Every finding on record at The Rehabilitation Center of Oakland

Based on interview and record review:1. For three of three sampled residents (Resident 9, Resident 10, and Resident 11) the facility failed to ensure accurate representations of change in condition (COC, any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual) had documented entries that were signed by licensed nurses (LNs) in real time. 2. The facility failed to provide complete, accurate, and prompt recordings of clinical services and documentation on Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their residents) Meeting Notes as the events of clinical discussion occurred in real time during IDT meetings. These failures resulted in incomplete and inaccurate reflections of the medical care and services provided to each residents' actual date and time of COCs, as well as IDT notes and recommendations.1. A review of Resident 9's Face Sheet, printed on 6/12/26, indicated Resident 9 was admitted to the facility in 2026 with multiple diagnoses that included dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior) with agitation and metabolic encephalopathy (a brain dysfunction which can affect one's mood, thinking, and memory caused by an underlying condition). A review of Resident 9's medical record titled, Change in Condition Evaluation, indicated, Effective Date: 5/20/2026 21:27, showed, Resident 9 noted with agitation, irritability, and impulsive behavior. Noted to continue with loud vocalizations and calling out behaviors unresolved with current medication regimen. Nurse Practitioner 1 (NP 1) assessed resident today and provided new orders. COC Evaluation indicated Resident 9's Resident Representative (RR 9, whose name was not listed as one of Resident 9's contacts) was notified on 5/20/26, at 12 midnight. Resident 9's medical record further indicated the COC Evaluation was electronically signed (e-signed) by the Director of Nursing (DON) on 5/21/26. A review of Resident 10's Face Sheet, printed on 6/12/26, indicated Resident 10 was admitted to the facility in 2026 with multiple diagnoses that included schizophrenia (a mental condition which makes it difficult to think clearly, have normal emotional responses, act normally in social situations, and tell the difference between what is real and what is not real), major depressive disorder (a serious mental health condition characterized by persistent low mood and loss of interest in activities), and quadriplegia (paralysis of both upper and lower extremities). A review of Resident 10's medical record titled, COC Evaluation, indicated, Effective Date: 5/20/2026 20:52, showed, Resident 10 noted to have itchy, flaky skin noted on scalp with dandruff. NP 1 assessed Resident 10 today.New orders in place. The COC Evaluation indicated Resident 10 was responsible for himself and aware of the situation on 5/20/26, at 12 midnight. Resident 10's medical record further indicated the COC Evaluation was e-signed by the DON on 5/21/26. A review of Resident 11's Face Sheet, printed on 6/12/26, indicated Resident 11 was admitted to the facility in 2026 with multiple diagnoses that included metabolic encephalopathy, dementia, major depressive disorder, and post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing a terrifying, life threatening, or deeply shocking event). A review of Resident 11's medical record titled, COC Evaluation, indicated, Effective Date: 5/20/2026 19:56, showed, Resident 11 continues to experience nightmares and sleep disturbances. The COC Evaluation indicated Resident 11's RR, RR 11 was notified on 5/20/26, at 7p.m. Resident 11's medical record further indicated the COC Evaluation was e-signed by Registered Nurse 2 (RN 2) on 5/21/26. During an interview on 6/12/26, at 11 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated COCs were created by assigned LNs on the floor, when resident COC occurred. LVN 2 stated best practice on resident documentation/charting was to create an electronic COC, saved, then locked in real time. LVN 2 stated saved and unlocked electronic records (e-Record, any information captured, created, or stored in a digital format) can always be unlocked for editing by another person. LVN 2 stated Director of Nursing (DON) had instructed LNs to keep e-Records unlocked so DON can edit the e-Records as needed. During an interview on 6/12/26, at 11:25 a.m., with LVN 1, LVN 1 stated DON had instructed the LNs not to lock the e-Records so that DON can check documentation of resident COCs were completed according to DON's standards. During an interview on 6/12/26, at 12:10 p.m., with DON, DON stated saving and signing COC documentation was what was required of the LNs unless the LNs needed education in real time. DON emphasized that a few of the facility's LNs were new graduates who currently needed guidance and education on situations so that documentations were not locked to ensure resident COCs were completed thoroughly. DON stated entries should be recorded promptly as the events of observation occur. A review of the facility's policy and procedure (P&P) titled Change of Condition, revised date 11/18/21, indicated, .The Facility will ensure Residents, family, legal representatives and physicians are informed of changes in the resident's condition in a timely manner.Documentation.Licensed Nurse will document the following: i. Date, time, and pertinent details of the incident and subsequent assessment in the Resident's chart.vi. Complete an incident report. 2. During an interview on 6/11/26, at 12:05 p.m., with the IDT M1, IDT M1 stated LNs on the floor documented the resident COCs and were overlooked by the IDT. IDT M1 stated COCs should be completed upon review by the IDT, however IDT M1 was unsure whether the COCs had been closed or locked before the IDT meetings took place. During an interview on 6/12/26, at 11:25 a.m., with the Infection Preventionist (IP), IP stated the IDT Members included LNs, IP, Minimum Data Set Coordinator (MDSC), Director of Staff Development (DSD), Case Manager (CM), Social Services Director (SSD), Director of Rehabilitation (DOR), Activity Director, Dietary Manager (DM), Registered Dietitian (RD), and Administrator (ADM). IP stated the DON documented on IDT Notes and the members signed a paper copy for attending the IDT meeting. During an interview on 6/12/26, at 1:45 p.m., with IDT M2, IDT M2 stated DON had LNs left resident COCs open and unlocked until DON had reviewed the COCs. IDT M2 stated DON routinely edited the COCs. IDT M2 further stated DON also did the IDT notes and had IDT members sign the IDT Notes and made it look like the members were present at the time of creation. During an interview on 6/12/26, at 2:15 p.m., with IDT M4, IDT M4 stated resident COCs were discussed during IDT meetings and at a separate time, the DON entered notes and recommendations and added the names of the IDT members, as if the team members were present during the time of creation. IDT M4 stated the IDT members signed their names on paper before the IDT Notes were completed. A review of the facility's P&P titled Completion & Correction, revised date 1/1/12, indicated, .To ensure that medical records are complete and accurate.The facility will work to complete and correct medical records in a standardized manner to provide the highest quality in accuracy in documentation.II. Entries will be recorded promptly as the events of observation occur. III. Entries will be complete, legible, descriptive and accurate. IV. Any person(s) making observations or rendering direct services to the resident will document in the record. V. Entries should be written in chronological sequence. If it is necessary to chart out of sequence during the appropriate date and time will be entered. A. When adding an entry at a later date, the entry is to be clearly identified as a late entry.XII. Documentation Content: XIII. No portion of the record is to be obliterated, erased, or destroyed. A. If an error needs to be corrected, draw one line through the entry, designate the entry as an error and initial next to the change. XIV. Facility staff may not sign or another person.XVII. An addendum provides additional information to address a specific situation or incident and should include the following: A. The current date and time B. Designate the information as addendum and state the reason for the addendum referring back to the original entry. XVIII. Clarification is a type of entry used to clarify a previous entry to avoid incorrect interpretation of information that has been previously documented and should include the following: A. The current date and time B. Designate the information as clarification and state the reason for the clarification referring back to the original entry.XIX. Computerized Records: A. Correcting an error in an electronic/computerized medical record system follows the same principles as correcting a paper record. B. The system must have the ability to track corrections or changes to the entry once the entry has been entered or authenticated.

Based on interview and record review the facility failed to maintain their compliance and ethics program when the facility did not promote honest and ethical behavior in all work-related activities. This failure resulted in false medical records and reports and placed the residents in the facility at risk of receiving unsafe care. 1. A review of the facility census, dated 6/2/26, indicated a mixed gender room arrangement between a male resident, Resident 1 who at this time was transferred to the hospital for a medical procedure and a female resident, Resident 2, newly admitted to the facility on this day, at 6:20 p.m. A review of the facility census, dated 6/3/26, indicated Resident 1 returned from the hospital at 3:20 a.m., and was placed in B bed, while Resident 2's A bed now showed as vacant when Resident 2 moved to an all-female room with two other female residents. The census manipulation reflected an attempt to obscure the overnight mixed gender room situation. A review of Resident 1's Progress Notes, dated 6/3/26, at 3:15 a.m., indicated curtains were drawn to maintain privacy between Resident 1 and Resident 2. From 3:20 a.m., up until the time Resident 1 and Resident 2 were both relocated to different rooms sometime during the day shift (7 a.m., -3:30 p.m.), the two residents, male Resident 1 in B bed and female Resident 2 in A bed, slept through the remainder of the NOC shift (11 p.m.-7:30 a.m.) in the same room simultaneously. During an interview on 6/11/26, at 1:03 p.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated CNA 2 was assigned to care for Resident 1 and Resident 2 who occupied the same room during the evening shift (3 p.m.-11:30 p.m.) on 6/2/26. CNA 2 stated it was a complicated resident room arrangement. During a telephone interview on 6/11/26, at 1:20 p.m., with CNA 1, CNA 1 stated CNA 1 provided care to Resident 1 and Resident 2 who occupied the same room during the NOC shift until 7:30 a.m. on 6/3/26. CNA 2 stated it was an abnormal resident room arrangement. 2. During a concurrent interview and record review on 6/11/26, at 12:37 p.m., with Registered Nurse Supervisor 1 (RNS 1), Resident 1's medical records were incomplete. RNS 1 stated it was practiced that charge nurses took care of the written 7-day bed hold notice during resident transfers to hospital, however, there was no 7-day Bed Hold Notice found for Resident 1. RNS 1 was also unable to present Resident 1's Room Change Notification from Resident 1's previous room to a new room designation upon return from the hospital in less than 24 hours on 6/3/26. RNS 1 only presented Resident 1's Room Change Notification from 6/4/26, after a second change of room relocation took place since Resident 1 returned from the hospital. 3. During random reviews of Resident Change of Conditions (COC, any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual), Resident 9, Resident 10, and Resident 11's COCs indicated resident COCs were created by the licensed nurses (LNs) on 5/20/26 in real time. Resident 9, Resident 10, and Resident 11's COCs also indicated signed by the Director of Nursing (DON) on 5/21/26. During in-person random interviews, on 6/11/26 to 6/12/26, with Licensed Vocational Nurses (LVN), both LVN 1 and LVN 2 confirmed DON had instructed the LNs to leave electronic records (e-Record, any information captured, created, or stored in a digital format) saved but unlocked so DON can edit the e-Records as needed and complete resident COCs according to DON's standards. 4. During in-person random interviews, on 6/12/26, with Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their residents) members (IDT M), both IDT M2 and IDT M4 stated resident COCs were discussed during IDT meetings and DON routinely edited the COCs. IDT M2 and IDT M4 also stated DON entered notes and recommendations and added the names of the IDT members, and made it look like the members were present at the time of creation. During an interview on 6/11/26, at 1:11p.m., with the Administrator (ADM), ADM stated there was no documentation of Resident 1's room changes on 6/3/26 and 6/4/26, there was no room change notification on 6/3/26, only on 6/4/26. ADM also stated Resident 1 and Resident 2's mixed room management was not normal practice, but ADM had to accommodate all parties involved. ADM confirmed that overall decision-making regarding welfare of the residents and the facility was ADM's responsibility. During an interview and record review on 6/12/26, at 12:10 p.m., with the DON, Resident Census from 6/2/26-6/4/26 revealed multiple room changes for multiple residents who had been in the facility. The Resident Census, dated 6/2/26, indicated Resident 2's admission, with two male residents switched rooms. Resident Census, dated 6/3/26, indicated Resident 1's readmission and four female residents room changes. Resident Census, dated 6/4/26, indicated three admissions and three male resident room changes. DON stated the multiple room changes that took place from 6/2/26 to 6/4/26 were necessary to meet the residents and facility needs. During follow-up interview on 6/12/26, at 12:20 p.m., with DON, DON emphasized that few of the facility's LNs were new graduates who currently needed guidance and education on incidents so that documentations were not locked to ensure resident COCs were completed thoroughly after DON's review. A review of the facility's policy and procedure (P&P) titled Compliance Plan and Program, undated, indicated, .The facility is committed to prevention, detection and to take all appropriate action to assure compliance with all legal requirements and to promote honest and ethical behavior in all work-related activities.to ensure that quality patient care is provided. in a manner that fully complies with all applicable state and federal laws and regulations.(1) all employees are educated about the applicable laws and trained in matters of compliance, (2) there is periodic auditing, monitoring, and oversight of compliance with those laws, (3) there exists an atmosphere that encourages and enables the reporting of noncompliance without fear of retribution or retaliation, (4) responsibility is not delegated to persons with a propensity to act in a non-compliant manner, and (5) mechanisms exist to investigate, discipline and correct non-compliance. Supervisors and administrators are expected to report issues of suspected non-compliance issues through established management channels. The facility's Administrator/Executive Director shall serve as the facilities own Corporate Compliance Officer to implement and oversee the compliance program responsibilities specific to the facility.The facility's Corporate Compliance Officer shall be responsible for the day-to-day oversight of compliance efforts at the facility.

Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 1 and Resident 2 ) and/or their individual Resident Representatives (RRs) were notified of the mixed gender room arrangement when male resident, Resident 1's unexpected return to facility following less than a 24-hour hospitalization stay, was placed together in a room with newly admitted female resident (Resident 2). This failure resulted in Resident 1 and Resident 2's inappropriate room accommodation, roomed in with the person not of their choice, and without individual consent or advanced written notifications in place.A review of Resident 1's Face Sheet, printed on 6/11/26, indicated Resident 1 was admitted to the facility in 2025 with multiple diagnoses that included Diabetes Mellitus (a long-term [chronic] disease in which the body cannot regulate the amount of sugar in the blood), bipolar disorder (a mental condition in which a person has wide or extreme swings in their mood. Periods of feeling sad and depressed may alternate with periods of intense excitement and activity or being cross or irritable), and schizophrenia (a mental condition which makes it difficult to think clearly, have normal emotional responses, act normally in social situations, and tell the difference between what is real and what is not real). A review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 4/17/26, indicated Resident 1 had a Brief Interview of Mental Status (BIMS, an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS score ranges from 0-15, with 15 as an indication of intact skills) score of 8, a moderately impaired cognition. A review of Resident 2's Face Sheet, printed on 6/11/26, indicated Resident 2 was admitted to the facility on [DATE], with multiple diagnoses that included metabolic encephalopathy (a brain dysfunction which can affect one's mood, thinking, and memory caused by an underlying condition) and muscle weakness. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had impairment on both lower extremities (hip, knee, ankle, and foot) and was bedbound. A review of the Facility Census, dated Tuesday, June 2, 2026, indicated Resident 2 (a female resident) was admitted on [DATE], at 6:10 p.m. in A bed, to a room already designated for a male resident (Resident 1) in B bed, who was on bed hold as of 6/2/26. A review of the Facility Census, dated Wednesday, June 3, 2026, indicated Resident 1 was readmitted on [DATE], at 3:20 a.m. in B bed, with female resident, Resident 2 in A bed. A review of Resident 1's Progress Notes, dated 6/3/26, at 3:15 a.m., indicated Resident 1 was readmitted to the facility following return from the hospital on 6/3/26 around 3:20 a.m. Progress Notes further indicated Resident 1 was placed in a room and the curtains were drawn to maintain privacy between the two residents. The Progress Notes, however, did not indicate that male resident, Resident 1 was placed in the resident room's A bed, with B bed already occupied by female resident, Resident 2. During an interview on 6/11/26, at 1:11 a.m., with the Administrator (ADM), ADM stated resident admission room assignments were generally the responsibility of either Admissions Department, Department Managers, or nursing staff on the floor but normally fell under the ADM for the overall decision making. During a follow-up interview on 6/11/26, at 3:13 p.m., with the ADM, ADM stated both Resident 1 and Resident 2 did not have the capacity to make medical decisions and no informed consents were requested from or approved by each residents' RRs. ADM stated neither Resident 1 nor Resident 2, nor the residents' RRs were notified of the mixed gender room arrangement. During a telephone interview on 6/11/25, at 3:56 p.m., with Resident 1's RR (RR 1), RR 1 stated she was not aware Resident 1, after being transferred and returned from the hospital to the facility in less than 24 hours, was placed in a newly assigned room with a newly admitted female resident (Resident 2). RR 1 stated she was shocked and disappointed and was unaware of the facility's anomaly (something that deviates from the normal or expected standard). RR 1 stated had she been notified by the facility in a timely manner, RR 1 would have requested Resident 1's immediate transfer to a different room with strictly male only residents. During an interview on 6/12/25, at 12:10 p.m., with the Director of Nursing (DON), DON claimed responsibility for Resident 1 and Resident 2's inappropriate mixed-gender room accommodation. DON stated the room changes were necessary, however, the decisions on resident room designations were not addressed appropriately. A review of the facility's policy and procedure (P&P) titled, Room or Roommate Change, dated 6/9/26, indicated, .Purpose: To enable residents to exercise their right to change rooms or roommates. A review of the facility's P&P titled, Resident Rights, 1/1/12, indicated, To promote and protect the rights of all resident at the facility.Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights.The resident is encouraged to make choices about aspects of his or her life in the Facility including: A. Rooming with the person of his or her choice, providing both individuals consent to the choice.

Based on interview and record review, for one of eleven sampled residents (Resident 1), the facility did not provide Resident 1 and Resident Representative 1 (RR 1) a written seven (7) day Bed Hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave [absences for purposes other than required hospitalization] or hospitalization) Agreement when Resident 1 was transferred to the hospital and sent back to the facility the same day, in less than 24 hours. This failure resulted in Resident 1 and/or RR1 not having a written notification of the facility's Bed Hold Agreement prior to hospitalization and led Resident 1 not to be able to return to his previous room following an unexpected less than 24-hour stay at the hospital.A review of Resident 1's Face Sheet, printed on 6/11/26, indicated Resident 1 was admitted to the facility in 2025. A review of Resident 1's Order Summary, dated 6/2/26, indicated transfer resident to hospital for nasogastric (NG, a flexible tube passed through the nose, down the esophagus, and into the stomach for feeding and medication administration) tube placement due to failure to thrive (a syndrome of global physical, cognitive, and functional decline characterized by unexplained weight loss, poor nutrition, decreased appetite, inactivity, and social isolation). Order Summary further indicated, Bed hold for 7 days if admitted . During an interview on 6/11/26, at 12:05 p.m., with Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their residents) Member 1 (IDT M1), IDT M1 stated it was the facility's policy that all residents and/or RRs signed a written 7-day Bed Hold Agreement upon admission and before every resident therapeutic leave or hospitalization. During a telephone interview on 6/11/25, at 3:56 p.m., with Resident 1's RR, RR 1 stated she was not aware of the 7-day bed hold but aware that the facility had to keep a bed and not refuse to take Resident 1 back. RR 1 confirmed she did not receive a written 7-day Bed Hold Agreement before Resident 1 was transferred to the hospital on 6/2/26. During a concurrent interview and record review on 6/12/26, at 9:30 a.m., with Medical Records (MR), MR presented Resident 1's admission 7-day Bed Hold Agreement, dated 10/9/25, but was unable to provide Resident 1's Bed Hold Agreement from Resident 1's recent transfer to the hospital on 6/2/26. MR stated DON confirmed with MR there was no written Bed Hold Agreement provided to Resident 1 and/or to RR 1 before the transfer to hospital took place on 6/2/26. A review of the facility's policy and procedure (P&P) titled, Bed Hold, revised on July 2017, indicated, To ensure that the resident and/or his/her representative is aware of the Facility's bed-hold policy, and that such policy complies with state and federal law regulations.Transfer to an Acute Care Hospital/Therapeutic Leave: A. the facility notifies the resident and/or representative, in writing, of the bed hold, option, any time the resident is transferred to an acute care hospital or request therapeutic leave.C. When the resident or his/her representative provides notice within 24 hours of transfer that the resident elects his/her right to hold the bed, the Facility keeps that bed available for seven (7) days.Bed Hold Agreement will be kept in the resident's medical record. The completed form will remain in the medical record with a copy placed in the resident's financial folder in the Business Office.

Based on observation, interview and record review the facility failed to honor one out of 3 residents (Resident 1) the right to retain personal possessions when Resident 1's personal possessions were not listed in detail and verified at admission. This failure had the potential to cause Resident 1 to feel their belongings were not treated with respect and had the potential to result in Resident 1 missing items without documentation of ownership.During a review of Resident 1's admission Record, printed 3/17/26, the Record indicated Resident 1 was admitted to the facility in 2024 with a diagnosis of depression. During a review of Resident 1's Brief Interview for Mental Status (BIMS - a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information, dated 3/6/26, the record indicated Resident 1's BIMS score was 14 (a BIMS score of thirteen to fifteen is an indication of intact cognitive response). During an interview on 3/16/26, at 12:58 p.m., with Resident 1, Resident 1 stated staff refused to complete an inventory of their items. Resident 1 stated they were missing a lot of items. Resident 1 stated they felt upset, disrespected, and insulted. During a concurrent interview and record review on 3/17/26, at 10:42 a.m., with Social Worker (SW) 1, Resident 1's Personal Effects Inventory Form, undated and Resident 1's Theft and Loss Report dated 2/23/26, were reviewed. SW 1 stated Resident 1's Personal Effects Inventory Form, was not signed or completed. SW 1 stated Resident 1's personal belongings were not fully inventoried. SW 1 stated Resident 1's Theft and Loss Report, indicated Resident 1 allegedly lost 4 boxes of clothes estimated at $971.17. SW 1 stated they were waiting for Resident 1 to provide receipts for the missing items to resolve the claim. SW 1 stated it was important to inventory Resident's property to keep track of everything in case something went missing. SW 1 stated it was important to resolve lost item investigations in a timely manner because residents may have valued the missing items. During an interview on 3/17/27, at 11:50 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 1's personal items should have been inventoried and Resident 1's Personal Effects Inventory Form, should have been completed when they were admitted , readmitted or when they came back from the hospital. RNS 1 stated that it was important to acknowledge and inventory resident's belongings because the facility was responsible to safeguard their belongings. During a review of the facility's policy and procedure (P&P) titled, Theft and Loss Program, revised 10/2/25, the P&P indicated, The inventory list will be completed upon admission, updated when items are added or removed from the facility, and upon transfer/ discharge. The P&P indicate, The administrator or designee investigates all reports of stolen items and documents the investigation on the Theft and Loss Report. The investigation may consist of the following. a review of the Resident's inventory record to determine if the missing items were recorded. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised 1/1/12, the P&P indicated, State and federal laws guarantee certain basic rights to all residents of the Facility. These rights include, but are not limited to, a resident's right to. Retain and use personal possessions to the maximum extent that space and safety permit.

Based on interview and record review, the facility failed to protect personal belongings for one resident (Resident 1), when Resident 1's clothes and personal items were missing and were not accounted for.This failure had compromised the right of Resident 1 to retain personal possessions. A review of the admission record for Resident 1 indicated that Resident 1 was admitted on [DATE], and initially admitted [DATE] with diagnoses that included diabetes, hypertension, and end-stage kidney disease on dialysis. Resident 1 was discharged on 10/9/24. During a telephone interview on 8/12/25, at 8:48 a.m. with Resident 1's Responsible Party (RP), RP stated that upon discharge, Resident 1 had missing personal items. RP stated Resident 1's missing personal items were reported to Social Services Director (SSD) 2 during Resident 1's stay in 2024. RP stated there was no inventory of Resident 1's personal items provided to Resident 1 and/or family upon discharge. During an interview on 8/12/25 at 2:55 p.m. with the current Social Services Director (SSD 1), SSD 1 stated they should have a theft and loss form in the log when resident's belongings were reported missing. SSD 1 stated SSD 2 was no longer working in the facility. During a concurrent interview and record review of the facility's 2024 Theft and Loss Log, on 8/12/25 at 4:05 p.m. with SSD 1, SSD 1 stated there was no record of missing clothes/items for Resident 1. During a telephone interview on 8/13/25 at 12:38 p.m. with the Medical Records Director (MRD), a request was made for a record of Resident 1's inventory of personal belongings upon admission and discharge. MRD provided Resident 1's inventory of belongings upon admission, but none was provided for the discharge. MRD stated they did not have the record. During a review of a copy of Resident 1's inventory form upon admission, titled Inventory of Personal Effects signed 11/16/22, the form indicated two coats, two jackets, one shoes [pair], one black shirt, three sweaters, two watches (one brown and one brown) and another inventory form, titled Resident Inventory Form B (Per MRD, it was an added inventory in August 2024). The form indicated one stripe red & white T shirt, but with no date and signature. During a concurrent telephone interview and record review on 8/13/25 at 12:45 p.m. with the Director of Nursing (DON), DON acknowledged the facility did not have Resident 1's Inventoried list of personal belongings upon discharge. DON stated the original would have been given to the Resident and/or RP and they would have a copy of it. DON also stated there was no information on Resident 1's discharge summary note about the resident's inventory of personal belongings. A review of the signed inventory form on admission indicated, Instructions:.Upon discharge, use the columns to indicate that all personal belongings are accounted for. During a review of the facility's policy and procedure (P & P) titled, Personal Property, dated 7/14/17, the P&P indicated, To ensure the facility takes reasonable steps to protect resident's property.the facility will return inventoried personal items to residents or their representative upon discharge. the resident/resident representative will review the Resident inventory to ensure all personal items are taken. The resident/resident representative will sign the inventory indicating that all personal property is released to them. If an item(s) is missing, the staff will initial a search and notify Social Services/ designee in accordance with the Theft and Loss policy for resolution. During a review of the facility's P&P titled, Theft and Loss, dated 7/11/17, the P&P indicated, To assist residents in safeguarding their personal property. At the time of admission and discharge, Facility staff complete a Resident Inventory. Social Services staff documents report of lost and stolen resident property on .Theft and Loss Log.

