with falls.the licensed nurse will develop a care plan according to the identified risk factors.will initiate, review and update the Resident's.care plan.The licensed nurse will evaluate the Resident's response to the interventions.and update.as necessary.

Based on interview and record review the facility failed to provide care in a respectful and dignified manner when an employee showed a soiled linen wipe with bowel movement to Resident 1's face. As a result, Resident 1 was disrespected and had the potential to decrease resident's self-worth. Findings: On 6/3/25 at 10:16 A.M. an interview and record with Licensed Nurse (LN) 1 were conducted. LN 1 stated he received a report form the nocturnal shift nurse that Certified Nurse Assistant (CNA) 1 had put the soiled linen wipes with bowel movement to Resident 1's face while CNA 1 was providing care to Resident 1. According to LN 1's progress notes on 5/25/25 at 11:56 A.M., CNA 1 was taking excessive amount of time to clean up urine and so Resident 1 asked CNA 1 what was going on. CNA 1 placed the soiled wet wipe 2 inches from my face and told Resident 1 had bowel movement. On 6/3/25 at 10:45 A.M. an interview was conducted with Resident 1. Resident 1 stated CNA 1 was providing care when CNA 1 placed the soiled wipes with bowel movement about one to two (1 to 2) inches to Resident 1's face. Resident 1 stated he was so upset and had not experienced this with other CNAs. Resident 1 stated he felt violated as a man, he was not expecting anything like this and he wanted respect because the CNA was helping him. On 6/3/25 at 1:18 P.M., a phone interview with CNA 1 was conducted with the Assistant Director of Nursing (ADON) and Director of Staff Development (DSD) present. CNA 1 stated she was providing care to Resident 1, CNA 1 stated she showed the soiled wipe with bowel movement to Resident 1's face because Resident 1 did not believe her. CNA 1 stated she did not think showing the soiled wipe with bowel movement to Resident 1's face was inappropriate when Resident 1 did not believe her. On 6/3/25 at 1:54 P.M., an interview was conducted with the DSD. The DSD stated it was inappropriate for CNA 1 to show the soiled wipes with bowel movement to Resident 1. On 6/24/25 at 9:57 A.M., an interview and record review were conducted with the ADON. According to the Interdisciplinary team (IDT- a group of healthcare workers from different fields to who work together to address a resident's physical, psychological and social needs) notes indicated .On 05/25/2025 at approximately 0415, the patient requested a different CNA, stating the previously assigned CNA 1 made him feel disrespected, humiliated, and uncomfortable during perineal care. The patient reported requesting a brief change due to urination. During the perineal care, he stated CNA 1 excessively wiped his buttocks for a prolonged period while he was turned on his side. When he questioned her actions, he alleged CNA 1 held soiled wipes close to his face and stated he had pooped. The patient reported becoming upset and asking CNA 1 to stop . During this interview and record review, the ADON stated it was not appropriate to show the soiled linen or wipes with bowel movement to Resident 1 because it could be seen as a demeaning practice. According to the facility policy entitled Resident Rights Quality of Life, revised date March 2027, indicated .Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being . XI. Demeaning practices and standards of care that compromise dignity are prohibited. Facility Staff promote dignity and assist residents as needed by: .B. Promptly responding to the resident's request for toileting assistance .