Based on observation, interview and record review, the facility failed to assist one of five sampled residents (Resident 1) to push the wheelchair safely, while she was sitting in her unlocked wheelchair, sliding down the slope of the ramp (ramp is a slope or an incline, a surface that tilts from one level to another) to enter the smoking patio on the left side of the facility. This failure resulted in Resident 1 falling out of wheelchair facing downwards, sustaining a contusion (bruise caused by direct blow to the body that can cause damage to the surface of the skin and to deeper tissues as well) of nose, closed fracture (broken bone) of nasal bone and feeling embarrassed. Findings: During a record review of Resident 1's Admission Record (record with residents' basic personal information), the record indicated Resident 1 was admitted to the facility in January 2023. A review of Resident 1's Minimum Data Set (MDS, an assessment used to guide care), dated 11/19/24, indicated Resident 1 was usually able to make herself understood and was usually able to understand others. The MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 11 out of 15, indicated moderately cognitive (mental) impairment. The assessment indicated Resident 1 used Manual wheelchair for mobility. The assessment also indicated Resident 1 had diagnoses of cervical spinal stenosis (space in back bone in the neck area becomes small pressing the nerves going through the spinal cord), gout (a painful form of inflammation of joints), bilateral osteoarthritis (when tissues in the joint break down) of knees and left shoulder. During a record review of Resident 1's untitled Care Plan, dated 11/28/23, the care plan indicated Resident 1 had impaired physical mobility, she was at risk for decline in Activities of Daily Living (ADLs) and functional mobility. The Care plan indicated to assist Resident 1 in performing movements/tasks and monitor for environmental barriers to mobility. Review of an untitled care plan, dated 12/11/24, indicated Resident 1 had decreased functional mobility with wheelchair, had poor seating and positioning and there was a need for assistance with personal care. During a concurrent observation and interview on 2/6/25 at 10:38 a.m. with Director of Environment (DOE), facility's smoking patio area on the left side of building was observed. There was a ramp on the left side of the facility guarded by a gate going into smoking area. The ramp was made of brown plastic board slacks, and the first two slacks were uneven with cracks in the cement. The ramp had twelve pieces of black nonskid straps spaced out and taped on it. The DOE stated the first two boards created a divot (small hole) and became uneven at times. During an interview on 2/6/25 at 10:48 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had previous falls in the past and was at high risk for falls. LVN 1 stated Resident 1 was a smoker, and she was the charge nurse for Resident 1 on 12/13/24. LVN 1 stated on 12/13/24 around 10:00 a.m., Resident 1 was going outside to smoke with a Certified Nurse Assistant (CNA 1). LVN 1 stated Resident 1 slipped and fell on her left side and succumbed an injury to nose and left arm. LVN 1 stated after injury Resident 1 was alert and responsive but was bleeding heavily from nose. LVN 1 stated 911 was called, Resident 1 went to the emergency room and returned the same day in the evening. During an interview on 2/6/25 at 10:55 a.m. LVN 1 stated she recalled that on 12/13/24, CNA 1 tried to wheel two residents (Resident 1 and Resident 2) at the same time. LVN 1 stated it was not safe for one staff member to push two wheelchair bound residents at the same time because staff needed two hands to push one wheelchair safely. During an observation and interview on 2/6/25 at 11:26 a.m. Resident 1 was sitting upright in a wheelchair in Activity Room. Resident 1 stated staff usually wheeled her whenever she needed to go through the ramp to go the smoking area; Resident 1 stated on 12/13/24, she was under the impression that CNA 1 was pushing and controlling her wheelchair from the behind, but she was unaware CNA 1 was pushing Resident 2's wheelchair at that time. Resident 1 stated she went down the ramp too fast and fell out of wheelchair. Resident 1 stated she felt embarrassed after falling out of wheelchair as that had never happened before. Resident 1 stated she was bleeding from nose and was taken to the emergency room after the fall. During an interview on 2/6/25 at 12:08 p.m. Director of Nursing (DON) stated facility had designated staff monitoring the smoking residents all the time. The DON stated, on 12/13/24 CNA 1 was the assigned staff to monitor the smoking area at the time of incident. The DON stated CNA 1 was behind Resident 1 but was pushing Resident 2 down the ramp. The DON stated Resident 1 fell down ramp and out of wheelchair. The DON stated the incident was avoidable, if CNA 1 communicated with Resident 1 that she was not pushing Resident 1 wheelchair at the time, she was pushing Resident 2. The DON stated facility installed twelve pieces of black reflector nonskid tape on the ramp after Resident 1's fall. The DON also stated CNA 1 did not work at the facility anymore. During an interview on 2/6/25 at 12:25 p.m. Resident 2 stated she remembered the incident when Resident 1 fell out of wheelchair on 12/13/24. Resident 2 stated she was in her wheelchair, behind Resident 1 when they were going down the slope of the ramp, to the smoking area. Resident 2 stated she witnessed Resident 1 wheeled herself, without any assistance from the staff, fell out of her wheelchair, got bloody nose and was taken by ambulance. During a review of Resident 1's Nursing Progress Notes, dated 12/13/24, the notes indicated [Resident 1] fell outside of the building from the wheelchair when going out for smoke at 11:30 am, fell on the cemented floor and she was bleeding the left side of the nose. Per [staff] she fell on her left arm. Kept resident flat on the floor with sheet underneath and covered with blanket, gave pressure on the left nose with gauge. Applied ice top of the nose. 911 called [a way to get immediate help from ambulance service] .sent out to [Acute Care Hospital- ACH]. During a review of Resident 1's After Visit Summary (AVS) from the post fall hospitalization at ACH, dated 12/13/24, the AVS indicated Resident 1 sustained contusion of nose and closed fracture of nasal bone.

Based on interview and record review, the facility failed to protect one of five sampled residents (Resident 4) from physical abuse, when Resident 5, with a known of history of aggressive behavior, hit Resident 4 with a bed power cord (a thick electrical cord that connects the hospital bed with a power outlet). The failure resulted in Resident 4 suffering from a bleeding facial/scalp wound and received and hospitalization for further care. Findings: During a review of Resident 4's Admission Record (a document that records a patient's information when they are admitted to a hospital or other healthcare facility), printed on 2/6/25, the record indicated Resident 4 was admitted to the facility in November 2023 with vascular dementia (a loss of brain function, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior). During a review of Resident 4's Minimum Data Set (MDS, an assessment used to guide care), dated 9/5/24, the MDS indicated Resident 4's Brief Interview of Mental Status (BIMS, is a scoring system used to determine the resident ' s cognitive status) score of eight (8) out of 15, indicating Resident 4 was moderately cognitively impaired. During a review of Resident 5's Admission Record, printed on 2/6/25, the record indicated Resident 5 was admitted to the facility in November 2022 with diagnoses of unspecific dementia, unspecific psychosis (a mental health condition characterized by a loss of contact with reality that can cause significant distress and impairment in daily functioning) and anxiety (feeling of unease, worry, fear, and apprehension) During a review of Resident 5's MDS assessment, dated 10/5/24, the MDS indicated Resident 5's BIMS score was14 out of 15, indicating Resident 5 was cognitively intact. During a concurrent interview and record review on 2/6/24 at 11:30 a.m. with MDS Coordinator (MDSC), Resident 4's Nursing Progress Notes, dated 9/24/24, were reviewed. Licensed Vocation Nurse (LVN) 4 documented, at 0015, [LVN] [heard] a shout from the room, help rushed in to see [Resident 4] bleeding profusely from the head .[Resident 5] hit [Resident 4] with bed control cord on her head .called 911 immediately, and she was transferred to [Acute care Hospital] by paramedic for further evaluation . MDSC stated Resident 4 did not come back to the facility after this hospitalization . During a concurrent interview and record review on 2/6/25 at 11:40 a.m. with MDSC, Resident 5's Nursing Progress Notes, dated 9/24/24 and Behavior Care Plans, dated 8/26/24, were reviewed. LVN 4 documented [Resident 5] hit [Resident 4] with her bed control cord on her head, to the face . MDSC stated Behavior Care Plan indicated Resident 5 is/has potential to be physically aggressive, threatening to hit roommate with a hanger, related to anger. The MDSC stated Resident 5 had a few room-changes in the past because of conflict with prior roommates. During an interview on 2/6/25 at 12:30 p.m. with Director of Nursing (DON), DON stated she was aware of the incident between Resident 4 and Resident 5. The DON stated the staff involved in the incident did not work at the facility anymore. The DON stated the involved staff told her, on 9/24/24 when they rushed to Resident 4 and 5's shared room, they saw Resident 5 was sitting on the floor, swinging the bed power cord in her hand, and Resident 4 was bleeding heavily. During a phone interview on 2/6/25 at 4:57 p.m. with LVN 4, LVN 4 stated she heard one of the staff members was shouting that Resident 4 was bleeding, and she rushed to Resident 4's room. LVN 4 stated Oh, my gosh, there was a lot of blood on [Resident 4's] face and head. LVN 4 stated she had to put pressure on Resident 4's head to stop the bleeding and called 911 for further care. During a review of the facility's policy and procedure (P&P) titled Abuse-Prevention, Screening, and Training Program, revised 7/2018, the P&P indicated the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment and develops facility policies, procedures, training programs, and screening and prevention system to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 2 did not have access to facility residents and their personal care, after one of five sampled residents (Resident 3) alleged that CNA 2 hit him. CNA 2 continued to provide care to Resident 3 and at least 18 other residents for 12 more hours after the allegation was made. This failure placed Resident 3 and other residents at the facility at risk for abuse and further complications. Findings: During a record review of Resident 3's undated Admission Record (a document with patient's basic personal information), the record indicated Resident 3 was admitted to the facility in April 2022. During a review of Resident 3's Minimum Data Set (MDS, an assessment tool used to guide care), dated 10/11/24, showed Resident 3's short-term memory was intact. A record review of Resident 3's Nursing Progress Notes, dated 9/14/24, the notes indicated Licensed Vocational Nurse (LVN) 3 documented, on 9/14/24 around 7:30 pm resident called 911. Paramedic is here to [check] him. Resident stated he is physically hurt by CNA [with CNA 2's full name] .they recommended to us to keep monitoring him . During a concurrent phone interview and record review with Director of Nursing (DON) on 2/7/25 at 4:10 p.m., the facility's documents titled Nursing Staffing Assignment and Sign- in Sheet, dated 9/14/25, were reviewed. The DON stated the Sign- In Sheet indicated CNA 2 worked Shift 2 and Shift 3. The Sign- in Sheet indicated CNA 2 started working on 9/14/24 at 3:40 p.m. and did not leave the facility until 7:37 a.m. on 9/15/24. The DON stated she was under the impression that CNA 2 was sent home after Resident 3 made an allegation of abuse against CNA 2 but was unable to state why Sign-in Sheet indicated that CNA 2 continued to work for 12 more hours in the resident care areas even after the abuse allegation was still under investigation. During a phone interview on 2/7/25 at 8:45 a.m. with CNA 2, he stated he recalled Resident 3 becoming upset at him, and then police came to the facility on the evening of 9/14/24. CNA 2 stated police talked to him about Resident 3. CNA 3 stated however, nobody, including facility staff told him that Resident 3 had alleged that he had abused Resident 3. CNA 3 stated he did not hit Resident 3, but he kept his distance from Resident 3 after the police left the facility and continued working for rest of the evening and night shift, until the morning of 9/15/24. CNA 3 stated he continued to provide care to all his assigned residents. During a phone interview on 2/7/25 at 12:42 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated she was the nurse assigned to Resident 3 on 9/14/24. LVN 3 stated she had started one week prior to incident. LVN 3 stated Resident 3 alleged CNA 2 kicked him, but it was an unwitnessed event. LVN 3 stated Resident 3 called the police by himself. LVN 3 stated she interviewed CNA 2, he denied the allegation and indicated nothing happened. During a phone Interview with LVN 3 on 2/7/25 at 1:46 p.m. LVN 3 stated she was not aware of the incident until the police arrived at the building. LVN 3 stated she was not sure if CNA 2 was removed from resident care areas and or sent home. During a phone interview on 2/11/25 at 1:39 p.m. with DON, DON stated CNA 2 provided direct personal care to at least 11-12 residents during evening shift and up to 18 residents during the night shift on 9/14/24. DON stated CNA 2 worked for at least 12 more hours after Resident 3 had alleged that CNA 2 hit him around 7:30 p.m. on 9/14/24. During a review of facility's Policy and Procedure (P&P) titled Abuse & Neglect- Reporting and Investigations, dated 1/1/24, the P&P indicated, 2. Immediate Action a. The Administrator or designated representative will provide for a safe environment for the resident as indicated by the situation . ii. If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident (s) and immediately suspend the employee pending the outcome of the investigation in accordance with facility policies.

Based on observation, interview, and document review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1. Fish being prepared to be served for lunch, which included time/temperature controlled for safety (TCS) foods (foods such as meat, including fish, are high potential for bacteria growth), was stored in the freezer with a temperature of 30 degrees (*) Fahrenheit (F), above 0 *F the food inside a freezer number (#) 2 will not be safe temperature for storage and may be at risk for bacterial growth, spoilage and food borne illness; facility did not ensure staff followed procedures in proper thawing of fish, creating an Immediate Jeopardy [IJ - a situation in which recipient(s) of care has suffered or is likely to suffer from gastrointestinal distress (nausea, vomiting, diarrhea), dehydration (when body loses fluids and body does not have fluids to carry out its normal functions) and/or systemic infections (infection in the bloodstream) from foodborne illness as a result of provider's noncompliance with one or more health safety requirements] situation. On 9/9/24, at 11:56 a.m., an IJ was called. The Administrator was notified of the IJ regarding improper thawing of fish and the temperatures of food stored above 0 *F in the freezer. On 9/9/24, at 12:20 p.m., it was verified fish prepared for lunch was discarded. On 9/9/24, at 3:07 p.m., it was verified the food in the freezer were discarded. On 9/9/24, at 3:20 p.m., an acceptable plan of action was provided by the Administrator. The actions to remove the IJ situation included: removal and discarding the fish prepared for lunch; food items in the freezer with the temperature of 30 *F were discarded; in-service was initiated by the Administrator and Registered Dietician to dietary staff; and corrective action taken; beef stew substitute was served; the freezer with a temperature of 30 *F will not be used for resident food storage until repairs are completed; Dinner menu supplies bought fresh for dinner and stored in other working freezer unit. On 9/9/24, at 3:40 p.m., while on-site the surveyors confirmed the IJ was removed. 2. Three-compartment sink (dedicated to cleaning and sanitizing utensils and equipment) was used as food preparation area; 3. Equipment was dirty and in poor conditions 4. Facility did not ensure storage freezer was at 0 degrees F and foods were not frozen solid; 5. Scoop was stored inside powdered thickener (substance use to thicken liquids to help people with swallowing difficulty); 6. Activity Director (AD) did not wear hair covering in the kitchen; 7. AD , [NAME] (CK) 1, Senior [NAME] President of Operations (SVPO), and Registered Dietician (RD) 2 did not wash hands in the kitchen; 7. Moldy and unusable foods were not discarded; 8. Grease trap under 3-compartment sink had thick yellow/brown greasy residue build up on top and around edges. 9. Garbage disposal was highly malodorous with food particles, white build-up around rubber edges; 10. Garbage bin was dirty with black residue on top of lid and around bin; 11. Dry food item did not have a use by date or open date; 12. Multiple refrigerated items were stored beyond use by. (1 gallon dill pickle opened 7/22/24 use by 8/22/24, 6 pounds (lbs -unit of measurement) container yellow mustard opened 6/17/24 use by 8/17/24). These failures had the potential to cause food borne illness to 65 residents who receive food from the kitchen. Findings: During a concurrent interview and observation on 9/9/24 at 9:24 a.m. with Dietary Manager (DM), a black portable blower fan placed on top of a stainless-steel rolling cart was dirty with white/brown/black residue stuck on the vents blowing air towards steam table (equipment that keep hot foods at safe temperature); DM acknowledged the dirty blower fan and removed from the kitchen. During a concurrent interview and observation on 9/9/24 at 9:30 a.m. with the DM, the reach-in refrigerator stored four tomatoes that were wrinkled with black spots, celery stalks had black spots, six bananas had white/gray spots and were mushy. The DM acknowledged these were unusable foods. DM then removed and discarded all unusable foods. During a review of the facility's policy and procedure (P&P) titled, Food Storage and Handling, dated, 6/4/24, indicated .6. Fresh Fruits Storage a. Fresh fruit should be checked and sorted for ripeness.e. Label and date all food items. During a concurrent interview and observation on 9/9/24 at 9:31 a.m. with DM, a stainless-steel bowl covered with foil was observed resting inside 3-compartment dishwashing sink. DM opened the foil and revealed the bowl containing fish fillet thawing without running water. DM stated, the fish was being prepared for today's lunch. During an observation on 9/9/24 at 9:55 a.m. the AD, AD did not wear hair covering inside the kitchen. AD walked towards kitchen counter, grabbed a food tray from clean stack without performing hand hygiene. During a review of facility's P&P titled, Dietary Department - Infection Control, revised date, 2/29/24, indicated 1. b. Cover hair, beard, and mustache with an effective hair restraint, such as hats, hair coverings, or nets while in any kitchen and food storage areas.2. Proper hand washing a. Upon entering the kitchen. b. Immediately before engaging in food preparation, including working with non-prepackaged food, clean equipment and utensils . During a concurrent interview and observation on 9/9/24 at 9:56 a.m. with the DM, the industrial can opener mounted to countertop next the stove was observed with crusty yellow/orange and black residue build up and blade coating was peeled off. DM acknowledged it was dirty then removed the shank of can opener (a long, narrow part of a tool connecting the handle to the operational end) from the mount. During a review of the facility's P&P titled, Can Opener Use and Cleaning, dated 10/1/14, indicated under II. Sanitation of Equipment .B. Scrub shank, paying special attention to blade and moving parts.F. Inspect the blade and replace if notched. During a concurrent interview and observation on 9/9/24 at 9:57 a.m. with [NAME] (CK) 1, CK 1 entered kitchen door from the hallway wheeling a rolling cart wearing gloves. CK1 then washed a rag in a 3-compartment dishwashing sink, and wiped the rolling cart. CK stated, she did not wash her hands because she was already wearing gloves. During a review of the facility's P&P titled, Dietary Department - Infection Control, revised date, 2/29/24, indicated .2. Proper hand washing a. Upon entering the kitchen.g. During food preparation, as often as necessary to remove soil and contamination, and to prevent cross-contamination when changing tasks. During a concurrent interview and observation on 9/9/24, at 9:57 a.m., with CK 1, scooper was seen inside powdered thickener container sitting on counter at the food preparation area. CK 1, removed the scooper and stated, it was not to be left inside the container. During an observation on 9/9/24 at 10:00 a.m., with DM, the blender in the food preparation area had white sticky residue around the surface and mobile pan rack (used to hold desserts) between reach-in refrigerator and food preparation area had white/yellow and brown debris on side bars. During a review of facility's P&P titled, Blender Use and Cleaning, dated 10/1/14, indicated, .II. G. Wash the base with detergent solution and clean cloth .H. Rinse the base with clean water and wipe with sanitizing solution using a clean cloth. During a concurrent interview and observation on 9/9/24, at 10:11 a.m., with the DM, reach-in freezer # 2's thermometer reading was 30 degrees F. DM stated the door to the freezer does not fully close. Multiple food items stored were soft to touch that included fish fillets, corn dogs, French fries, meatballs, kernel corn and hash browns. Multiple food items contained moisture inside the bags including spinach, green beans and green peas. Corn on cobs had freezer burn. During a review of the facility's P&P titled, Food Storage and Handling, dated, 6/4/24, indicated 2. Frozen Meat, Poultry and Food a. Frozen products purchased are to be held at a temperature of 0 degrees F or below . b.Examine products for signs of defrosting. c. Store items promptly at 0 degrees F or below.g. Refreezing of defrosted food is not recommended because of the increase in growth of food bacteria and the deterioration in food quality.10. Frozen Vegetable Storage a. Store frozen vegetables as purchased in a freezer with temperature of -10 degrees F to 0 degrees F. During a concurrent observation and interview on 9/9/24, at 10:26 a.m. SVPO walked towards kitchen freezer, did not perform hand hygiene.

Based on observation, interview and document review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when: 1. [NAME] failed to thaw fish safely in a sink. 2. [NAME] failed to report out of range temperatures on 9/9/24. 3. Dietary Manager was not able to state appropriate thawing procedures. 4. Dietary Manager was not able to state the importance of keeping freezer at proper temperature. These failures had the potential to result in food borne illness. Findings: During an interview on 9/9/24, at 10:26 a.m., with Dietary Manager (DM) and [NAME] (CK) 1, DM stated, the fish fillet inside 3-compartment dishwashing sink was going to be served for lunch. CK 1, then stated the fish fillet was taken out of the freezer at around 8:00 a.m. When asked which freezer did the fish fillet came from, CK 1 pointed to the freezer with temperature reading of 30 degrees F. During a concurrent observation and interview on 9/9/24 at 10:46 a.m. with DM, in the presence of Registered Dietician (RD) 1 and Senior [NAME] President of Operations (SVPO). DM stated, if corn on cob was covered in ice it meant freezer was working and everything inside was still good and safe to cook. RD 1 stated, freezer should be at zero degrees Fahrenheit (F) for safe storage of frozen food. RD 1 added, fish especially was a high risk for bacterial growth and could cause serious illness. RD 1 also added, fish prepared for today's lunch was not safe to be served to residents. RD 1 further added, produce that has been crystallized (with freezer burns) like corn on cob, meant it was thawed and re-frozen and should no longer be used for safety. During a concurrent observation and interview on 9/9/24, at 11:03 a.m., with CK 1, CK 1 pointed to freezer 2 and confirmed she retrieved the fish being prepared from this freezer. CK 1 further added, freezer 2's temperature was at 30 degrees F when she removed the fish at 8:00 a.m. CK 1 stated, she did not thaw fish under running water. CK 1 added, she washed and left the fish in colander then let it sit to drain. During a concurrent observation and interview, on 9/9/24 at 11:45 a.m., with CK 1 and RD 1, CK 1 was seen frying fish fillet. CK 1 stated, these were the fish that she prepared since 8:00 a.m., and will be served for lunch. RD 1 then stated, fish had to be continuously under running water before cooking. RD 1 further added, there was chance of bacterial growth and the fish may not be safe to serve to residents. During an interview on 9/10/24, at 12:35 p.m., with CK 1, CK 1 stated, she did not have competency evaluation with DM since he started employment. CK 1 further added, she has not been evaluated by a supervisor even prior to current DM. During an interview on 9/10/24, at 10:37 a.m., with the DM, DM stated, he was not evaluated by a Registered Dietician when he began his employment. DM also stated, he did not conduct nor completed competency skills check for the dietary staff. During an interview on 9/11/24, at 1:55 p.m., with Dietary Aide (DA) 1, DA 1 stated, she only had competency check done by previous supervisor three years go. DA 1 added, there was no ongoing or annual competency evaluation given by the DM. During an interview on 9/12/24, at 1:21 p.m., with the RD 1, stated she had never performed skills competency performance evaluation for the DM. RD 1, further stated, she has never been asked to do it. During an interview on 9/12/24, at 1:30 p.m., with CK 2, CK 2 stated she worked here for a long time and has not done any competency skills training for many years. During an interview on 9/13/24, at 12:42 p.m., with the Administrator (ADM), ADM stated, the DM was supposed monitor all kitchen staff performance to ensure competency. During a review of the facility's policy and procedure (P&P) titled, Meat Cookery and Storage, dated 7/1/14, indicated, under procedure I. Meat will be stored in a freezer of 0 degrees F or less until pulled for defrosting. II. Meat to be defrosted will be pulled three days prior to service and defrosted in a dry, cool area 41 degrees F or lower.B. If meat is frozen and needs a quick defrost, it may be defrosted in a pan or sink with constant running cold water until adequately defrosted for preparation. During a concurrent interview and record review on 9/11/24 at 10:37 a.m., with the DM, DM stated he did not complete staff competency for kitchen staff since he started employment in March 2024. DM also stated, he was unaware of the policy dietary staff competency. During a review of the facility's job description: Titled, Dietary Services Supervisor/Certified Dietary Manager, (undated) indicated under Administrative: Maintains all records and documentation according to Federal, State and Company requirements. Under Supervisory: .Monitors staff performance and addresses any needs. Evaluates quality of service accomplished by staff. During a review of the facility's P&P titled, Staff Competency Assessment, dated 3/17/22, indicated, Competency assessments will be performed upon hire during the employee's 90-day employment period, annually, or anytime new equipment or a procedure is introduced and as needed.II. All staff are required to have competency assessments by the Director of Staff Development or department manager based on their job description or assigned duties within the first 90 days of employment. III. The competency evaluations or sills checks will be done by an individual who has the licensure education and experience qualifying them to perform the competency assessment. IV. The annual evaluation of an employee will include review of completed competency assessments which may have been done throughout the year. During a review of facility's document titled, Dietary Quality Control Review, dated, 9/4/24, indicated under Clinical/Staffing J. Are all staff and Dietary Manager competencies in place at orientation and reevaluated at least annually - NOT MET. Under Observation indicated, Need competencies on new employees to be completed by the CDM (Certified Dietary Manager).