Based on observation, interview and record review the facility did not ensure a TV (television) remote control was provided for 1 of 3 resident's (Resident 1) in a shared room. As a result, Resident 1 was upset and an altercation with another resident occurred/transpired. Findings: On 6/3/25 the Department received a facility reported incident about a resident-to-resident altercation on 6/1/25. On 6/3/25 at 11:27 A.M., an observation and interview with Resident 2 were conducted. Resident 2 was observed sitting in a wheelchair. Resident 2's room was observed to have three beds and each bed had TV. There was two TV remote control. Resident 2 stated about two days ago after dinner, he was upset because he could find the TV remote control. Resident 2 asked his roommate where the TV remote control was. Resident 2 stated his roommate hit him once in the chest. Resident 2 stated there was only one TV remote control at that time. On 6/3/25 at 11:55 A.M. an interview was conducted with Certified Nurse Assistant (CNA) 2. CNA 2 stated Resident was asking for his TV remote control. A review of the Interdisciplinary team (IDT- team (IDT- a group of healthcare workers from different fields to who work together to address a resident's physical, psychological and social needs) notes on 6/4/25 at 1:25 P.M. indicated .On June 1, 2025, the resident was involved in a physical altercation with another resident (resident #5435527), in which the resident was reportedly hit by the roommate. This incident led to a reported physical abuse case to CDPH via SOC 341. The resident reported that the incident occurred when he asked the other resident for the TV remote control . On 6/24/25 at 9:23 A.M., an interview and record review were conducted with the Maintenance Director. The Maintenance Director stated staff should notify the maintenance team and write a work order request in the work order binder. According to the facility binder for work order there was no written request for a TV remote control for Resident 2. The Maintenance Director stated he was not aware Resident 1's room only had one TV remote control. The Maintenance Director stated each resident should have provided their own TV remote control. On 6/24/5 at 9:33 A.M., an interview the Director of Nursing (DON) and Assistant Director of Nursing (ADON) was conducted. The ADON stated Resident 2 went outside the hallway asking for his TV remote control and no one assisted Resident 2. The ADON stated Resident 2 went back to his room and a resident-to-resident altercation occurred. The ADON stated the staff at that time should d have assisted Resident 2 to avoid the altercation. The ADON stated the staff should have help locate the missing TV remote control. The ADON stated each resident should a TV remote control. The DON stated staff should have assisted Resident 2 in looking for the TV remote control. According to the facility policy entitled Resident Rights- Accommodation of Needs, revised date 1/1/12, indicated .The Facility's environment is designed to assist the resident in achieving independent functioning and maintaining the resident's dignity and well-being. Facility Staff will assist residents in achieving these goals . V. In order to accommodate residents' individual needs and preferences, Facility Staff attitude and behavior are directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible according to residents' wishes. VI. Facility Staff interacts with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains each resident's dignity .

Based on interview and record review, the facility failed to ensure an appropriate discharge plan was implemented for 1 of 2 sampled residents (Resident 1) when: Resident 1 was transferred from the skilled nursing facility to a general acute care hospital (GACH) and denied readmission to the skilled nursing facility (SNF) when the GACH medically cleared the resident for return. As a result, Resident 1 did not receive an appropriate discharge notice that included the reasons for the discharge, notification to responsible parties and the right to appeal the discharge decision. Findings: On 4/15/25 at 1:00 P.M. a joint interview and record review was conducted with the facility's Administration: Administrator (ADM), DON, ADON, Social Services Staff (SSD) 1 and SSD 2. Resident 1 was initially admitted to the facility on [DATE]. Resident 1 was transferred from the SNF to a GACH on 12/23/24 and re admitted to the SNF on 1/21/25 according to Resident 1's demographics and length of stay (LOS) reported by Administration. During the same interview, Administration stated Resident 1 had a history of transfers to GACH and readmission to their SNF however, the facility was unable to provide documented evidence of a discussion with Resident 1 and/or responsible parties related to a discharge notification and process. In addition, during the interview, Administration stated resident 1 was transferred from their SNF to a GACH on 2/3/25 and was not readmitted to their facility. Administration stated the GACH attempted to transfer Resident 1 back to their SNF on 2/19/25 however, the skilled nursing facility declined the transfer. Furthermore, during the interview, Administration acknowledged the lack of discharge notice to Resident 1 which excluded a timely written notice and right to appeal.