Based on observation, interview, and record review, the facility failed to assist four out of eight sampled residents (Resident 30, 46, 48, 52) with personal hygiene when: 1. Resident 30 and Resident 46's long facial hair was not shaved. 2. Resident 48 and Resident 52's fingernails were not clean and trimmed. These failures resulted in Resident 30 feeling yuck, Resident 46 feeling crutty and unkept and placed Resident 48 and Resident 52 at risk for getting infections from lack of proper hygiene and injuring themselves with long fingernails. Findings: 1.a. During a concurrent observation and interview, on 9/9/24 at 10:14 a.m. with Resident 30 in Resident 30's room, Resident 30's beard was approximately 1 centimeter (cm) long. Resident 30 stated he preferred to keep his mustache long, but his beard shaved. Resident 30 stated staff doesn't offer to help him shave. Resident 30 stated feeling yuck with the long beard. During a concurrent observation and interview, on 9/12/24 at 11:00 a.m. with Licensed Vocational Nurse (LVN) 2 in the activity room, Resident 30 was sitting on the wheelchair with long beard. LVN 2 stated Resident 30's beard looked long and needed to be shaved. During a record review of Resident 30's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) dated 7/11/24, indicated, Resident 30 required Partial/moderate assistance from staff with personal hygiene. b. During a concurrent observation and interview, on 9/9/24 at 9:45 a.m. with Resident 46 in Resident 46's room, Resident 46's beard was approximately 2 centimeters long. Resident 46 stated he doesn't remember when he was last shaved. Resident 46 stated staff doesn't offer to help him shave. Resident 46 stated feeling crutty and unkept with the long beard. During a concurrent observation and interview, on 9/9/24 at 9:52 a.m. with Certified Nursing Assistant (CNA) 5 in Resident 46's room, Resident 46's beard was long. CNA 5 stated Resident 46's beard was long and would assist Resident 46 with shaving. During a record review of Resident 46's MDS dated [DATE], indicated Resident 46 required Partial/moderate assistance from staff with personal hygiene. During an interview on 9/12/24 at 11:07 a.m. with CNA 9, CNA 9 stated there was no option in the Electronic Health Record (EHR) to document staff assistance of resident with shaving. CNA 9 stated a paper documentation of shaving was available at the nursing station one. During a concurrent interview and record review, on 9/12/24 at 11:20 a.m. with LVN 4 at the nursing station one, Resident Skin & Body Check form inside the white Shower Schedule binder was reviewed. The form indicated, date on when the resident was shaved. LVN 4 stated Resident Skin & Body Check form was the only place the staff documented assisting residents with shaving. LVN 4 stated she was unable to find documentation in the shower schedule binder when Resident 30 and Resident 46 was last shaved. LVN 4 stated there was only one shower schedule binder. LVN 4 stated the Director of Staff Development (DSD) kept the old Resident Skin & Body Check forms. During a concurrent interview and record review on 9/12/24 at 1:39 p.m. with the DSD in the DSD office, Resident Skin & Body Check form in a black Completed Shower Sheet Forms 2024 binder was reviewed, the binder indicated the months of June, July, August and September did not have any Resident Skin & Body Check forms. The DSD stated she had to check the completed forms in the DSD box located in the nursing station one. During a concurrent observation and interview on 9/12/24 at 1:46 p.m. with the DSD in the nursing station one, the DSD checked the completed Resident Skin & Body Check forms at the DSD box attached to the wall and inside the cabinet. The DSD stated the completed forms was not in the box nor the cabinet. During a concurrent interview and record review, on 9/12/24 at 1:50 p.m. with the DSD at the nursing station two, Resident 46's Resident Skin & Body Check form dated 8/13/24 in a black shower schedule binder was reviewed, the form indicated, Resident 46 had a bed bath and resident shaved was unmarked. The DSD stated no other documentation of Resident 30 and Resident 46 was in the shower schedule binder. During a review of the facility's policy and procedure (P&P) titled Resident Rights, dated 1/1/2012, indicated, Each resident is allowed to choose activities, schedule, and health care that are consistent with his or her interests, assessments and plans of care, including: Personal care needs such as grooming styles. During a review of the facility's (P&P) titled, Grooming, dated 1/1/12, indicated, The facility will work with residents to improve their ability to groom him/herself to promote independence, hygiene, comfort, self-esteem and dignity. 2a. During a review of Resident 48's admission record dated, 9/12/24, indicated Resident 48 was admitted to the facility on [DATE] with multiple diagnoses that included, surgical after care (treatment and care to ensure healing and prevent infection) following surgery on the digestive system and muscle weakness. During a review of Resident 48's Minimum Data Set (MDS- an assessment tool used to guide care) dated, 8/30/24, indicated Resident 48 had a Brief Interview for Mental Status (BIMS -a tool used to assess mental function) Score of 15. Meaning, Resident 48 was cognitively intact. The MDS also indicated, Resident 48 required substantial / maximal assistance with personal hygiene. During a concurrent observation and interview on 9/10/24 at 1:05 p.m. with Resident 48, Resident 48's toenails were overgrown, thick, and dirty with black matter underneath. Resident 48's fingernails were also long and dirty with brown matter underneath. Resident 48 stated, her toenails hurt, heavy and very uncomfortable. Resident 48 also stated, staff did do anything to clean and/or trim her toenails and fingernails. During a concurrent interview and observation, on 9/10/24 at 1:10 p.m. with Certified Nursing Assistant (CNA) 7, in the presence of Resident 48, CNA 7 acknowledged Resident 48 had thick, long, dirty toenails and dirty fingernails. CNA 7 stated, she did not include toenails and fingernails when she provided Activities of Daily Living (ADL) to Resident 48 because no one asked her to. CNA 7 added, Resident 48 can get infection if dirt from nails got in Resident 48's wound. During a concurrent interview and observation, on 9/10/24 at 1:18 p.m. with Licensed Vocational Nurse (LVN) 1, in the presence of Resident 48, LVN 1 agreed Resident 48 had overgrown, thick, dirty toenails and long and dirty fingernails. LVN 1 stated, it was everyone's responsibility to make sure Resident 48's nails are clean to avoid infection. 2b. During a review of Resident 52's admission record dated, 9/12/24, indicated Resident 52 was admitted to the facility on [DATE] with multiple diagnoses that included muscle weakness, reduced mobility, aphasia (difficulty speaking) following Cerebral Infarction (stroke), and need for assistance with personal care. During a review of Resident 52's MDS, dated [DATE], indicated Resident 52 was unable to make self-understood/unable to express ideas and wants. The MDS also indicated, Resident 52 was dependent on helper with personal hygiene. During a concurrent observation and interview on 9/10/24 at 1:30 p.m., with Registered Nurse Regional Consultant (RNRC), Resident 52 had overgrown toenails and fingernails with black matter underneath. RNRC stated, direct care staff should have ensured Resident 52's nails are cleaned. During a concurrent interview and record review on 9/12/24 at 12:05 p.m., with the Director of Nursing (DON), DON confirmed Resident 48 did not have diagnosis of Diabetes Mellitus (DM). DON added, there was no documentation nail care was done for Resident 48. DON stated, the expectation was for staff to ensure Resident 48 and Resident 52 had clean and trimmed nails. DON added, there was no excuse for staff not to keep residents overgrown and dirty nails as there was risk for infection.

Based on interview and record review the facility failed to ensure 4 Certified Nursing Assistants (CNAs) and 1 Licensed Vocational Nurse (LVN) had the appropriate competencies to care for residents when the facility did not complete Orientation Evaluation Checklists for LVN 1 and CNA 3, and Annual Performance Evaluations for CNAs 1, 2 and 4. This failure had the potential for resident care to be provided in an unsafe and incompetent manner. Findings: During a concurrent interview and record review on 9/12/24, at 11:59 a.m., with Director of Staffing Development (DSD), CNAs 1, 2, and 3 and LVN 1's personnel folders were reviewed. DSD stated CNA 1's personnel folder indicated CNA 1 was hired on 8/17/23 and did not have an Annual Performance Evaluation. DSD stated CNA 2's personnel folder indicated CNA 2 was hired on 5/17/23 and did not have an Annual Performance Evaluation. DSD stated Annual Performance Evaluations had to be done annually and were important to evaluate CNA's competency. DSD stated CNA 3's personnel folder indicated CNA 3 was hired on 5/23/24 and did not have an Orientation Evaluation Checklist. DSD stated Orientation Evaluation Checklists had to be done when staff were hired and were important to evaluate their competency. During an interview on 9/12/24, at 2:20 p.m., with CNA 4, CNA 4 stated they had not done an Annual Performance Evaluation in over a year. During a concurrent interview and record review on 9/12/24, at 2:36 p.m., with DSD, CNA 4's personnel folder was reviewed. DSD stated CNA 4's personnel record indicated her last Annual Performance Evaluation was on 8/4/22. During a concurrent interview and record review on 9/12/24, at 2:51 p.m., with DSD, LVN 1's personnel folder was reviewed. DSD stated LVN 1's personnel folder indicated they were hired on 1/31/24 and did not have an Orientation Evaluation Checklist. During an interview on 9/12/24, at 3:05 p.m., with CNA 1, CNA 1 stated they had not done an Annual Performance Evaluation in over a year. During an interview on 9/12/24, at 3:18 p.m. with Director of Nursing (DON), DON stated DSD was supposed to complete CNA Annual Performance Evaluations for each CNA every year from the date of hire and more often if there were any resident concerns. DON stated during Annual Performance Evaluations DSD was supposed to watch CNAs perform their skills and verify their competency and was important to identify any areas where they needed training. DON stated CNA and LVN Orientation Evaluation Checklists were supposed to be done before they work on the floor. DON stated Orientation Evaluation Checklists were important so staff know their scope of practice, to assess how safe they are practicing and to find any areas where the needed training. During an interview on 9/13/24, at 11:43 a.m., DON stated they did not have a Policy and Procedure on Annual Performance Evaluations or Orientation Evaluation Checklists.

Based on observation, interview, and record review the facility failed to ensure proper storage and labeling of medication and biologicals (made from a variety of natural sources human, animal, or microorganisms and are used to treat, prevent, or diagnose diseases and medical conditions) for one of one sample medication room and two of two medication carts when: 1. Three opened vials of Tuberculin Purified Protein Derivative (PPD- indicated to aid diagnosis of tuberculosis infection (TB) in persons at increased risk of developing active disease) was unlabeled and undated with an open date. 2. Two activase (a clot-busting medication. It helps the body to produce a substance that dissolves unwanted blood clots.) vials for a discharged resident (Resident 222) were stored in the refrigerator. 3. Thirteen expired Influenza (common respiratory illness. Symptoms often include fever, head, and body aches, coughing and a stuffy or runny nose.) vaccine vials were stored in the refrigerator. 4. Expired medications for Resident 13, 14 and 52 was stored in the medication cart. 5. Two opened fluticasone furoate-vilanterol inhalation powder (medication used to control wheezing, shortness of breath, coughing, and chest tightness caused by asthma and chronic obstructive pulmonary (COPD- a group of diseases that affect the lungs and airways, that includes chronic bronchitis and emphysema)) inhaler for Resident 59's was unlabeled and undated with an open date. These failures had the potential to result in unsafe medication administration and storage practices. Findings: 1. During a concurrent observation and interview on 9/9/24 at 3:24 p.m. with the Director of Nursing (DON) in the medication room, three 1 milliliter (mL) multi-dose vial of PPD was in the refrigerator without a vial cap and a label of the open date. The DON stated the nurse who opened the vial should label it with the open date because it expires in 30 days. During a review of the facility's policy and procedure (P&P) titled Storage of Medication, dated 4/2008, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. During a review of the Tuberculin PPD product information from www.fda.gov/media/74862/download?attachment, dated 11/2013, indicated, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. 2. During a concurrent observation and interview, on 9/9/24 at 3:28 p.m. with the DON, Resident 222's two 2 mL activase vials with an expiration date of 12/2025 was inside the medication refrigerator. The DON stated Resident 222 had been discharge. The DON stated the vials doesn't need to be stored in the medication destruction container because it was not expired. During a review of Order Summary, dated 4/9/24, the Order Summary indicated, Resident 222 had an order for activase to declog the peripherally inserted central catheter (PICC- a long, thin tube that goes through a vein in the upper arm. The end of this catheter goes into a large vein near the heart to help carry nutrients and medicines into the body.) line. During a review of undated Admission Record, printed on 9/11/24, the Admission Record indicated Resident 222 was discharged on [DATE]. During a review of the facility's (P&P) titled Medication Destruction, dated 12/2017, indicated Discontinued medication and medications left in the facility after a resident's discharge are destroyed . Medication is destroyed within 90 days from the date the medication was discontinued. 3. During a concurrent observation and interview on 9/9/24 at 3:35 p.m. with the DON in the medication room, thirteen unopened 5 mL multi-dose vials of Influenza vaccine with an expiration date of 6/30/24 was in the medication refrigerator. The DON stated the Influenza vaccines should have been stored in the medication destruction container and destructed. During a review of the facility's (P&P) titled Disposal of Medications and Medication-Related Supplies, dated 12/2018, indicated When medications are expired . the medications are stored in a separate location and later destroyed. 4. During a concurrent observation and interview on 9/10/24 at 10:47 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 13's 18 tablets of Sertraline (medication used to treat depression) 25 milligrams (mg) medication bubble pack with an expiration date of 7/1/24, Resident 14's 30 tablets of Metformin (medication that help lower blood sugar levels in people with type 2 diabetes.) 1,000 mg medication bubble pack with an expiration date of 9/8/24 and Resident 52's one uncapped 3 mL vial of Humulin R 100 unit insulin (an essential hormone. It helps the body turn food into energy and manages blood sugar levels.) with an open date of 8/7/24 was in the medication cart 2. LVN 2 stated Residents 13, 14 and 52 were active residents in the facility. LVN 2 stated medication cart was checked for expired medications once a month by the nurses, Assistant DON, and DON. During a review of Order Summary, dated 8/9/24, the Order Summary indicated, Resident 13 had an order for Sertraline 25mg one time a day. During a review of Order Summary, dated 7/24/24, the Order Summary indicated Resident 14 had an order for Metformin 1,000mg two times a day. During a review of Order Summary, dated 4/30/24, the Order Summary indicated Resident 52 had an order for Humulin R 100-unit insulin two times a day. During a review of the Humulin R product information from https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/018780s180lbl.pdf, revised 6/2022, indicated, Throw away all opened vials after 31 days, even if there is still insulin left in the vial. During a review of the facility's policy and procedure (P&P) titled Storage of Medication, dated 4/2008, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. During a review of the facility's (P&P) titled Disposal of Medications and Medication-Related Supplies, dated 12/2018, indicated When medications are expired . the medications are stored in a separate location and later destroyed . Medications are removed from the medication cart or storage area prior to expiration. 5. During a concurrent observation and interview, on 9/10/24 at 11:56 p.m. with LVN 1, Resident 59 had two opened fluticasone furoate-vilanterol inhalation powder 200 mcg/25 mcg inhaler was undated and unlabeled with open date. LVN 1 stated the two inhalers did not have an open date. During a review of Order Summary, dated 7/24/24, the Order Summary indicated Resident 59 had an order for fluticasone furoate-vilanterol inhalation powder 200 mcg/25 mcg inhaler one puff orally one time a day. During a review of the facility's policy and procedure (P&P) titled Storage of Medication, dated 4/2008, indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. During a review of the fluticasone furoate-vilanterol inhalation powder inhaler product information from https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/204275s012lbl.pdf, revised 5/2017, indicated, Safely throw away the inhaler in the trash 6 weeks after you open the foil tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler.

Based on observation, interview, and record review, the facility failed to maintain and observe infection control practices when: 1. Certified Nursing Assistant (CNA) 6 picked up a soiled linen on the floor of Resident 37 and Resident 58's room and disposed the soiled linen in the cart across Resident 37 and Resident 58's room. 2. Licensed Vocational Nurse (LVN) 3 did not perform hand hygiene and did not put on a new pair of gloves prior to administering eye drops to Resident 51. 3. LVN 3 did not remove gloves after applying topical medication (a medication that is applied to a particular place on or in the body.) to Resident 20. 4. Resident 17, 22 and 44's nasal cannula tubing was undated, unlabeled and was touching the floor. These failures had the potential for cross contamination and spread of infections among residents at the facility. Findings: 1. During an observation on 9/9/24 at 12:32 p.m. in Resident 37 and Resident 58's room, CNA 6 picked up a white linen on the floor with a gloved hand and proceeded to walk out of the room. During a concurrent observation and interview, on 9/9/24 at 12:33 p.m. with CNA 6, CNA 6 walked out of Resident 37 and Resident 58's room holding the white linen and threw the linen in the cart labeled soiled linen across Resident 37 and Resident 58's room. CNA 6 stated the linen was dirty. CNA 6 stated the dirty linen should be placed inside a plastic bag during transport or the soiled linen cart should be placed in front of the resident's room door to prevent the spread of infection. During a review of the facility's policy and procedure (P&P) titled Soiled Laundry & Bedding, dated 9/2016, indicated Facility staff handle soiled laundry and bedding in a manner that prevent gross microbial contamination of the air and those handling the linen . Contaminated laundry is placed in a bag or container at the location where it is used to prevent contamination during transport. 2. During medication administration observation on 9/10/24 at 8:19 a.m. with LVN 3 in Resident 51's room, LVN 3 moved Resident 51's bedside table away from Resident 51's bed and pulled the privacy curtain with her left gloved hand. LVN 3 informed Resident 51 that she would give the eye drops. LVN 3 proceeded to pull Resident 51's left lower eyelid with the same left gloved hand to administer the Dorzolamide HCl Solution (used to treat glaucoma, a condition in which increased pressure in the eye can lead to gradual loss of vision.) 2% eye drop. Resident 51 stated he did not want the eye drop. During an interview on 9/10/24 at 8:50 a.m. with LVN 3, LVN 3 stated a new pair of gloves should have been worn before giving the eye drops to prevent spread of infection. During an interview on 9/11/24 at 2:10 p.m. with the DON, the DON stated the staff should perform hand hygiene before wearing clean gloves and not touch resident's surroundings. The DON stated administering eye drops was a clean procedure and a clean glove should be used to prevent infection. During a review of facility's P&P titled Eye Drops, dated 1/1/12, indicated Gloves are worn when contact with body fluids or secretions are expected . Wash hands before and after administration of eye drops. During a review of facility's P&P titled Hand Hygiene, dated 9/1/20, indicated, The facility considers hand hygiene as the primary means to prevent the spread of infections . Wearing gloves does not replace the need for hand hygiene. 3. During medication administration observation on 9/10/24 at 8:42 a.m. with LVN 3 in Resident 20's room, LVN 3 used her gloved left hand to open Resident 20's right and left lower abdominal fold and shook the Nystatin (treats fungal or yeast infections of the skin) powder bottle with her right gloved hand to apply the powder. LVN 3 proceeded to move Resident 20's bedside table closer to the resident with the same gloved hands. During an interview on 9/10/24 at 8:50 a.m. with LVN 3, LVN 3 stated gloves should be removed after the Nystatin powder was applied. During an interview on 9/11/24 at 2:13 p.m. with the DON, the DON stated gloves should be removed after applying the powder, perform hand hygiene and not touch anything in between. During a review of facility's P&P titled Medication Administration-General Guidelines, dated 10/17, indicated Hands are washed before and after administration of topical medications. During a review of facility's P&P titled Personal Protective Equipment, dated 1/1/12, indicated Hands are washed before and after removing gloves. 4. During a review of Resident 22's admission record, dated 9/13/24, indicated Resident 22 was admitted to the facility on [DATE], with multiple diagnoses that included Chronic Respiratory Failure (a condition that occurs when the lungs are unable to get enough oxygen into the blood or remove enough carbon dioxide from the blood) with Hypoxia (a condition that occurs when the body's tissues, blood, or cells don't have enough oxygen to function normally) During a review of Resident 44's admission record, dated 9/10/24, indicated Resident 44 was admitted to the facility on [DATE], with multiple diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - ongoing lung condition caused by damage to lungs), Chronic Respiratory Failure with Hypoxia. During a review of Resident 17's admission record, dated 9/10/24, indicated Resident 17 was admitted to the facility on [DATE] with multiple diagnoses that included COPD, wheezing, dependence on supplemental oxygen. During a concurrent observation and interview on 9/10/24, at 12:46 p.m. with Licensed Vocational Nurse (LVN) 2, in Resident 22's room. Resident 22's oxygen tubing was on the floor, kinked and stuck under wheel of Resident 22's wheelchair. LVN 2 acknowledged the oxygen tubing was not labeled and removed the tubing from the floor. LVN 2 stated, it was infection control issue. During a concurrent observation and interview on 9/10/24, at 12:50 p.m. with LVN 2, in Resident 44's presence, LVN 2 picked up oxygen tubing from the floor and stated the tubing was too long that's why it was easy to fall on the floor. LVN 2 stated, Resident 44's oxygen tubing was not labeled. During a concurrent observation and interviews on 9/10/24, at 12:55 p.m. with LVN 2, in Resident 17's presence, Resident 17's oxygen was not labeled. LVN 2 stated, if oxygen tubing are not labeled it was unknown when the tubing was changed, and when it was due to be changed. LVN 2 further added, this was infection control issue. During an interview on 9/12/24 11:22 p.m. with the Director of Nursing (DON), DON stated oxygen tubing must be labeled with date when changed. DON also stated, if tubing was not dated, nursing staff will not know when it will be due to be changed. DON added, oxygen tubing should not be touching the floor, must be secured to head of bed. DON further added, it was both infection control issue when the oxygen tubing is touching the floor and/or if unlabeled. During a review of facility's policy and procedure (P&P), titled Oxygen Therapy, dated November 2017, indicated, Oxygen is administered under safe and sanitary conditions to meet resident needs. The P&P also indicated, under Procedure I.E. The humidifier and tubing should be changed no more than every 7 days and labeled with the date of change. II.C. Oxygen tubing, mask, and cannulas will be changed no more than every seven (7) days and as needed. The supplies will be dated each time they are changed.

Based on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 30) was treated with dignity and respect when Resident 30 attended activity wearing facility gown and disposable undergarment was soaking wet with urine. This failure had the potential to negatively impact Resident 30's sense of self-worth and self-esteem. Findings: During an observation on 9/9/24 at 12:38 p.m. in the activity room, Resident 30 was sitting on the wheelchair wearing facility gown and liquid was dripping from the wheelchair onto the floor. Other residents in the room were wearing personal clothes. During a concurrent observation and interview on 9/9/24 at 12:40 p.m. with the Activity Director (AD) in the activity room, the AD pulled up Resident 30's gown to check the disposable undergarment. The AD stated Resident 30's diaper was soaking wet with urine. The AD stated Resident 30 wearing gown and soaking wet affected their dignity. During a review of the facility's policy and procedure titled, Resident Rights, dated 1/1/12, indicated, Employees are to treat all residents with kindness, respect, and dignity and honor the exercises of resident's rights.