Based on observation, interview, record review and document review, the facility failed to protect one of two residents (Resident 2) from abuse when certified nursing assistant (CNA) 1, who was involved with a previous alleged abuse, was allowed to return to work prior to the completion of the facility's abuse investigation. As result, Resident 2 was punched by CNA 1 which caused the resident pain and also caused the resident to experience anger. This had the potential to affect all residents at the facility. Findings: An unannounced visit to the facility was conducted on 3/15/21 due to allegations of abuse reported by the facility. The facility reported to the Department, the first incident, involving Resident 1 on 3/11/21, and reported a second incident to the Department, which involved Resident 2 on 3/15/21. According to the facility report submitted to the Department, both allegations involved CNA 1. On 3/15/21 at 12:10 P.M., an interview was conducted with the facility's Director of Nursing (DON). The DON stated Resident 1 reported that certified nursing assistant (CNA) 1 pushed her (Resident 1) hard during brief change on 3/10/21. The DON stated she was not done with the abuse investigation for Resident 1. The DON stated she was almost done with the investigation, but she was waiting on a statement from License Nurse 1 (LN 1). The DON stated she would probably be done with the investigation for Resident 1 by the end of the day today. The DON stated she interviewed Resident 1 and CNA 1 on 3/11/21. The DON stated she brought CNA 1 in for an interview on 3/11/21 and suspended CNA 1 for just one day. The DON was asked why she allowed CNA 1 to come back to work on the night shift of 3/11/21, before the investigation for Resident 1 was completed. The DON stated CNA 1 received one on one education from the Director of Staff Development (DSD) on abuse and she (DON) felt, from her initial investigation, that CNA 1 was ok to return to work and care for the residents before the investigation was completed. The DON stated CNA 1 was currently suspended due to a second allegation reported by Resident 2 against CNA 1. Resident 2 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's Minimum Data Set (MDS - assessment tool), dated 3/29/21, indicated Resident 2 required one person physical assist with bed mobility and toileting. On 3/17/21 at 11:05 A.M., an observation and interview of Resident 2 was conducted. A pad of paper was used during the interview to communicate with Resident 2 due to her hearing loss. Resident 2 stated she was asleep and was woken up when CNA 1 rolled her over using the cloth pad under her and pulled her legs up hard. Resident 2 stated CNA 1 did not announce herself or explain what she was going to do to her. Resident 2 stated she told CNA 1 she was in pain. Resident 2 stated CNA 1 proceeded to roll her onto her other side to change her brief, then CNA 1 hit her on the left shoulder with a punch. Resident 2 closed her fist and demonstrated the punch with this writer's own arm, and said CNA 1's punch was harder, while the resident grimaced her face. Resident 2 stated she told CNA 1 to leave her alone or she would tell the supervisor. Resident 2 stated, It made me mad. Resident 2 stated, If I had the strength I would have fought back and hit the CNA to protect myself. Resident 2 stated CNA 1 also punched her twice in the center of her back during the same brief change. A document review was conducted. The document titled Abuse Prevention and Prohibition Program dated January 30, 2020, indicated; . B. Facility Staff members accused of committing abuse against a resident are suspended until the investigation is complete and the findings have been reviewed by the administrator. i. Staff members alleged to have committed abuse against a resident will not be reinstated to the regular assignment until the abuse investigation is complete. On 4/5/21 at 3:15 P.M., an interview was conducted with the facility's Administrator (ADM). The ADM stated the DON never told him that the investigation for Resident 1 was not completed when the decision was being made to bring back CNA 1. ADM stated, No way would I bring CNA 1 back if investigation was not complete. On 4/5/21 at 3:46 P.M., an interview was conducted with the facility's Director of Nursing (DON) and Administrator (ADM). The DON and the ADM acknowledged bringing back CNA 1 before the investigation for Resident 1 was completed, did not follow the facility's policy to protect residents from abuse. The ADM stated an employee suspension is made to protect residents.