Based on observation, interview, and record review, the facility failed to ensure one of 4 sampled residents (Resident 11), had a Doctor's Order for supplemental oxygen before they received the supplemental oxygen. This failure had the potential for Resident 11 to receive supplemental oxygen inappropriately and in an unsafe manner. Findings: A review of Resident 11's Admission Record printed 9/12/24, indicated Resident 11 was admitted to the facility in 2024 with multiple diagnoses including a primary admitting diagnosis of Acute and Chronic Respiratory Failure (a condition that occurs when the lungs are unable to get enough oxygen into the blood or remove enough carbon dioxide from the blood) with Hypoxia (a condition that occurs when the body's tissues, blood, or cells don't have enough oxygen to function normally). During a concurrent observation and interview on 9/09/24, at 10:48 a.m., Resident 11 was observed as they used an oxygen concentrator (a medical device that gives you extra oxygen) via nasal canula (a thin, flexible tube with two prongs that sit inside the nostrils and delivers oxygen) at a rate of 2L (liters). During a concurrent interview and record review on 9/11/24, at 1:30 p.m., with Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) Coordinator (MDSC), Resident 11's Doctor's orders, were reviewed. MDSC stated Resident 11 did not have a Doctor's Order for an oxygen concentrator. During a concurrent interview and record review on 9/12/24, at 11:07 a.m. with Assistant Director of Nursing (ADON), Resident 11's Doctor's Orders, were reviewed. The orders indicated Resident 11 had a Doctor's Order dated 9/11/24, at 14:39 p.m., for Oxygen 2 liters as needed for SOB (shortness of breath), to keep O 2 (oxygen) above 90% Via N/C (Nasal Cannula). ADON confirmed Resident 11 did not previously have a Doctor's Order for O2. ADON stated Residents needed a Doctor's Order for O2 because it can harm the resident. During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, revised November 2017, the P&P indicated, To ensure the safe storage and administration of oxygen in the Facility. The P&P indicated Licensed Nursing staff will administer oxygen as prescribed. The P&P indicated Administer oxygen per physician orders.

Based on observation, interview, and record review, the facility failed to ensure the call light (a device used by a patient to signal his or her need for assistance) was within reach for one of three sampled Residents (Resident 56). This deficient practice resulted in the delay of care and services. Findings: During a review of Resident 56's face sheet dated, 9/10/24, indicated Resident 56 was admitted to the facility on [DATE]. During a review of Resident 56 Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) dated 8/13/24, the MDS indicated, Resident 56 had multiple diagnoses that included, muscle weakness, polyneuropathy (nerve damage causing problems with sensation, coordination, or other body functions). The MDS also indicated Resident 56 had a Brief Interview for Mental Status (BIMS - is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status) Score of 13, meaning Resident 56 had intact cognition. During a concurrent observation and interview on 9/9/24 at 10:18 a.m. Resident 56's call light was on the floor behind the bed. Resident 56's urinary collection bag measured 1600 cubic centimeter (cc - measure of volume). Resident 56 stated, staff did not empty drainage bag and it felt heavy. Resident 56 also stated, he could not ask for help because staff took his call light from within reach. During a concurrent observation and interview on 9/10/24 at 10:23 a.m. with Certified Nursing Assistant (CNA) 8, CNA 8 stated, she was not aware Resident 56 needed assistant. CNA 8 then picked up the call light from the floor behind Resident 56's bed and stated, I should have checked call light when I came this morning. During an interview on 9/12/24, at 11:22 a.m., with the Director of Nursing (DON), DON stated the expectation for the nursing staff was to ensure call light for Resident was within reach. DON further added, especially for Resident 56 who required extensive assistance. During a review of Resident 56's care plan dated 8/6/24, indicated Resident 56 was at risk for fall related to diabetes, polyarthritis (swelling of one or more joints), chronic pain, CKD (chronic kidney disease - gradual loss of kidney function) . One of the interventions is: Be sure the Resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. During a review of facility's policy and procedure, titled Communication-Call System, dated 1/1/12, indicated, Under Purpose: To provide a mechanism for residents to promptly communicate with Nursing Staff. Under Policy: The facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities.Under Procedure II. Call cords will be placed within the resident's reach in the resident's room.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled Residents (Resident 1) had staff identify themselves with name badges while they received care. This failure had the potential to cause Resident 1 emotional distress and anxiety. Findings: During a review of Resident 1's face sheet, dated 4/12/24, face sheet revealed Resident 1 was admitted to the facility in 1/2024. During a review of Resident 1's Minimum Data Set (MDS- an assessment tool used to guide care) dated 2/1/24, the MDS indicated Resident 1 had multiple diagnoses that included arthritis (swelling and tenderness of one or more joints) and anxiety disorder. The MDS also revealed Resident 1 had a Brief Interview for Mental Status (BIMS -a screening tool used to assess cognition) score of 15/15. Meaning, Resident 15 was able to understand and understood others. During a telephone interview on 4/12/24, at 8:26 a.m. with the Responsible Party (RP), RP stated there were multiple issues with staff members that included leaving Resident 1 in bloody bed sheets. RP further stated, she did not know name of staff assigned because they do not wear name badges. RP also stated, staff members did not identify themselves when asked. During an interview on 4/12/24 at 10:47 a.m. in Resident 1's room, Resident 1 stated, there were several issues with staff member that included neglecting his request to shower. When asked which staff in particular, Resident 1 stated, it was hard to remember staff members assigned to him because they do not wear identification (ID) badges. During a concurrent observation and interview on 4/12/24 at 11:07 a.m., CNA 1 entered Resident 1's room, and was observed without a name badge. CNA 1 stated, he was a registry staff assigned to Resident 1. CNA 1 further added, the facility did not provide registry staff ID badge. CNA 1 also stated, Resident 1 had the right to know who was taking care of him. During a concurrent observation and interview on 4/12/24 at 11:58 a.m., CNA 2 was seen in the hallway entering communal dining room. CNA 2 did not have ID name badge. CNA 2 stated, she was registry assigned to help residents in the dining room. CNA 2 also stated, the facility did not supply ID name badge. CNA 2 further added, it was important to wear name badge, so residents know who they are working with. Residents have the right to know who's caring for them. During an interview on 4/12/24 at 12:00 p.m. with Facility Staff (FS), FS 1 stated, he was responsible for scheduling staff including registry. FS 1 also stated, it was important for residents to be able to identify staff taking care of them. FS 1 further added, registry staff were not required to wear ID name badge. During an interview on 4/12/24 at 12:27 p.m. with the facility Administrator (ADM), ADM stated, the facility received deficiency in the past related to staff not wearing ID name badges. ADM also stated, all facility staff, regular and registry are supposed to wear name badge at all times. ADM further added, name badges are to be worn for residents to be able to identify employee and their designated role. During a review of facility schedule dated 4/12/24, revealed CNA 1 was employed as Registry (R) and was assigned to Resident 1. The facility schedule also showed, CNA 2 (R) was assigned to social dining.

Based on observation, interview, and record review, the facility failed to implement their Policy and Procedure (P&P) for one of four sampled residents when Resident 1's social security card, a watch, and other personal items reported missing were not investigated thoroughly and documented. This failure placed resident 1 at risk for emotional distress, potential financial hardship and affected Resident 1's sense of security and well-being. Findings: During a review of Resident 1's Admission Record , printed on 9/29/23, the Admission Record indicated Resident 1 was originally admitted to the facility on admitted to the facility in December 2019. The admission records also indicated that Resident 1 had a medical diagnosis including unspecified dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior). During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 7/10/23, the MDS assessment section C indicated Resident 1's Brief Interview of Mental Status (BIMS- an assessment for cognition status) score was 11 out of 15 which indicates moderately impaired mental status. During a review of Resident 1's Discharge Evaluation 1.0 - V 2 , printed on 9/29/23, the Discharge Evaluation indicated Resident 1 was discharged on [DATE] from the facility. During an interview on 9/29/23 at 12:43 p.m., with the administrator, the administrator stated when a resident reports any missing items in the facility, they would initiate a search and start a theft and loss form and do an investigation for 3 days. The administrator also stated, if the item was in the inventory, they would replace it or estimate the value and re-imburse them. During a concurrent interview and record review on 9/29/23 at 1:55 p.m., with the administrator, Resident 1's Inventory of personal effects dated 12/18/2020 were reviewed. The inventory of personal effects indicated Resident 1 owned a Gold colored Timex watch with Matching Gold Band . The administrator stated few days prior to discharge (9/8/23), Resident Representative (RR) for Resident 1 reported to him that Resident 1 s watch, his original social security card and few other documents were missing. The administrator also stated, the RR reported that the social security card and other documents were given to the Social Worker (SW) in January 2023 and the social worker reported she cannot produce them when the RR requested them back prior to discharge. The administrator stated when he inquired about the documents to SW, she told him she looked everywhere, and she cannot find them. During a concurrent interview and record review on 9/29/23 at 2:00 p.m., with the administrator, the facility's loss and theft binder was reviewed. The administrator stated he had asked the social worker to initiate a theft and loss form for Resident 1 but cannot find a loss and theft form for Resident 1's reported missing items in the binder. The administrator stated he did not report the loss of social security card to police yet as he was hoping the social worker would be able to locate them. During an interview and record review on 9/29/23 at 2:08 pm., with the administrator, the administrator stated Resident 1 is a Canadian Citizen and it's going to be a while to replace these crucial documents and it is going to be a hardship and would need assistance to get them replaced. The administrator also stated Resident 1 is in a new environment and must be feeling frustrated and upset. During a concurrent interview and record review on 10/2/23 at 10:40 p.m., with the administrator, the administrator stated he reported the missing social security card for Resident 1 to Oakland police department on 9/28/23 at 4 pm and the incident number was 2309001038. During a concurrent interview on 10/2/23 at 11:21 a.m. with SW and the administrator, SW stated she has not completed a loss and theft form for the reported missing items for Resident 1. SW also stated she did not document about the missing items reported to her in any of Residents or facility records. SW was unable to provide any documentation of an investigation done to locate the missing items reported on or before 9/8/23. During a review of the facility's P&P titled, Theft and Loss , revised 07/11/2017, the P&P indicated, Policy- The Facility is committed to preventing the misappropriation of resident property. The facility investigates all reports of stolen items, reports to authorities as required by law, and maintains documentation of all reports of lost or stolen property .Procedure. IV. Social service staff documents reports of lost and stolen resident property on AP-11-Form C-Theft and Loss Log .B. The document includes, but is not limited to, the following: i. A description of the article; ii. Its estimated value; iii. The date and time the theft or loss was discovered; iv. If determinable, the date and time of loss or theft; and V. the action taken.