Based on observation, interview, record review and document review, the facility failed to ensure two of five residents (Resident 1 and Resident 2) were free from abuse when: 1. Certified Nursing Assistant 1 (CNA 1) pushed Resident 1 hard and told the resident, Why don't you god damn move, during care. 2. Certified Nursing Assistant 1 (CNA 1) punched and roughly handled Resident 2 during care. These failures resulted in physical and psychological harm to both Resident 1 and Resident 2. Findings: 1. Resident 1 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The face sheet indicated Resident 1 was her own responsible party. The Minimum Data Set (MDS - an assessment tool) indicated Resident 1 required extensive assistance with bed mobility and toileting. On 3/15/21 at 1:18 P.M., an observation and interview were conducted with Resident 1. Resident 1 laid in bed. Resident 1 was pleasant, alert and engaged with the interview. Resident 1 stated that she tried to turn on her left side where certified nursing assistant (CNA) 1 told her to turn. Resident 1 stated she must have been going too slow because CNA 1 pushed her really hard. Resident 1 stated CNA 1 said to her why don't you god damn move? Resident 1 stated she told CNA 1 she was as far as she could go. Resident 1 stated CNA 1 then threw her right leg over her left leg and her right leg went off the bed. Resident 1 stated she told CNA 1 that she was going to fall out of the bed. Resident 1 stated CNA 1 did not respond to her concern and continued with her care. Resident 1 stated she was brought up in a family where you did not speak to anyone or treat anyone like that. On 3/17/21 at 10:20 A.M., an observation and interview were conducted with Resident 1. Resident 1 stated the incident on 3/10/21 with CNA 1 made her feel icky. Resident 1 was visibly upset; Resident 1 looked toward the ground and shook her head when discussing the incident with CNA 1. A review of Resident 1's Physicians Progress Notes written by Psychiatrist 1, dated 3/10/21, was conducted. The document indicated, Pt (Resident 1) states that > [sic] was brought up not to be rude and she felt the staff was rude to her-this is especially bothersome to her because her dad used to be this way .perceives staff's action as abusive. On 4/5/21 at 9 A.M., an observation and interview of Resident 1 was conducted. This writer discussed with Resident 1, the conversation she (Resident 1) had with Psychiatrist 1, on 3/10/21. Resident 1 stated she informed Psychiatrist 1 that CNA 1's action was abusive. Resident 1 stated CNA 1's actions brought back memories of her dad hitting her when she did something wrong or used any swear words. Resident 1 stated when CNA 1 pushed her hard and spoke to her in the manner that she did, she (Resident 1) considered that physically and verbally abusive. Resident 1 stated she told the Director of Nursing (DON) that CNA 1 should not be working with any residents. On 3/16/21 at 1:37 P.M., a phone interview was conducted with CNA 1. CNA 1 stated she did not recall the incident with Resident 1 that allegedly occurred on 3/10/21. CNA 1 stated Resident 1 was easy to care for and that she did not have any issues with Resident 1. CNA 1 stated Resident 1 required minimal assistance and that the resident was able to turn herself in bed. CNA 1 stated the only time she touched Resident 1 the morning of 3/10/21 was when she used peri-wipes to clean Resident 1's perineal area (area between the tail bone and the pubic arch) during the brief change. CNA 1 stated Resident 1 did all of the turning herself. A document review was conducted. The document titled Abuse Prevention and Prohibition Program dated January 30, 2020 indicated, I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero- tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident's property. II. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitor. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing. On 4/13/21 at 4:15 P.M., a phone interview was conducted with the facility's Administrator (ADM). The ADM stated his intentions was to provide an environment free from abuse for all residents at the facility. The ADM stated Yes when asked if the facility ensured that Resident 1 was free from abuse. The ADM stated the facility had deficiencies and inconsistencies in their investigation of Resident 1's allegation but stated the facility could not take the responsibility that it caused the abuse. The ADM stated he believed Resident 1's perception of the incident was accurate. The ADM stated all residents at the facility should be free from abuse because that was the human thing to do. The ADM stated the facility should protect all residents. 2. Resident 2 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2's face sheet also indicated the resident's daughter was the resident's responsible party. A review of Resident 2's Minimum Date Set (MDS - assessment tool), dated 3/29/21, indicated Resident 2 required one person physical assist with bed mobility and toileting. On 3/17/21 at 11:05 A.M., an observation and interview of Resident 2 was conducted. A pad of paper was used during the interview to communicate with Resident 2 due to her hearing loss. Resident 2 stated she was asleep and was woken up when CNA 1 rolled her over, using the cloth pad under her, and pulled her legs up hard. Resident 2 stated CNA 1 did not announce herself or explain what she was going to do to her. Resident 2 stated she told CNA 1 she was in pain. Resident 2 stated CNA 1 proceeded to roll her onto her other side to change her brief, then CNA 1 hit her on the left shoulder with a punch. Resident 2 closed her fist and demonstrated the punch with this writer's own arm, and said CNA 1's punch was harder, while the resident grimaced her face. Resident 2 stated she told CNA 1 to leave her alone or she would tell the supervisor. Resident 2 stated, It made me mad. Resident 2 stated, If I had the strength I would have fought back and hit the CNA to protect myself. Resident 2 stated CNA 1 also punched her twice in the center of her back during the same brief change. On 3/16/21 at 10:45 A.M., a telephone interview was conducted with Resident 2's Responsible Party (RP). RP stated when she asked Resident 2 about the incident, Resident 2 told her that she was punched in the back twice by CNA 1 using her fist and that CNA 1 also punched her in the left shoulder. RP stated Resident 2 demonstrated what happened to her by putting her hand in a fist and hit the palm of her other hand with force to show how CNA 1 punched her. RP stated Resident 2 told her that she asked CNA 1 what she was doing, and CNA 1 did not answer. The RP stated Resident 2 had been at the facility for 1 year and had never once complained about care or mistreatment. The RP stated, That is why I know something happened. On 3/16/21 at 4:23 P.M., a review of the document titled Initial interview done with (Resident 2's name) on 3/12/21 at approximately 8:40 am: was conducted. The document indicated that Resident 2 reported to the facility, that lady last night hurt me, I told her to stop and she didn't, it hurt bad, it hurt real bad. According to the document Resident 2 told CNA 1 stop it, your [sic] hurting me. Per the report CNA 1 again lifted the resident's legs in the air and dropped Resident 2's legs on the bed. The document indicated Resident 2 yelled again stop it and that was when CNA 1 began to change Resident 2's brief. The document indicated CNA 1 turned Resident 2 on her side and punched her on the back. Per the document, Resident 2 grabbed CNA 1 and pushed her, and then CNA 1 went to the other side of Resident 2's bed and punched the resident again in the back. Per the document, Resident 2 pushed the call light to asked for pain medication, CNA 1 answered the call light and told Resident 1, no and walked out. A document review was conducted. The document titled Abuse Prevention and Prohibition Program dated January 30, 2020, indicated, I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero- tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident's property. II. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitor. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing. On 4/13/21 at 4:15 P.M., a phone interview was conducted with the facility's Administrator (ADM). The ADM stated his intentions was to provide an environment free from abuse for all residents at the facility. The ADM stated Yes when asked if the facility ensured that Resident 2 was free from abuse. The ADM stated the facility had deficiencies and inconsistencies in their investigation of Resident 2's allegation but stated the facility could not take the responsibility that it caused the abuse. The ADM stated he believed Resident 2's perception of the incident was accurate. The ADM stated all residents at the facility should be free from abuse because that was the human thing to do. The ADM stated the facility should protect all residents.

Based on observation, interview, and record review, the facility failed to identify and manage potential smoking hazards for 1 of 24 sampled residents (5) and 3 randomly sampled residents (23, 34, 61). As a result: A). One Resident 61 was documented as a known smoker; however, was not assessed for safe smoking. B). Resident 5 was identified as an unsafe smoker (requires supervision while smoking), per the Safe Smoking Assessment but was allowed to smoke independently. As an unsafe smoker, Resident 5 kept personal smoking materials at the bedside, which included cigarettes and lighters. C). Resident 23 was identified as an unsafe smoker (requires supervision while smoking), per the Safe Smoking Assessment but was allowed to smoke independently. Resident 23 was not identified on the facility's smoking list. D). Resident 34 was initially identified as a safe smoker by the activity director. Upon re-assessment by a licensed nurse, Resident 34 was identified as an unsafe smoker who required supervision and a smoking apron. Resident 34 reported on several occasions cigarettes and lighters were stolen off the bed. The fire extinguisher was out of reach of the wheelchair bound residents. The facility did not provide a safe access to staff in case of an emergency situation while on the smoking patio. The facility process in place was to have the activity director as a member of the interdisciplinary team conduct the smoking assessment on all smokers. This assessment failed to take into consideration any resident's medical and medication history or health/or behavioral issues that would impact a resident's ability to smoke safely. The facility's systems failure presented a risk that residents who smoke could catch their clothes on fire when lighting cigarettes. Residents who smoke also could cause a fire inside the facility since they were allowed to keep their personal smoking materials in their rooms. These residents who smoke also could have been severely injured since there was no staff supervision and residents were allowed to smoke independently. The facility's administrator was informed of the Immediate Jeopardy (IJ) called on 11/14/13 at 6:13 P.M. via telephone conference call. On 11/14/13 at 8:15 P.M., the facility assistant administrator (AA), the director of nursing (DON), and the facility's nurse practitioner (NP) provided a written plan of correction. However, due to the need to have all smokers re-assessed by a licensed nurse and update the current smoking list, the Immediate Jeopardy could not be abated. On 11/18/13 at 7:50 A.M., a meeting with the AA, the DON and the NP was conducted and the plan to ensure resident safety and correction was provided, and the Immediate Jeopardy was abated. The AA stated that the facility's interdisciplinary team (IDT) had met individually with residents; each smoker had been re-assessed by a licensed nurse. The AA stated during the assessments the smoking list had been updated. The AA stated each smoker had been informed of the new smoking safety processes that were to be implemented immediately; all signed the smoking guideline form and a care plan was either revised or developed. The current smoking schedule had been revised and posted throughout the facility. The AA stated the facility now had a designated staff member to supervise the smoking patio 24 hours continuously. The AA stated the facility provided labeled containers for all smokers to store cigarettes and lighters which would be controlled by the smoking attendant. The AA stated the smoking attendant would document on the newly developed smoking log which was kept on the smoking patio. The AA stated the fire extinguisher was lowered for accessibility in case of a fire. The AA reported smoking aprons were now available and kept on the smoking patio. The AA stated that the plan included that all staff would receive in-service training regarding the smoking policy and new process for residents who smoke. In addition, the AA stated that this training would occur until each and every staff person was in-serviced. A quality assurance (QA) program was developed to address the identified smoking concerns and monitor the plan of correction compliance. The QA program, the policy and procedure, the smoking list, and in-service were provided and reviewed during the meeting with the AA. On 11/18/13 at 7:50 A.M., the facility's AA was informed that the IJ was abated. The facility's AA provided written documentation of the plan of correction. Additional records provided by the AA regarding the new policy and procedure for all residents who smoked included all staff in-service training records which supported that the fact that all staff had been educated regarding the new systems. The facility staff were observed managing and supervising residents who smoked cigarettes, as per the smoking schedule, and in the designated smoking area. Storage of cigarettes and lighters were now being maintained at the central nursing station. Findings A). Resident 61 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Face Sheet Resident 61 also had muscle weakness, spasm of muscles and lack of coordination. According to the MDS (minimum data set/assessment) dated 9/24/13, Resident 61 had a cognitive score of 14 out of 15 with disorganized thinking. A summary score of less than 15 indicated a cognitive ability deficit. A review of the form titled "Skilled Nursing Facility (SNF) Progress Note" dated 11/11/13, and signed by the attending physician indicated "Reviewed legal document by which patient (Pt) is allowed to smoke marijuana for medical purposes by (a physician's name)." No safe smoking assessment or care plan could be found in the medical record. B). Resident 5 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. The history and physical (H&P) dated 4/6/13, indicated that Resident 5 was dependent on nicotine. The Safe Smoking Assessment completed by the activities director and dated 4/8/13, indicated that Resident 5 was an unsafe smoker. The Safe Smoking Assessment form only addressed cognitive function, visual function, communication coupled with resident observation and interview. The form further indicated "..., the resident is determined to be an unsafe smoker and the resident is required to wear a protective smoking vest/apron and/or direct observation by caregivers." An observation and interview with Residents 5 and 34 and one confidential resident was conducted on 11/12/13 at 4:45 P.M. The six residents sat around the patio table smoking and conversing amongst themselves. There was no staff member present. The residents stated that they usually do not have supervision while smoking. One Resident stated, "We all look out for each other." All of the residents present on the smoking patio held their own cigarettes and lighters, most were smoking prior to arrival on the patio. Resident 5 and 34 were observed to remove a cigarette and lighter from their pockets and light their cigarettes. They were not wearing a smoking apron. In addition, there were no smoking aprons observed on the patio. An interview and joint review of Resident 5's Safe Smoking Assessment with the activities director (AD) was conducted on 11/13/13 at 1:20 P.M. The AD stated she conducted the safe smoking assessments only upon admission. The AD stated there were only four residents (5, 9, 27, and 86) who required supervision when they smoked. The AD stated that a staff member from the activity department was present during the smoking hours of 9:00 A.M., 11:30 A.M., 1:30 P.M., and 4:00 P.M. An observation and interview with Resident 5 was conducted on 11/13/13, at 5:00 P.M. Both residents were observed smoking on the smoking patio. There was no staff present. Resident 5 stated a smoking apron had never been worn. An observation of the smoking patio was conducted on 11/14/13 at 3:45 P.M. Residents 5 and 34 sat around the back patio table and were smoking cigarettes. Resident 5 smoked a tobacco cigarette while talking to 2 other smokers and wore no smoking apron. A joint observation of the smoking patio and interview with activity staff (AS) 1 was conducted on 11/14/13 at 3:50 P.M. AS 1 stated he was assigned to supervise the smoking patio. When asked which resident required supervision, AS 1 stated he was unsure and reported he usually was told by the AD. AS 1 stated he was not sure where the smoking aprons were and did not know who needed to wear a smoking apron. Resident 5 asked why supervision was necessary since no one supervised before now. Resident 5 stated smoked at various times, Resident 5 confirmed that smoking often occurred after 4:00 P.M. C). Resident 23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated Resident 23 was able to recall two out of three questions after cueing. The Summary Score from the cognition (thought process) score totaled 11 out of 15, less than 15 indicated cognitive ability deficit. The Safe Smoking Assessment completed by the activities director and dated 10/7/11, indicated that Resident 23 was an unsafe smoker and required constant supervision while smoking. The form further indicated "..., the resident is determined to be an unsafe smoker and the resident is required to wear a protective smoking vest/apron and/or direct observation by caregivers." An observation of the smoking patio was conducted on 11/14/13 at 3:45 P.M. Resident 23, not identified on the smoking list, sat in the wheelchair alone and smoked a tobacco cigarette. Resident 23 did not wear a smoking apron. D). Resident 34 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 34 initial Safe Smoking Assessment completed by the activities director and dated 8/12/13, indicated as a safe smoker with occasional supervision. On 11/15/13, Resident 34 was re-assessed and identified as an unsafe smoker and required constant supervision and a smoking apron. An observation and interview with Residents 5, 34, and one confidential resident was conducted on 11/12/13 at 4:45 P.M. The six residents sat around the patio table smoking and conversing amongst themselves. There was no staff member present. The residents stated that they usually do not have supervision while smoking. One Resident stated, "We all look out for each other." All of the residents present on the smoking patio held their own cigarettes and lighters, most were smoking prior to arrival on the patio. Resident 5 and 34 were observed to remove a cigarette and lighter from their pockets and light their cigarettes. Neither wore a smoking apron and there were none seen available on the smoking patio. An interview with Resident 34 was conducted on 11/12/13, at 5:45 P.M. Resident 34 reported stolen cigarettes and lighters on several occasions when they were left unattended on the resident's bed. An interview with the AD was conducted on 11/14/13 at 4:10 P.M. The AD stated she had discussed the smoking concerns with the assistant director of nursing (ADON) and she would develop a care plan for those non-compliant with the smoking guidelines. When asked if she had a list for those cigarettes and lighters she kept, the AD stated, "At this time there no residents who required the activities department to keep their smoking materials." An observation of the smoking patio was conducted on 11/14/13 at 5:50 P.M. A Resident was observed in the parking lot smoking a cigarette and conversing with the maintenance director. There were six residents on the smoking patio around the first table, all were smoking. There was a fire extinguisher attached to post of the wooden patio cover hung in a position that could not reached in case of an emergency for wheelchair bound individuals. There were no staff on the smoking patio and no smoking aprons were found. A review of the facility's policy titled, "Smoking by Residents" dated 1/1/12, was conducted on 11/14/13 at 6:00 P.M. The policy indicated, "Residents who are not able to smoke independently safely will be accompanied by facility staff while smoking. II. A licensed nurse will complete NP-132 Form-A-Safe Smoking Assessment for residents who wish to smoke. A. The licensed nurse will provide the Safe Smoking Assessment for review by the interdisciplinary team (IDT) ... i. The physical ability of the resident to handle smoking materials ..." On 11/18/13 at 7:56 A.M., an interview was conducted with the director of nursing (DON). The DON stated that before, a permanent staff was assigned in the smoking patio before but "not sure what happened to the schedule." The DON acknowledged that supervision had not been provided on the smoking patio for those who required supervision.