Based on observation, interview, and record review, the facility failed to ensure the bed was kept in a low position, in order to prevent fall injuries, for one of three residents (Resident 1) at increased risk of falling. For Resident 1, the failure to maintain his bed in a low position caused him to fracture his right humeral head and neck (break the bone in the upper arm at the shoulder level), when he used his right arm to slow his fall from the bed. Findings: A review of the facility Face Sheet reflected Resident 1's original admission was in (MONTH) (YEAR), with a readmission on 12/28/18. The Face Sheet indicated Resident 1 had [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, an assessment tool used to guide care) dated 9/13/18, reflected Resident 1 had intact thinking and remembering skills, with a Brief Interview for Mental Status (BIMS is an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS range is from 0-15, with 15 an indication of intact skills.) score of 15. The MDS showed Resident 1 was totally dependent on one to two people for assistance with bed mobility, transfer from one surface to another, dressing, eating, and personal hygiene. A review of the facility form, Fall Risk Assessment, dated 11/2/18, showed Resident 1's fall risk score was ten. The form instructions indicated, If the total score is 10 or greater, the resident should be considered at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. A review of the facility, Fall Risk Prevention Care Plan, dated 11/4/18, indicated Resident 1's interventions to prevent falls included, provide an environment that supports minimized hazards over which the facility has control, bed in low position, and remind resident to use call light. A review of the facility, Situation, Background, Appearance, Review (SBAR), dated 12/21/18 at 12:10 a.m., indicated Licensed Vocational Nurse 2 (LVN 2) completed a physical assessment of Resident 1 after a certified nursing assistant found Resident 1 on 12/20/18 at 11:25 p.m., hanging on the edge of his bed with right leg and right arm touching the floor. Resident was using right hand and arm pushing down on floor to hold himself up to prevent falling to floor. During a concurrent observation and interview with Resident 1 on 1/8/19 at 10:45 a.m., Resident 1 lay in bed, his head pointed towards the left side rail; Resident 1 wore a sling (a fabric device used for support) on his right arm. Resident 1 stated he fell from his bed one night after a certified nursing assistant (CNA) elevated his bed too high. Resident 1 could not remember which CNA elevated his bed, but remembered he told the CNA it was painful, and asked for it to be lowered; the CNA left the room without lowering the bed. Resident 1 stated he later fell off the bed, and had to call for help. Resident 1 stated Certified Nursing Assistant 1 (CNA 1) answered his call, and assisted him back into bed. During an interview with Certified Nursing Assistant 2 (CNA 2) on 1/8/19 at 12:35 p.m., CNA 2 stated she was assigned to Resident 1 on the evening shift (3 p.m. to 11:30 p.m.) of 12/20/18. CNA 2 stated she assisted Resident 1 with hygiene needs at 9:30 p.m., and left his room with the head of the bed up only a little bit. CNA 2 stated at 10:45 p.m. the same evening, she heard Resident 1 calling to have his eyes cleaned. CNA 2 stated she did not answer his call. A review of the facility care plan, Activities of Daily Living, dated 11/4/18, indicated the intervention, provide assistance with ADL (Activities of Daily Living) as needed. During an interview with CNA 1 on 1/23/19 at 2:58 p.m., CNA 1 stated he was Resident 1's primary CNA on the overnight shift (11 p.m. to 7 a.m. of the following day). CNA 1 stated he went to Resident 1's room on 12/20/18 at 11:24 p.m., when he heard Resident 1 yell. CNA 1 entered the room and saw Resident 1 hanging off the right side of his bed: his right arm and leg were off the bed, touching the floor; his left hand held onto the bed. CNA 1 stated Resident 1's bed was not in the lowest position, but at a medium height, and without the usual positioning pillows (two for the head, one at each side, and one under the right foot). During an interview with Licensed Vocational Nurse (LVN) 2 on 1/30/19 at 12:45 p.m., LVN 2 stated she assessed Resident 1 after CNA 1 reported the fall incident on 12/20/18. LVN 2 stated Resident 1 was on fall risk precautions, and known to wiggle a lot in bed, so precautions included keeping his bed in a low position, and the call light in reach. A review of the facility Interdisciplinary Team notes dated 12/21/18, reflected Resident 1 complained of falling the previous night and now had pain on his right side. Resident 1 went to the acute care hospital for evaluation of the right sided pain, and blood in his urinary catheter (an artificial tube inserted through the urethra (the anatomical tube connecting the internal urinary bladder to the opening on the exterior of the body), and into the bladder in order to drain urine into an external collection bag). A review of the acute care hospital emergency department History and Physical, dated 12/21/18, indicated Resident 1 complained to the emergency department physician of right arm pain, in addition to the chief complaint of blood in the urinary catheter. The physician ordered radiology (X-ray) studies in addition to treatments for the catheter bleeding, and admitted Resident 1 to the acute care hospital. A review of the acute care hospital Orthopedic (the study of muscles and bones) Consultation Note dated 12/25/18, noted Resident 1 complained of right-sided shoulder pain. The orthopedic surgeon documented Resident 1's right arm X-ray showed an acute comminuted humeral head/neck fracture (a break or splintering of the upper arm bone at the shoulder, into more than two fragments). The surgeon, after consultation with Resident 1 and his medical decision-maker, recommended non-surgical treatment of [REDACTED].

Based on observation, interview, and record review, for one of two sampled residents (Resident 1) the facility failed to provide supervision to prevent accidents when Certified Nursing Assistant 1 left Resident 1 unattended during nursing care. This failure resulted in Resident 1 falling from bed and sustaining a broken left elbow. Findings: During observations on 10/12/16 from 11:15 a.m. to 4:30 p.m., Resident 1 was sleeping in the bed nearest to the door of a three bed room, her left arm was in a sling, she responded to touch and voice, and was unable to participate in interview. Review of the Resident Admission Assessment, dated 9/13/16 indicated Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. The assessment also indicated Resident 1 required total assistance with bathing, dressing, hygiene, toileting, moving from bed to chair, walking, and had a history of [REDACTED]. Review of the Skilled Nursing Notes, dated 9/24/16, indicated Resident 1 needed extensive assistance with bed mobility, transfer (assistance moving from bed to chair), and toileting. Review of the Physical Restraint Device Assessment, dated 9/22/16, indicated Resident 1 also required the use of two hand rails to assist with turning and moving while in bed. Review of the Resident Care Plan Fall Risk Prevention and Management, dated 9/20/16, indicated Resident 1 was at risk for fall and had limited mobility. The goal of care was to provide a safe environment that minimized complications associated with falls. The care plan also indicated the facility was to .provide an environment that supports minimized hazards over which the facility had control . and to .orient Resident 1 to the environment each time changes were made During an interview on 10/12/16 at 2:45 p.m., Licensed Vocational Nurse (LVN) stated on 9/28/16 at 9:30 a.m., she asked Certified Nursing Assistant (CNA) 1 to get Resident 1 ready for wound care. LVN 1 stated she asked CNA 1 to turn Resident 1 on her right side, hold her in that position, and to stay with Resident 1 to assist LVN 1. LVN 1 stated that at 9:55 a.m., CNA 1 informed her that Resident 1 was ready (for care). LVN 1 stated CNA 1 was standing behind Resident 1 at the side of bed holding her in position for care. LVN 1 stated she was standing at the door to Resident 1's room when she heard a loud noise; she looked up and saw Resident 1 was on the floor in an awkward position. LVN 1 stated CNA 1 was standing at the foot of Resident 1's bed. LVN 1 also stated CNA 1 told her that she turned around to help another resident in the room. During a telephone interview 11/10/16 at 1:30 p.m. CNA 1 said on 9/28/16 at about 9:30 a.m. she was bathing Resident 1. CNA 1 stated LVN 1 asked her to get the resident ready for wound care and have her on her right side. CNA 1 stated she told LVN 1 she was ready, a few minutes before 10 a.m. CNA 1 stated she had Resident 1 positioned on her right side, facing the door, both side rails were up, Resident 1 was holding onto the side rail closest to the door, and the bed was in highest position. CNA 1 stated I was behind her holding and supporting her, and waiting for the wound nurse. CNA 1 stated suddenly, another resident called me, and I said to 'hold on'. CNA 1 stated the other resident said 'quick I need my clothes.' CNA 1 stated she turned to the other resident for just seconds, heard Resident 1 fall, and the wound nurse came in immediately. CNA 1 stated she went quickly to Resident 1 on the floor and asked her what happened. CNA 1 stated Resident 1 told her she moved her legs and fell over. Review of the Post Fall Assessment, dated 9/28/16, indicated Resident 1 was not able to move her (left) arm without pain. Review of the Nursing Notes and Situation Background Assessment Recommendation (SBAR), dated 9/28/16, at 10:30 a.m., indicated a CNA (CNA 1) was assisting Resident 1 in bed .when the roommate summoned her and asked for assist. CNA (CNA 1) left the resident (Resident 1) and went to roommate's bed resulting in resident (Resident 1) rolling off the edge of the bed and ending up on floor. Noted swelling to the (left) arm The SBAR also indicated the Nurse Practitioner was at the facility and ordered Resident 1 to be transported to the emergency room . Review of the emergency room Notes, dated 9/28/16, Medical Doctor (MD) 1 indicated a left Humerus (bone in lower arm) fracture was treated with immobilization (long arm splint) and referred Resident 1 to orthopedic (bone) specialist. During clinical record review of the MD 2 orthopedic consult office visit dated 9/30/16 indicated Resident 1 had a left elbow fracture, swelling through the hand, pain and difficulty with use of left arm. X-ray revealed a severely dislocated and unstable broken left elbow. During an interview on 10/12/16, at 12:45 p.m. the Director of Nursing (DON) stated he was present at the time of the fall, and CNA 1 used poor judgement when she left Resident 1 during care to answer a call from another resident in the same room. According to Hegner's Nursing Assistant Basics, the ending procedure action to lower the bed to its lowest position .ensures patient safely. Prevents falls, accidents, and injuries Review of the facility's policy and procedure titled Fall Prevention and Management Program, dated 8/1/14 indicated .Purpose - To provide a safe environment that minimizes complications associated with falls . and .supports providing an environment free from the hazards over which the Facility has control

Based on interviews and record reviews, the facility mistreated one of three sampled residents (Resident 1) when Resident 1 came back to the facility after she went to check for a couple of low income apartments in Stockton. She was left outside the facility on 9/28/15 from 7:30 p.m. to 11:30 p.m. and had no place to go. She was scared as she hid in back of a bush, in the back of the building. This failure resulted in that Resident 1 suffered emotional distress and placed her at high risk for potential physical injury. Findings: 1. A complainant reported to the Department of Public Health that on 9/28/15, Resident 1 was locked out of the facility from 7:30 p.m. to 11:30 p.m. An unannounced onsite visit to the facility was conducted on 9/30/15. Resident 1's record was reviewed on 9/30/15 at 1:00 p.m. According to the face sheet, Resident 1 was a [AGE] year old individual who was admitted to the facility from an acute hospital on [DATE], for an opened wound on her left arm due to [MEDICAL CONDITION]/abscess (skin infection/pocket of pus). Resident 1 was interviewed on 9/30/15 at 2:30 p.m., she stated that about two weeks ago, Staff person 5 asked the resident, What are you going to do with yourself (after being discharged ). He gave me a one way ticket to Stockton on Amtrak, a $50.00 credit card and a taxicab voucher. When I came back, they (the facility staff) wouldn't let me in. My clothes were by the trash can outside. One of the nurses came and said that I was supposed to be back by 5:00 p.m. I got back here at 7:30 (p.m.). I stayed outside in the back until 10:00 (p.m.). I was scared. I stayed in a corner, back of a bush. I thought someone was going to do something to me . I was so tired. I lay down on the concrete. My back is still hurting me. They tricked me that day. Who can I trust? Review of Social Service Progress Notes, dated 9/24/15 showed that Resident 1 thought she might find an apartment in Stockton and she is planning on visiting it sometimes early next week. SS (social services) will continue to f/u (follow up) and assist as needed. During an interview with the Assistant Administrator on 9/30/15 at 1:30 p.m., she stated that on 9/28/15 at 1 p.m., Resident 1 went to Stockton to look at a couple of places. Resident 1 did not notify any of the nurses when she left. Social Services knew about it, but the social services staff did not relate it to the nurses. The resident had not come back for a long time. She took a taxicab and Amtrak. Review of Nurse's Notes dated on 9/28/15 at 10:00 p.m., showed that Nurse 4 received Resident 1 standing outside of the facility. All resident's belongings were placed outside. Resident 1 stood at the outside of the facility without leaving. During a telephone interview with Staff person 5 on 10/12/15 at 8:45 a.m., he stated, I work as the business developer for the company. I gave her (Resident 1) an Amtrak ticket a $50.00 voucher and a taxicab voucher at 9:00 or 10:00 in the morning. Then I left. The social worker knew about this. During a telephone interview with Nurse 4 on 10/12/15 at 11:00 a.m., she stated, At 3:00 (p.m.) when I got to work, the door in (was) locked. The day shift (staff) told me Resident 1 is going look for an apartment. She said if she (Resident 1) is not back at 5:00 p.m., she is no longer our patient . She came back between 8:00 and 9:00 p.m. and I didn't let her in. Staff person 5 came in a half to one hour (after the resident came back) and said, 'call the police. She is no longer our patient.' I went outside and talked to her for a few minutes . I told her, 'you supposed to be back at 5:00 p.m. So our facility (is) not allowing you back in.' The police officer came and I explained to the police officer. The police officer called Staff person 5, he didn't answer the phone. The police officer stayed with her (the resident) until 11 - 11:30 p.m . The night nurse let her in the facility. She stayed on the right hand side of the building until the nurse let her back in . The facility policy and procedure titled Abuse - Prevention Program, dated 1/1/2012, indicated, The facility does not condone any form of resident abuse, neglect and/or mistreatment, and continually monitors Facility policies, procedures, training programs, and systems in order to maintain an environment free from abuse and mistreatment. Under Procedure, it indicated, The facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff . The facility policy and procedure titled Resident Abuse - Recognizing Signs and Symptoms, dated 1/1/2012, indicated, 'Neglect' is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness.