Every finding on record at Vale Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure Resident 1 was free from physical abuse when Resident 2 hit Resident 1 with a cane during an encounter in the resident hallway.This failure resulted in Resident 1 sustaining a skin abrasion on the left arm.Findings:On 5/5/26, the facility reported an allegation of abuse incident to the California Department of Health (CDPH) involving Resident 1 (the victim) and Resident 2, the suspected abuser.During a record review of the facility's Investigation Summary (IS), dated 5/11/26, the IS indicated, On 5/5/2026 at approximately 9:40 AM, [Resident 1] was headed to the smoking area.when he encountered [Resident 2]. [Resident 2] allegedly confronted him [Resident 1] and struck him with is cane. CNA [Certified Nursing Assistant] who was in the hall nearby witnessed [Resident 2] make contact with [Resident 1] approximately 3-4 times. [Resident 1 was hit by [Resident 2] with a cane. Staff nearby responded and separated the residents.During a record review of Resident 1's Observation Detail List Report, with completion date 5/5/26, the report indicated, Observation Date: 05/05/2026 12:57 PM. Situation - Physical Altercation Between Residents.Description of Change of Condition - .the resident [Resident 1] sustained an [sic] abrasion on his left posterior arm.During a record review of Resident 1's Face Sheet (FS), the FS indicated, Resident 1 was admitted to facility on 4/9/2024 with diagnoses that included. Chronic obstructive pulmonary disease (long term lung disease causing breathlessness), Displaced simple supracondylar fracture without Intercondylar fracture of left humerus (a break in the upper part of the lower arm bone just above the elbow joint), and fracture of humerus following insertion of orthopedic implant, joint prosthesis or bone plate right arm (a break in the upper arm bone around or near previously placed surgical hardware).During a record 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 7/13/2026, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status about attention, orientation, and ability to register and recall information) score of 12 out of 15. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.During a record review of Resident 2's Face Sheet (FS), the FS indicated, Resident 2 was admitted to facility on 5/7/2024 with diagnoses that included, Hypertension (high blood pressure) and Type II Diabetes Mellitus (high blood sugar level).During a record review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had a BIMS score of 15. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.During an interview on 7/28/26 at 10:21 a.m. with Licensed Vocational Nurse (LVN) 1, LVN1 stated she had heard of the alleged incident involving Resident 1 and Resident 2. LVN 1 stated she viewed the video footage of the incident. LVN 1 stated in the video, Resident 2 was seen hitting Resident 1 on the left elbow with his cane.During a concurrent observation and interview on 7/28/26 at 11:11 a.m., with Resident 1, in his room, Resident 1 was lying on the bed. Resident 1 was alert and oriented. When asked about the incident, Resident 1 stated he had used the bathroom shared with Resident 2 and the room next door. Resident 1 stated several days later when he was passing by Resident 2's room on his way to the smoking area, Resident 2 was standing in the doorway of the room and Resident 2 began hitting him with a cane. Resident 1 stated he put his left arm up to block blows from Resident 2. Resident 1 stated his left arm was the one previously broken in a fall. Resident 1 stated staff were present and witnessed the incident.During a review of the facility's policy and procedure (P&P), titled, Abuse, Neglect and Exploitation Prohibition, undated, the P&P indicated, Purpose - Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property.During a review of the facility's policy and procedure (P&P), titled, Abuse and Neglect Prohibition California Addendum, undated, the P&P indicated, The purpose of this policy is to establish procedures for the prevention, identification, reporting, investigation, response, and documentation of abuse. and other alleged violations involving residents in accordance with Federal regulations. This facility is committed to maintaining an environment free from abuse. The facility shall protect residents from further potential harm during all investigations and shall ensure residents maintain the right to dignity, privacy, self-determination, and freedom from abuse.

Based on interview and record review, the facility failed to protect residents in the facility from potential physical abuse when Certified Nursing Assistant 1 (CNA1) was accused of deliberately slapping one resident (Resident 1) on the left arm and the facility failed to maintain documentation of a thorough abuse investigation and failed to notify the responsible party (RP) for Resident 1 of the allegation as required by facility policy.This failure resulted in placing all residents in the facility at risk of physical abuse and resulted in the RP for Resident 1 feeling alarmed.During a record review of facility's document titled, Resident Face Sheet, dated 4/7/26, for Resident 1, the document indicated Resident 1 was originally admitted to the facility in April 2023 with multiple diagnoses including nontraumatic intracranial hemorrhage (bleeding within the skull) and chronic kidney disease, stage 4 (the final stage of long-term kidney disease when the kidneys are no longer sufficiently able to remove waste products and excess water to support the body's needs), dependence on renal dialysis (a treatment for kidney failure to remove waste products and excess fluids by external filtration of blood).During a record review of Resident 1's Minimum Data Set (MDS, a tool used to guide care) Assessment, Section GG, dated 1/15/26, the MDS, Section GG indicated Resident 1 was totally dependent (helper does all of the effort) on staff for care.During a record review of facility's document titled, Care Plan, dated 2/15/24, for Resident 1, the document indicated Resident 1 was totally dependent (resident relies entirely on other people for care) due to impaired cognition (ability to think, learn, make decisions). During a record review of facility's document titled, General Order, dated 9/16/25, for Resident 1, the General Order indicated Resident 1 was to have a sitter (a caregiver who provides constant supervision) during renal dialysis to monitor and ensure that any care concerns are addressed.During an interview on 4/7/26 at 1:50 p.m. with the Director of Nursing (DON), DON stated they conducted the investigation into an allegation that CNA1 slapped Resident 1's arm on 3/6/26. DON stated they interviewed CNA1 and the Registered Nurse (RN1) who reported the incident. DON stated they did not keep notes about these interviews and were not sure of the dates and times the interviews occurred. During a concurrent interview and record review on 4/7/26 at 2:10 p.m. with DON, facility's document titled, Investigation Summary, dated 3/11/26 was reviewed. DON stated the document represented the entire record of their investigation into the allegation of abuse involving CNA1 and Resident 1. DON stated there were no notes in the document about the interviews with CNA1 and RN1.During a concurrent interview and record review on 4/9/26 at 2:35 p.m. with the facility's administrator (ADM), the facility's document titled, Investigation Summary, dated 3/11/26 was reviewed. ADM stated the document contains all records related to the allegation of abuse involving CNA1 and Resident 1. ADM stated there should have been a written and dated statement from CNA1 and RN1.During a concurrent interview and record review on 4/9/26 at 2:40 p.m. with ADM, facility's policy titled, Abuse Investigation & Reporting, undated, was reviewed. ADM stated the policy was not dated and the policy indicated that witnesses should sign and date statements involving allegations of abuse. ADM stated the reason to take notes on interviews with witnesses is to help remember and to write the report.During an interview on 4/9/26 at 4:33 p.m., ADM stated the RP should be notified of allegations of abuse. ADM stated they were out of the office when the allegation of abuse between CNA1 and Resident 1 occurred on 3/6/26 and, in their absence, the DON should have notified the RP for Resident 1. ADM stated the reason to notify the RP is so they are informed and the RP should know what's going on.During a phone interview on 4/9/26 at 4:41 with DON, DON stated they did not notify the RP for Resident 1 about the incident. During a phone interview on 4/9/26 at 12:23 p.m. with the RP for Resident 1 (RP1), RP1 stated they were not aware of the abuse allegation involving CNA1 and Resident 1 on 3/6/26. RP1 stated they use a cell phone and there would be a record of a missed call or a voicemail. RP1 stated that they checked their call and voicemail history and there was no record of a missed call or a voicemail from the facility about this incident. RP1 stated they would want to be informed and it makes them feel alarmed that they were not notified. RP1 stated that, if they had known, they would have followed up and asked questions when they visited the facility.During a review of the facility's policy and procedure, titled, Abuse Investigation & Reporting, undated, the policy indicated, .Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and ate it. The policy also indicated, All alleged violations involving abuse. will be reported by the Company Administrator, or his/her designee, to the following persons. The Resident's Representative.

Based on interview and record review, the facility failed to implement adequate supervision and interventions to prevent a resident-to-resident physical altercation for two of two sampled residents (Resident 1 and Resident 2), when Resident 2 entered Resident 1's room and punched Resident 1 in the face.This failure resulted in redness to Resident 1's face and caused feeling upset, and had the potential to result in serious physical injury and psychosocial harm including fear and emotional distress.During a record review of Resident 1's Face Sheet dated on 3/17/26, the Face Sheet indicated Resident 1 was admitted to the facility in September 2024 with diagnoses of malignant neoplasm (cancer) of rectum and depression (serious mental health condition characterized by persistent sadness and a loss of interest).During a record review of Resident 1's 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.) Resident 1's BIMS score was 15.During a record review of Resident 2's Face Sheet dated on 3/17/26, the Face Sheet indicated Resident 2 was admitted to the facility in March 2024 with diagnosis of alcoholic cirrhosis of liver with ascites (advanced liver scarring from chronic alcohol misuse).During a record review of Resident 2's Progress Notes dated 1/27/26 at 2:15 p.m., the Progress Notes indicated, Around this time, the staff noted Resident 2 with different speech.Resident 2 was noted with a slurred speech (when someone talks in a way that's hard to understand). When Resident 2 was intervened about drinking alcohol.During a record review of Resident 2's SBAR (Situation, Background, Assessment, Recommendation) Note dated 1/27/26, the SBAR indicated the physical altercation between Resident 1 and Resident 2 occurred at 4:30 p.m. SBAR also indicated Resident 1 reported Resident 2 looking drunk, entered Resident 1's room, talking in a loud manner and hit Resident 1 on the right side of the face. SBAR further indicated Resident 2 was suspected of consuming alcohol earlier in the afternoon.During an interview on 3/17/26 at 10:53 a.m. with Resident 1, Resident 1 stated a physical altercation occurred a couple of months ago during the afternoon. Resident 1 described being in a wheelchair in their room, when Resident 2, who was also in a wheelchair and appeared to be under the influence of alcohol, entered the room. Resident 1 stated they repeatedly requested Resident 2 to leave their room, but Resident 2 did not comply. Resident 1 stated Resident 2 stood up from the wheelchair, approached Resident 1, and punched Resident 1 on the right side of the face. Resident 1 stated being upset that the facility failed to protect them from Resident 2. Resident 1 further stated the facility was aware of Resident 2's alcohol use and associated behaviors yet failed to adequately monitor and implement interventions to prevent Resident 2's physical aggression.During an interview on 3/17/26 at 2:09 p.m. with the Social Worker (SW), SW stated they were aware of Resident 2's alcohol use and aggression. The SW stated staff should have monitored Resident 2 if alcohol use was suspected, due to unpredictable behavior toward others.During an interview on 3/17/26 at 2:38 p.m. with the Administrator (ADM), ADM stated during the incident, she was passing by the hallway when she observed Resident 2 standing partially inside Resident 1's doorway. ADM stated suddenly, she heard yelling and she immediately proceeded to Resident 1's room. ADM stated Resident 1 informed her that Resident 2 struck Resident 1 in the face. ADM stated she observed redness on the right side of Resident 1's face. ADM further stated, it looked like Resident 1 was hit in the face. ADM stated Resident 2 could have possibly consumed alcohol prior to the incident. ADM stated they checked Resident 2's room and found a full bottle of alcohol. ADM also confirmed that they were aware of Resident 2's use of alcohol and Resident 2 should have been monitored for safety and to prevent escalation of negative behaviors.During a record review of the facility's undated policy and procedure (P&P), titled, Abuse Prevention Program, the P&P indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.Protect our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.

Based on interview and record review, the facility failed to ensure for one out of three sampled residents (Resident 1), to identify risk and develop a plan to help prevent Resident 1 from leaving the facility without authorization and unannounced. This failure resulted in Resident 1 eloping from the facility.Findings:A review of the facility's Resident Face Sheet indicated Resident 1 was admitted on [DATE], with diagnoses that included cellulitis of left lower limb, unspecified behavioral and emotional disorder, psychoactive substance abuse, Schizophrenia, and alcohol dependence. Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 01/25/2026, indicated a 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) score of 08, (BIMS score of 00 - 07: severe impairment; 08 - 12: moderately impaired; and 13 - 15: cognitively intact).During a review of Resident 1's Elopement Risk Assessment dated 11/13/2025, indicated Resident 1 was ambulatory, with behaviors of Hx [History] of wanting to leave the facility within the last 30 days, and Resident 1 was not identified to have Substance Abuse/Psych History. Facility identified Resident 1 as NOT AT RISK.During an interview on 03/05/2026 at 01:27 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 01/12/2026, after Resident 1 had her morning snack, she was last seen heading towards the smoking area at around 10 a.m. to 10:30 a.m. LVN 1 stated while she was eating her lunch between 12:30 p.m. to 1 p.m., a Certified Nursing Assistant (CNA) told LVN 1 that Resident 1 was not in her room and did not eat her lunch. LVN 1 stated the lunch tray was passed out in Station 2 between 11:30 a.m. to 12 p.m. LVN 1 checked Resident 1's room and bathrooms, shower rooms, and the smoking area, then LVN 1 notified her supervisor they could not find Resident 1. LVN 1 stated they called Code Yellow. ( A code used to notify staff of a missing resident)During a review of Resident 1's Progress Note dated 01/12/2026 at 09:32 a.m., it indicated Resident came by to my office this morning asking when she was going home. I explained to her that per our last conversation with her sister, she will not be moving with family and we will help look for a place for her to move to but it will not be today. She said ok and went on about her way.During a review of Resident 1's Progress Note dated 01/13/2026 at 10:14 a.m., the notes indicated [Recorded as Late Entry 01 01/14/2026 at 07:33 PM] Resident eloped from the facility. All appropriate agencies were notified. Resident was later located by authorities due to public intoxication and was transported to her sister's home. The following morning, the sister contacted the facility to report the resident's whereabouts.During a review of the facility's policy and procedures titled Resident Elopement indicated The facility will provide a safe environment and preventative measures for elopement with the aim to monitor and document patients at risk of elopement.

Based on interview, observation, and record review, the facility failed to report Resident 2's verbal abuse and threat of harm against Resident 1 (one of three sampled residents) to the State Agency, local law enforcement, and/or the Long-Term Care Ombudsman (Resident advocate for rights and care in long-term facilities). This failure had the potential to place residents at risk for further abuse and psychosocial harm.During a record review of Resident 1's Face Sheet (resident demographic and clinical summary), Face Sheet indicated Resident 1 was admitted to the facility on [DATE].During a record 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 11/17/25, MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information). This score indicated Resident 1 had a score of 15/15 indicating cognitively intact and the mental capacity to make medical decisions.During an interview with Resident 1 in his room on 1/2/26 at 10:55 a.m., Resident 1 was found lying on his left side in bed. Resident 1 stated his former roommate (Resident 2) threatened to kill him. Resident 1 stated Resident 2 threw many things across the room and broke dishes. Resident 1 stated the facility initially moved Resident 2 to another room, however, an hour later they brought Resident 2 back and moved Resident 1 to another room. Resident 1 stated when he expressed his concern for his safety staff asked him, What else do you want me to do?During a record review of Resident 1's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE].During a record review of Resident 2's MDS, MDS indicated Resident 2 had a BIMS score of 15 out of 15. This score indicated that Resident 2 had the mental capacity to make medical decisions.During an interview with Resident 2 in his room on 1/20/25 at 1:30 p.m., Resident 2 stated he didn't remember much about the incident. Resident 2 stated he was moved to another room because Resident 1 was talking too loudly on the phone in the mornings.During a record review of Resident 1's Progress Notes, dated 11/3/25 at 11:24am, Social Services Assistant (SSA) documented, spoke with resident [Resident 1] regarding altercation with roommate [Resident 2]. Per resident [Resident 1], he was on the phone this morning and roommate got upset.he [Resident 2] called me faggot and threatens to 'kill me'. Progress notes stated, reassured resident his roommate already moved to another room and staff is aware of the altercation.During a record review of Resident 2's Progress Notes, dated 11/3/25 at 8:11 a.m., Licensed Vocational Nurse 1 (LVN 1) documented, .resident [Resident 2] got upset that every morning he [Resident 1] is on the phone . [Resident 2] throw his breakfast tray on the floor. [Resident 2] said he wants to change his room.During an interview with LVN 1 on 1/20/25 at 1:10 p.m., LVN 1 stated she was the assigned nurse for Resident 1 and Resident 2 on 11/3/25. LVN 1 stated she was made aware of the incident between Resident 1 and Resident 2 while doing her rounds the morning of 11/3/25. LVN 1 stated Resident 2 had pushed his breakfast tray on the floor. LVN 1 stated Resident 2 told her that Resident 1 was always on the phone in the morning and that he was sick of this Bull shit. LVN 1 stated she was not aware of any verbal altercation or exchange between Resident 1 and Resident 2.During an interview with SSA on 1/20/25 at 2:00 p.m., SSA stated the assigned nurse for Resident 1 and Resident 2 made her aware of the incident between the two of them, . when she arrived the morning of 11/3/25. SSA stated threats between residents are considered abuse and must be reported to the State agency, local law enforcement and the Ombudsman. SSA stated facility's Administrator was the Abuse Coordinator and she did not recall whether she spoke with Administrator regarding the incident. SSA also stated if she talked to the Administrator, she would have documented it, but she did not.During an interview with Director of Nursing (DON) on 1/2/25 at 2:00 p.m., DON stated the incident between Resident 1 and Resident 2 was not reported to the State Agency, local law enforcement, or the Ombudsman. The DON stated the incident was not reported because an internal investigation was conducted and found unsubstantiated (not supported or proven by evidence).During a record review of Policy and Procedure (P&P) titled Abuse Investigation and Reporting, dated 11/17/25, P&P indicated All allegations of resident abuse.shall be promptly reported to the appropriate local, state, and/or federal agencies.and thoroughly investigated by Company Management.

Based on interview and record review, Facility 2 failed to document Resident 1's needs that could not be met by Facility 2 and the reasons why Resident 1's transfer or discharge was necessary. Facility 2 failed to appropriately communicate information concerning Resident 1's condition to Facility 1 prior to sending Resident 1 back to Facility 1. Facility 2 staff failed to properly admit Resident 1 to Facility 2 and then had Resident 1 transported back to Facility 1 from Facility 2, without properly discharging Resident 1 (from Facility 2) or having his medical needs assessed. This failure had the potential to result in a lapse in care when Resident 1 was sent back to Facility 1 from Facility 2 within a seven hour period on the same day.During a record review of Facility 1's document titled, Inpatient Medicine Discharge Summary, dated 7/11/25, the Inpatient Medicine Discharge Summary indicated Resident 1 had been admitted at Facility 1 from 6/12/2024 to 7/11/2025 with multiple diagnoses including dementia (a decline in mental ability severe enough to interfere with daily life) and altered mental status (a change in mental function). The Inpatient Medicine Discharge Summary also indicated Resident 1 was discharged on 7/11/25 at 10:30 a.m. from Facility 1. During an interview on 9/23/25 at 4:10 p.m. at Facility 2 with Registered Nurse 2 (RN2), RN2 stated when a new resident was going to be admitted , there will be a group text thread started on facility-issued phones so that they know when to expect the resident and can assign staff to care for them. During a concurrent interview and record review on 9/23/25 at 4:12 p.m. at Facility 2, text messages on RN2's facility-issued phone were reviewed. RN2 stated two text messages dated 7/10/25 sent from Registered Nurse 1 (RN1) indicated that Resident 1 was expected to arrive at Facility 2 around 10 a.m. on 7/11/25. During a concurrent interview and record review on 1/7/26 at 2:25 p.m. at Facility 2 with Assistant Director of Nursing (ADON), an Interfacility Transport Company's document titled, Receiving Facility Signature, dated 7/11/25 at 11:57 a.m., was reviewed. ADON stated the Receiving Facility Signature indicated that Resident 1 arrived at Facility 2 on 7/11/25 at 11:57 a.m. ADON also stated she signed the Receiving Facility Signature document because Resident 1 was unable to sign the document.During a concurrent phone interview and record review on 1/7/26 at 2:43 p.m. at Facility 2 with the Director of Nursing (DON), an email with the subject line, Male HMO Admission, dated 7/10/25 was reviewed. DON stated the Male HMO Admission email indicated Resident 1 was an expected admission and had approved insurance authorization. The Male HMO Admission email was sent on 7/10/25 at 4:29 p.m.During a follow-up phone interview on 1/7/26 at 2:45 p.m. at Facility 2 with DON, DON stated when Resident 1 arrived at Facility 2, it was determined that Resident 1 was not an appropriate fit for Facility 2. DON stated they offered Resident 1 food and then Resident 1 was sent back to Facility 1. DON stated there was no medical record created for Resident 1. DON stated Facility 2 did not document why Resident 1 was not appropriate for their facility [Facility 2]. DON also stated there was no nursing assessment done upon Resident 1's arrival to Facility 2. During a review of Facility 1's document titled, Medicine History and Physical, dated 7/11/25, the Medicine History and Physical indicated Resident 1 returned to Facility 1 on 7/11/25 at 5:22 p.m., after being gone approximately 7 hours. During a review of Facility 2's policy titled admission to the Facility, dated OP2 0203.00, the policy indicated, .The Medical Record Department logs the resident into the Admission/Discharge Register. The policy also indicated, .Nursing initiates clinical care. A. Take and record the resident's vital signs.During a review of Facility 2's policy titled Transfer and Discharge, dated OP 0209.00, the policy indicated, .the notices of transfer/discharge shall contain the following information: a. The reason for the transfer/discharge; b. The effective date of the transfer/discharge; c. The location to which the resident is being transferred or discharged . d. A statement of the resident's rights to appeal the transfer/discharge,.

Based on observations and interviews, the facility failed to repair a moderate dent in the wall in Resident 107's room.This deficient practice had the potential to result in the resident not feeling or having a safe and/or homelike environment.Findings: During a review of Resident 107's Face Sheet, dated 7/24/25, the Resident Face Sheet indicated, Resident 107 was admitted to facility 4/9/24. During an observation on 7/24/25 at 12:32 p.m. in Resident 107 room, there was a large dented and exposed wall area behind the head of Resident 107's bed. During an interview on 7/24/25 at 12:36 p.m. with Resident 107, Resident 107 stated that the dented and exposed wall looks awful and that they would not have their home look like this. During a concurrent observation and interview on 7/24/25 at 5:07 p.m. with Environmental Director (ED) in Resident 107 room, ED stated that the indented and exposed wall should not be there and will take care of it. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, [undated], the P&P indicated, .The resident has a right to a dignified existence.Residents have freedom of choice, to maximum extent possible.

Based on observation, interview and record review, for two sampled residents (Resident 15 and 184), the facility failed to provide podiatry referrals to treat their long toe nails. This failure did not provide necessary services for treatment and foot care to these residents. During a review of Resident 15's Face Sheet dated 7/24/25, the Face Sheet indicated Resident 15 was admitted to the facility in November 2023.During a review of the Resident 15's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 4/25/25, it indicated Section B indicated Resident 15 had clear speech, able to express ideas and wants, and has the ability to understand others. Section C indicated Resident 15's a BIMS (Brief Interview for Mental Status-a standardized cognitive assessment tool) score: 14, intact cognition.During a review of the nursing Progress Note, dated 3/21/25, for Resident 15, the nursing note indicated resident wants to see the podiatrist, referral given to social service office. During an interview on 7/24/25 at 1:25 p.m., Resident 15 stated her toe nails are gross, terrible, that the nails are curling over her skin and toenails really need to be clipped. Resident 15 stated the last time she was seen by podiatry was 1 1/2 years ago. During an interview on 7/24/25 at 12:06 p.m., with Social Services Director (SSD), the SSD is responsible to coordinate resident referrals to podiatry. SSD stated the last time Resident 182 was seen by podiatry was in December by referral. During a review of the undated P&P, titled Podiatry Services, the P&P indicated scheduling and coordination of podiatry visits will be scheduled regularly (e.g., every 61 days routinely or as clinically indicated, or on an as-needed basis for acute issues all podiatry appointments will be documented in the facility's scheduling system and communicated to relevant staff and residents by the Social Services Director/designee. 2. During a review of Resident 182's Face Sheet dated 7/24/25, the Face Sheet indicated Resident 182 was admitted to the facility in May 2023.During a review of Resident 182's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 5/14/25, Section B indicated Resident 182 had clear speech, able to express ideas and words and has the ability to understand others. Section C indicated Resident 11's BIMS (Brief Interview for Mental Status score: 11, moderate cognitive impairment.During an observation on 7/21/25 at 12:19 p.m., Resident 182 was laying on top of his covers in bed. Resident 182's feet were bare and toenails long, curved and jagged. During an observation on 7/21/25 at 1:47 p.m., Resident 182 was observed in the hallway sitting in his wheelchair propelling with his bare feet. During a review of Resident 182's face sheet, Resident 182 had diagnoses to include congestive heart failure, psychoactive substance abuse and hypertension. During a concurrent interview and record review on 7/24/25 at 12:06 p.m., with Social Services Director (SSD), the SSD stated it was her responsibility to coordinate resident referrals to podiatry. SSD stated the last time Resident 182 was seen by podiatry was in December by referral. The SSD provided a physician order, dated 7/26/24 indicated to refer Resident 182 to house podiatry for history of nail fungus infection (onychomycosis). During a review of the undated P&P, titled Podiatry Services, the P&P indicated scheduling and coordination of podiatry visits will be scheduled regularly (e.g., every 61 days routinely or as clinically indicated, or on an as-needed basis for acute issues all podiatry appointments will be documented in the facility's scheduling system and communicated to relevant staff and residents by the Social Services Director/designee.

Based on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling when: 1.One Breyna or Budesonide-Formoterol-Fumarate inhaler labeled only with a room number was found in medication cart 2 (an inhaler is a device used for delivering medicines into the lungs through breathing; Breyna is the brand name of Budesonide-Formoterol-Fumarate inhaler, and is a medication indicated for the treatment of breathing difficulties). 2. Two opened bottles of Refresh eyedrops (lubricating eye drops designed to soothe and relieve dry, irritated eyes) were found in medication cart 4. 3. Resident 11's one opened Incruse Ellipta inhaler was found with no open date label in medication cart 1 (Incruse Ellipta is an inhaler used to prevent and control symptoms associated chronic obstructive pulmonary disease or COPD, a long-term lung disease that makes it hard to breathe). 4. One opened unlabeled Nystatin powder and one unlabeled open tube of TheraHoney gel were found at Resident 121's bedside table ( Nystatin is a skin medication used to treat skin infections, TheraHoney is a skin medication used to heal wounds). 5. One used Purified Protein Derivative (PPD) vial was found with no open date label in Station 2‘s medication refrigerator (PPD is a substance used in skin tests to help detect tuberculosis infection - a contagious infection caused by bacteria that usually attack the lungs but can also affect other parts of the body). 6. One box of expired insulin syringes was stored in Station 2's medication room (insulin syringes are disposable tools designed to help people with diabetes inject insulin into their bodies; insulin is a medication that lowers blood sugar). 7. 12 loose pills were found in medication cart 3. Findings:1.During a concurrent observation and interview on [DATE], at 1149 a.m., with the Registered Nurse (RN) 1, while inspecting medication cart 1, observed an opened Breyna box with inhaler with no label except for the room number. The box of the inhaler had a handwritten note which read, 28 C. RN 1 stated that the inhaler belonged to Resident 121. Also stated Resident 121's inhaler should have been labeled with the resident's name and dosage, to prevent medication error. During a review of Resident 121's Facesheet (information containing contact details, brief medical history at-a-glance) indicated Resident 121 was readmitted to the facility on [DATE]. During a review of Resident 121's Physician Order (PO), dated [DATE], the PO indicated an order of Budesonide-Formoterol inhaler 2 puffs twice a day for COPD. During an interview on [DATE] at 3:25 p.m., the Director of Nursing (DON) stated all the residents' medications should have been labeled with the resident's name, dosage, open date and the initial of nurse who opened the medication and not just room number to prevent medication error. 2. During a concurrent observation and interview on [DATE], at 10:50 a.m., with the Licensed Vocational Nurse (LVN) 7, while inspecting medication cart 4, observed 2 opened boxes of Refresh eyedrops with just room [ROOM NUMBER] A written in both boxes. LVN 7 stated the eyedrops belonged to Resident 146. Stated the eyedrops should have been labeled with the resident's name and dosage to prevent medication error. Review of Resident 146's facesheet indicated the resident was admitted to the facility on [DATE]. A review of Resident 146's PO, dated [DATE] indicated an order of artificial tears OTC 1%, 1 drop in both eyes for dry eyes 3x a day (OTC means over the counter, Refresh Tears are a brand of artificial tears). During an interview on [DATE] at 3:25 p.m., the DON stated all the residents' medications should have been labeled with the resident's name, dosage, open date and the initial of nurse who opened the medication and not just room number to prevent medication error. During a review of the facility's policy and procedure titled, Medication and Medication Labels, dated 2007, indicated, . Medications are labeled in accordance with currently accepted professional principles including appropriate auxiliary and cautionary instructions to promote safe medication use following state and federal laws.1. Each prescription medication will be labeled to include a. Resident's name b. specific directions for use including route of administration. 3. During a concurrent observation and interview on [DATE], at 1149 a.m., with RN 1, while inspecting the medication cart 1, Resident 11's Incruse Ellipta inhaler was found with no open date label. RN 1 stated the inhaler should have had an open date label, because of the risk for Resident 11 to receive medication with less potency. During a review of box of Incruse Ellipta inhaler indicated, Discard the inhaler 6 weeks after opening the moisture protected foil tray . (The moisture protected foil tray is designed to safeguard the medication from moisture, which can decrease the inhaler's effectiveness).During a review Resident 11's Facesheet indicated the resident was admitted on [DATE]. During a review of Resident 11's Physician Order, dated [DATE], indicated an order for Incruse Ellipta inhaler 1 puff daily for COPD.During a review of Resident 11's Medication Administration Record (MAR) indicated Incruse Ellipta inhaler was last given on [DATE] at 8:16 a.m. During an interview on [DATE] at 8:27 a.m., with the DON, stated, the medication nurse who initially opened the inhaler should have written the open date label to make sure the facility could discard the medication as recommended by the manufacturer. During a review of the facility's policy and procedure titled, Medication and Medication Labels, dated 2007, indicated, . Medications are labeled in accordance with currently accepted professional principles including appropriate auxiliary and cautionary instructions to promote safe medication use following state and federal laws. 4. During a concurrent observation and interview on [DATE] at 10:46 a.m., with LVN 2, in Resident 121's room, one opened bottle of Nystatin powder and one opened tube of TheraHoney gel were found at Resident 121's bedside in the resident's wash basin mixed with other lotions and deodorant. LVN 2 stated Resident 121 used the basin of lotions and deodorant to apply it to her skin. Further stated the resident did not have physician orders of Nystatin powder and TheraHoney. Also stated the Nystatin and Therahoney should not be at the resident's bedside due to risk of allergic reaction if the resident accidentally applied them to her body. Review of Resident 121's indicated the resident was readmitted to the facility on [DATE]. A review of Resident 121's Minimum Data Set (MDS, an assessment tool) dated [DATE], indicated the resident was cognitively intact. During a review of Resident 121's PO, dated [DATE], the PO did not indicate an order of Nystatin powder and TheraHoney gel. During a review of the facility's policy and procedure titled, Bedside Medication Storage, dated 2007, indicated, . 5. All nurses and nursing aides are required to report to the charge nurse on duty any medications found at bedside not authorized for bedside storage . 5. During a concurrent observation and interview on [DATE] at 8:58., with RN 1, while inspecting the station 2 medication room refrigerator, one used PPD vial was found with no open date label. RN 1 stated should have open date label. During an interview on [DATE] at 3:25 p.m., the DON stated all the PPD vials required an open date label to ensure the potency and effectiveness of the solution. During a review of the facility's policy and procedure titled, Medication and Medication Labels, dated 2007, indicated, . Medications are labeled in accordance with currently accepted professional principles including appropriate auxiliary and cautionary instructions to promote safe medication use following state and federal laws.2. Multi dose vial shall be labeled to assure product integrity considering the manufacturers' specifications. nursing staff should document the date opened on multidose vials . 6. During a concurrent observation and interview on [DATE] at 8:58. a.m., with RN 1, while inspecting the station 2 medication room, one box of expired insulin syringes was found with an expiration date of [DATE]. RN 1 stated the expired insulin syringes should have been disposed due to the risk of adverse effects or unwanted undesirable effects that could be caused by using the expired syringes to the residents. During an interview on [DATE] at 3:25 p.m., the DON stated the expired insulin syringes should have been disposed and should not be in the medication room. During a review of the facility's undated policy and procedure titled, Cleaning Medication Storage Areas indicated, . Medication storage areas are kept neat and clean to prevent contamination of medication and treatment supplies. Keep the medication room organized. Check for discontinued outdated medication. Remove and dispose . 7. During an observation and concurrent interview with LVN 6, on [DATE], at 10:50 a.m., upon inspection of the medication cart 3, 12 loose tablets were found. LVN 6 was unable to identify the loose tablets and stated the loose tablets should not be in the medication cart and should have been disposed due to the risk of medication error. During an interview on [DATE] at 3:25 p.m., the DON stated the medication carts should be clean and there should not be loose pills due to the risk of drug diversion and medication error . During a review of the facility's undated policy and procedure titled, Cleaning Medication Storage Areas indicated, . Medication storage areas are kept neat and clean to prevent contamination of medication and treatment supplies. licensed staff should keep carts clean and organized. Check for discontinued outdated medication. Remove and dispose .

Based on observation, record reviews and interviews, the facility failed to ensure that Resident 53 was provided with up-to-date annual dental services.This deficient practice had the potential to result in the resident experiencing pain, infection or difficulty eating which could lead to potentially decreased nutritional intake and weight loss.Findings:During a review of Resident 53's Face sheet, dated 7/24/25, the Face sheet indicated, resident 53 was admitted to the facility 1/11/18. During a review of Resident 53's Face sheet, dated 7/24/25, the Face sheet indicated, Resident 53 had medical diagnoses to include altered mental status (change in a person's level of consciousness, alertness, and cognitive function), dementia (loss of memory, language, problem-solving and other thinking abilities), muscle weakness, dysphagia (difficulty swallowing) and visual impairment.During a review of Resident 53's Minimum Data Set (MDS-standardized assessment tool used to evaluate the health and functional status of residents), dated 7/16/25, The MDS indicated, the following: Section C (Cognitive Patterns-way of thinking) show a Brief Interview for Mental Status (BIMS-cognitive screening measure that focuses on orientation and short-term word recall) score was 3 (severe cognitive impairment per BIMS score scale), Section GG (Functional Abilities) noted Dependent assist (helper does all of the effort), Section K (Swallowing/Nutritional Status) noted with no check marks/documentation in this section at time of this survey and Section L (Oral/Dental Status) noted with no check marks/documentation in this section at the time of this survey.During a concurrent observation and interview on 7/21/25 at 12:11 p.m. with Resident 53 in their room, Resident 53's mouth was observed swollen gums with no teeth on the bottom row. Resident 53 stated, that at times it hurts to eat.During a review of the electronic health record (EHR) Provider Orders for Resident 53, dated 8/27/23, the Provider Orders indicated, Diet Order to be as follows: Regular: Pureed (all foods are blended or pureed to a smooth, pudding-like consistency); 1:1 Assist with feeds; Aspiration Precautions ; May have soft snacks such as bananas and soft sandwiches. and Refer for Dental Consult annually and as needed (if stay is long term).During a concurrent interview and record review on 7/22/25 at 1:04 p.m. with Social Worker (SW) in their office, EHR or hardcopy of dental records could not be found. SW stated that they always have a copy of gets dental done and we have a binder. SW stated that resident 53 has no teeth, so did not think needed an exam. SW stated that was unsure as to when resident 53 got their last annual dental exam. SW stated that Dental come often for the annual exams of the residents and they do it it in batches but could not find any recent record for resident 53.During a concurrent interview and record review on 7/22/25 at 1:04 p.m. SW in Facility Conference room, last documented record of an annual dental exam in the EHR or hardcopy was 11/2/22 with recommendation for annual exam.During a review of the facility's policy and procedures (P&P) titled, Dental Services, [undated], the P&P indicated, Routine and emergency dental services are available to meet the resident's assessment and plan of care.5. Social Services representatives will assist residents with appointments.6. Direct care staff will assist residents with denture care.

Based on observation, interview and record review, the facility failed to ensure safe, sanitary storage of food when:Multiple opened food items stored in the dry storage and refrigerators did not have open dates and use-by dates.Paper bag with food labeled 7/14 stored in the refrigerator had directions give to resident next day This failure had the potential to place all residents getting meals from the kitchen to be at risk for foodborne illness potentially leading to hospitalization or death. 1. During an observation and concurrent interview on 7/21/25 at 8:50 a.m., in the kitchen, refrigerator #2 had an opened box of cheesecake, with no open date and no used-by-date. The Registered Dietician (RD)stated he does not know when it was opened. RD stated opened refrigerated cheesecake was good for five days. In the dry storage room, five prepared bowls of dry cereal did not have open date and no use-by-date. RD stated the bowls of cereal should indicate when it was prepared and have a use-by-date. In a storage container of aluminum sealed items, were two eaten banana peels and a soiled paper cup. In the unnumbered nourishment refrigerator, an opened gallon of milk and orange juice pitcher did not have an open dates and no use-by-dates. During a record review of the facility P&P titled, Sanitation and Infection Control Subject Food Receiving and Storage of Cold Foods, dated 2023, the P&P indicated all open food items will have an open date and use-by-date per manufacturer's guidelines .cold food storage areas will be clean, dry, and free of contamination. During a review of the facility P&P, titled Sanitation and Infection Control Subject Canned and Dry Good Storage, dated 2023, the P&P indicated all food items will have an open date and use-by-date per manufacturer's guidelines .the storage area will be cleaned and maintained. 2. During an observation and concurrent interview on 7/21/25 at 8:53 a.m., a paper bag labeled for a resident dated 7/14/25, had instructions Dialysis bag for next day at 9AM. The RD identified the items in the bag to have a ham sandwich and two fruit cups. The RD stated the ham sandwich was good for 7 days so it was good until tonight. During a record review of the facility P&P titled, Sanitation and Infection Control Subject Refrigerated Storage, dated 2023, the suggested refrigerated storage guidelines indicated luncheon meats to be stored until their expiration date or less than or equal to 7 days of opening.

Based on observation, interview and record review, the facility failed to maintain an effective infection control program when:1.The specimen refrigerator (a specimen refrigerator is a specialized cooling unit used to store various biological samples collected from patients, such as urine, stool, blood, or tissue) was observed to be stored in the same room with the ice container for residents' consumption. 2. Station 2 medication storage room drawer was found to be disorganized and contained medications mixed with specimen sample containers, central line dressing kit, needles and socks stored together. (a specimen container is used to store various biological samples collected from patients, such as urine, stool, blood, or tissue; Central Line Dressing kits are used for very clean resident dressing changes). These failures placed the facility residents at increased risk of healthcare associated infections. Findings:1.During a concurrent observation and interview on 7/22/25, at 4:19 p.m., with Registered Nurse Supervisor (RNS) 3, in the Station 1 utility room, the specimen refrigerator was observed to be stored in the same room with the ice container that held ice cubes used for consumption by the facility residents. The scooper used to get ice from the ice container was observed to be hanging in the wall exposed to air beside the ice container. Also, observed inside the specimen refrigerator were stool specimens, urine specimen samples and blood samples. RNS 3 acknowledged that the risk of having the specimen refrigerator and the ice container in the same room was spread of infection. During an interview on 7/23/25 at 12:16 p.m., with the Infection Preventionist (IP), IP stated, the risk of having the ice container and the specimen refrigerator in the same utility room was the risk of the spread of infection to the residents who were using the ice for oral consumption. Also stated the risk of having the ice scooper hanging in the wall exposed to air in the utility room was cross contamination. 2. During a concurrent observation and interview on 7/21/25, at 8:58 a.m., with RN 1, in Station 2 medication storage room, the drawer was found to contain two boxes of Lidocaine patch medications, specimen sample containers, unused needles, test tubes, a pair of unused socks and a central line dressing kit mixed untidily together. RN1 acknowledged that the medication room drawer should be clean and orderly and should not store medications, needles and central line dressing kit due to the risk of spread of infection to the residents if these supplies were used. During an interview on 7/23/25 at 12:16 p.m., with the IP, IP stated, the medication storage drawers should be tidy and clean. Further stated that the lidocaine patches, needles and central dressing kit should not be mixed with the specimen containers and socks due to the risk of cross contamination and spread of infection. During an interview on 7/23/25 at 3:25 p.m., with the DON, stated, the risk of having the medication storage drawer storing medications, needles and central sterile dressing mixed with specimen containers was infection control. During a review of the facility's policy and procedure (P&P) titled, Infection Control Program, updated 11/22/21, the P&P indicated, . The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance .prevention of infection .and safety . Prevention of Infection a. Important facets of infection prevention include .2) instituting measures to avoid complications or dissemination; (3) educating staff and ensuring that they adhere to proper techniques and procedures.

Based on observations and interviews, the facility had three Resident rooms (Rooms 35, 41 and 43) with multiple beds that provided less that 80 square feet (sq. ft) per Resident who occupied these roomsThis deficient practice had the potential to result in inadequate space for the delivery of care to each Resident in each of these rooms and/or for storage of the Resident's belongings.Findings: During an observation 7/24/25 at 3:15 p.m., following rooms and corresponding sq. ft per bed were identified: room [ROOM NUMBER] had three beds, total sq. ft. is 231.6 and 77.2 sq. ft. per bed. room [ROOM NUMBER] had three beds, total sq. ft. is 231.6 and 77.2 sq. ft. per bed. room [ROOM NUMBER] had three beds, total sq. ft. is 231.6 and 77.2 sq. ft. per bed.During an interview on 7/24/25 at 12:32 p.m. with Resident 107, Resident 107 stated regarding the room size that it feels at little like a cubicle but making do and not to bothersome.During an interview on 7/24/25 at 12:43 p.m. with Resident 44, Resident 44 stated regarding the room size that it was ok, was not to bothersome and that she felt she had enough room to place her personal belongings.During an interview on 7/24/25 at 12:49p.m. with Resident 99, Resident 99 stated regarding the room size that it was fine and had no issues with space for her belongings.During an interview on 7/24/25 at 12:46 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated that they are staff personnel for the facility and has worked here for a while. CNA 4 stated that has worked and is currently working with the Residents in room [ROOM NUMBER]. CNA 4 stated the room size is adequate to provide care and for the Resident's belongings. CNA 4 stated that has not had issues with Resident transfers (moving a Resident from one place to another) or using wheelchairs in the room. During an observation on 7/24/25 at 12:32 p.m. of Resident room [ROOM NUMBER], no heavy medical equipment was observed that might interfere with each Resident's care. During an observation on 7/24/25 at 12:43 p.m. of Resident room [ROOM NUMBER], no heavy medical equipment was observed that might interfere with each Resident's care.During an observation on 7/24/25 at 12:49 p.m. of Resident room [ROOM NUMBER], no heavy medical equipment was observed that might interfere with each Resident's care.There were no complaints from any Residents in rooms 35, 41 and 43 regarding insufficient space for their belongings. There are no negative consequences that can be attributed to the decreased space and/or safety concerns in these rooms. Granting the room size waiver is recommended.

Based on interview and record review, the facility failed to update the code status (a medical term that indicates a patient's wishes regarding resuscitation and life-saving measures in the event of a medical emergency) for Resident 193.This deficient practice had the potential to result in the resident receiving treatments they may not want which could prolong their suffering or interventions inconsistent with their values and/or preferences.Findings: During a review of Resident 193's Face sheet, [undated], the Face sheet, indicated, that Resident 193 was admitted to the facility 7/9/25 and there was no Advance Directives (AD-a written statement of a person's wishes regarding medical treatment) or code status noted for this Resident. During a review of Resident 193's Progress Notes, dated 7/18/25, the Progress Notes, indicated, that at 8:50 p.m. Resident 193 was found unresponsive, no pulse, no respiration.Registered Nurse (RN) declare the time of death at 8:50 p.m. During a review of Resident 193's Physician Orders for Life-Sustaining Treatment (POLST- document to ensure that a patient's wishes are respected by healthcare providers in emergency situations or when they are unable to communicate for themselves completed by a physician, nurse practitioner, or physician assistant, in consultation with the patient or their healthcare proxy), [undated], the POLST indicated that the POLST form was prepared and signed by Resident 193 on 7/13/25 stating Do Not Resuscitate-(DNR); Comfort Focused (maximizing comfort). The POLST form also indicated that the form was signed by the medical provider 7/25/25. During a concurrent interview and record review on 7/25/25 at 4:06 p.m. with Director of Nursing (DON), Resident 193's Orders, Progress Notes, Face sheet and POLST were reviewed. The Orders did not show documentation of code status. The Face sheet did not show documentation of code status. The Progress Notes did not show documentation of code status prior to the Resident expiring on 7/18/25. The POLST indicated, that the POLST form was prepared and signed by Resident 193 on 7/13/25. The POLST form also indicated that the form was signed by the medical provider 7/25/25. The DON stated that the code status should be near the Resident name on the electronic health record (EHR) screen. DON also stated that if does not see no order for code status in the orders, resident records and has been trying to get a copy from Ace Hospice but has not been able to and that the POLST was signed today (7/25/25) by the medical provider. DON stated that would be easier if code status was in the orders. DON stated that if don't see order then assume full code status (all possible life-sustaining measures to be taken in the event of cardiac or respiratory arrest). During a review of the facility's policy and procedure (P&P) titled, Physician's Orders for Life Sustaining Treatment (POLST), [undated], the P&P indicated, .Completion of the POLST form must reflect a process of careful decision-making by the resident.in consultation with the Physician, about the resident's medical condition and known treatment preferences. During a review of policy and procedures (P&P) at website, https://emsa.ca.gov/dnr_and_polst_forms/ , titled, DNR and POLST Forms, dated 2025, the P&P indicated, .The Emergency Medical Services Authority (EMSA) approved POLST form must be signed and dated by a physician, or a nurse practitioner or a physician assistant acting under the supervision of the physician, and the patient or legally recognized health care decisionmaker. The POLST form should be clearly posted or maintained near the patient.

Based on interview and record review, the facility failed to follow up on a grievance for one of 36 sampled residents (Resident 38).This resulted in Resident 38's grievance to go unresolved. During a review of Resident 38's Facesheet (information containing contact details, brief medical history at a glance), the Face Sheet indicated, Resident 38 was admitted to the facility on [DATE]. Review of the resident's Minimum Data Set (MDS, an assessment tool used to guide care) dated 5/1/25, indicated Resident 38 had a brief interview for mental status or BIMS score of 15 (BIMS score of 13-15 indicates intact cognition).During an interview with Resident 38 on 7/21/25 at 12:03. p.m., Resident 38 stated my 500 dollars was stolen a few months ago and nothing has been done about it. Resident 38 also stated he had reported the missing money to the Director of Nursing (DON) and had not heard anything back.During a concurrent interview and record review, on 7/23/25, at 3:25 p.m., with DON, DON stated Resident 38 informed her of the missing money after the incident happened. DON stated that a grievance was done regarding the incident but a review of Resident 38's records did not indicate any documentation of the resident's missing money. During an interview with the Administrator (Adm) on 7/23/25 at 4:30 p.m., Adm stated that if Resident 38 filed a grievance regarding his lost money, the facility needed to investigate and there should be documentation of the incident in the resident's records. Adm stated there was no grievance filed for Resident 38‘s lost 500 dollars. Adm also stated, she had not heard of the incident until 7/23/25 when it was brought to her attention. During a review of the facility's undated policy and procedure (P&P) titled, Misappropriation of Resident Property, the P&P indicated, Reports of misappropriation of resident property shall be promptly and thoroughly investigated.Reports of misappropriation or mistreatment of resident property are to be investigated through the resident grievance process. and documented in the progress notes or through the grievance process .

Based on observation, interview and record review, for one of three sampled residents (Resident 200) who smoked, the facility failed to ensure a baseline care plan was developed to address Resident 200's smoking.This failure had the potential to result in the lack of interventions to promote safe smoking.During a review of Resident 200's RFS, the RFS indicated Resident 200 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis (infection in the bone), severe sepsis (serious condition resulting from the body's response to infection, can lead to tissue damage and death if not treated promptly), and generalized anxiety disorder (mental health condition, persistent and excessive worry about various aspects of life). During an observation and interview on 7/22/25 at 4:42 p.m. with Resident 200, there was an open pack of cigarettes on the overbed table. Resident 200 stated going out to smoke four times a day and that the facility staff had allowed cigarettes to be kept at the bedside. During a concurrent interview and record review on 7/24/25 at 4:06 p.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 200 smoked independently. LVN 5 stated the lighters and cigarettes were stored at the nurse station but was not sure if Resident 200 had some cigarettes at the bedside. LVN 5 stated a safe smoking assessment was initiated on 7/6/25 that indicated Resident 200 was a smoker but was not completed. LVN 5 also stated there was no baseline care plan completed to address Resident 200's smoking. LVN 5 stated the importance of ensuring smoking materials like cigarettes are not kept at the bedside, as residents could end up smoking in the room and potentially cause a fire. During a review of the Baseline Care Plan Summary (BCPS) dated 7/7/25, the BCPS did not indicate that Resident 200's smoking was addressed. During an interview on 7/25/25 at 3:55 p.m. with Minimum Data Set Coordinator (MDSC), MDSC stated any assessments upon admission would be completed by the admitting nurse, and any baseline care plan that should address the assessment results would be completed by the same admitting nurse. During a review of the facility's policy and procedure (P&P) titled Smoking Policy, undated, indicated a Safe Smoking Assessment is going to be completed to ensure safety or residents who may smoke and other residents other than smokers. The P&P also indicated, all residents that desire to exercise the privilege to smoke will be assessed to determine their smoking safety awareness, Interdisciplinary team (IDT, a group composed of individuals from different departments) will determine if a resident is a safe smoker, the Safe Smoking Assessment will be completed at the next morning meeting, following the resident's admission to the facility. Regardless of the Safe Smoking Assessment result, residents will need to keep smoking materials in the nurse station. Care plans will be developed based on assessment and findings of the IDT.

Based on observation, interview and record review, for two sampled residents (Resident 199 and 200), the facility failed to ensure an environment free of accident hazards and failed to ensure residents receive adequate supervision when:1. Resident 199 left the facility unsupervised. This failure had the potential to result in significant risks to resident's safety.2. Resident 200 had cigarettes at the bedside. This failure had the potential to result in fire hazards. 1.During a review of Resident 199's Resident Face Sheet (RFS), the RFS indicated Resident 119 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), other non-toxic encephalopathy (brain disease), congestive heart failure and pleural effusion (fluid buildup around the lungs).During an interview on 7/21/25 at 10 a.m. with Resident 199, Resident 199 stated there was no reason to stay in the facility, and that staying longer would make Resident 199 lose the apartment. Resident 199 had expressed wanting to go home.During an observation between 7/21/25 and 7/22/25, Resident 199 was seen walking along the hallway, sometimes sitting on the couch around the corner near the Administrator's office, looking sad and worried. During an interview on 7/24/25 at 2 p.m. with Director of Nursing (DON), DON stated Resident 199 went out on pass on 7/23/25 and did not return to the facility.During a joint interview on 7/24/25 at 4:06 p.m., with the Medical Records Director (MRD) and Receptionist (REC), MRD stated that if a resident went Out on Pass (OOP, refers to someone who has been granted temporary leave from a place such as a facility), they should sign out in the OOP binder at the nurse station. MRD stated that the charge nurse would give the resident an OOP slip, which should be handed to the receptionist on the way out the door. REC stated that there was no OOP slip with Resident 199's name among the slips from 7/23/25. REC added that she would not know if Resident 199 had gone out the door, as she did not know who Resident 199 was and was not familiar with all the residents' faces.During a concurrent interview and review of the OOP binder at the nurse station on 7/24/25 at 5:17 p.m. with Registered Nurse Supervisor (RNS) 2, RNS 2 stated, first, there should be an order written for OOP before a charge nurse issued the OOP slip to a resident. RNS 2 stated if there was no OOP order in the clinical record, there would be no OOP slip given to the resident.During a telephone interview on 7/24/25 at 5:55 p.m. with Licensed Vocational Nurse (LVN) 8, LVN 8 stated she did not see Resident 199 at the start of the afternoon shift on 7/23/25. LVN 8 stated that around dinner time at 5:40 p.m., Resident 199 was missing and both DON and Administrator (ADM) were informed. LVN 8 stated she found an OOP order in the clinical record around 7-8 p.m.During an interview on 7/25/25 at 11:07 a.m. with LVN 5, who worked the morning shift on 7/23/25, LVN 5 stated she did not know Resident 199 had left the building. LVN 5 also stated if she had known, she would have stopped Resident 199, or checked if there was OOP order, and documented it in the clinical record.During a review of Resident 199's clinical record, the Progress Notes indicated the following:-7/16/25, Resident 199 attempted to elope from the facility, triggering the wander guard alarm. This licensed nurse, along with another nurse, promptly responded and safely redirected the resident back into the facility. The progress notes did not indicate Attending Physician (AP) 1 was notified of Resident 199's elopement attempt.-7/16/25, Resident 199 exhibited behavior posing danger to self and others. Statements made and behaviors raised significant concern for the resident's safety and mental stability. Resident 199 was aggressive, agitated and expressed paranoid delusions. Resident 199 refused redirection and appeared disoriented to time and place. Resident 199 was transferred to acute hospital -7/17/25, Resident 199 returned to facility, 5150 hold was dropped, resistive to the wander guard, but was re-assured it was okay to have it. [Resident 199] up running through facility. Redirection attempts [were] unsuccessful to stop running. [Resident 199] will be evaluated by facility psychiatrist in house. The clinical record did not indicate an evaluation was done by in house psychiatrist.-7/23/25 at 5:45 p.m., progress note marked invalid by LVN 8 on 7/23/25 at 11:51 p.m., indicated, Resident 199 was Unable to be found during rounds, this writer spoke with previous nurse and [Resident 199] was last seen at 2 p.m. at nursing station 1. Resident known to wander around building. Wander guard bracelet was noted on resident per report. At dinner, resident was still not seen and staff immediately started searching for resident in building around 5:42 p.m. Searched the whole building and unable to find resident. Informed MD, DON, and the administrator. SPPD (police department) called after searching inside and outside of facility and reported about missing resident.-7/23/25 at 5:45 p.m., written by LVN 8, After four hours of this writer shift resident has not returned to facility. DON and ADM informed. SPPD notified.-7/23/25 at 8:36 p.m., recorded as late entry on 7/23/25 at 7:49 p.m. by DON, indicated, during morning rounds on 7/23/25, Attending Physician was advised that Resident 199 no longer showed signs of aggression or elopement risk. AP 1 gave an order that Resident 199 may go out on pass.-7/23/25 at 6:37 p.m., progress note edited by Registered Nurse Supervisor (RNS) 3 on 7/23/25 at 11:57 p.m., indicated, Resident found eloped from the building around 5:42 p.m. Searched the whole building but not able to find [Resident 199]. Informed MD, DON, and the administrator. Called SPPD and reported about missing resident.-7/23/25 at 6:37 p.m. written by RNS 3, indicated, Resident did not return to the facility. Informed MD, DON, and the administrator. Called SPPD and reported about the resident.During a review of Resident 199's General Order (GO) dated 7/23/25, the GO indicated a physician's order created on 7/23/25 at 7:58 p.m. by DON, after Resident 199 went missing, that Resident 199 may go out on pass. The GO indicated AP 2 gave the OOP order.During a concurrent interview and review of the GO on 7/24/25 at 6:34 p.m. with DON, DON stated the OOP order came from AP 1 in the morning of 7/23/25. DON also stated, she will update the OOP order to indicate it was AP 1 who gave the order, and stated it was an easy fix. During a follow-up review of the GO for OOP, dated 7/23/25, the OOP order dated 7/23/25 ordered by AP 2 was updated on 7/24/25 at 6:42 p.m. by DON, and indicated, AP 1 gave the order for OOP. During a telephone interview on 7/25/25 at 9:36 a.m., with AP 1, AP 1 stated sending Resident 199 to the hospital on 7/16/25 after Resident 199 showed signs of aggression. AP 1 stated that at the time, Resident 199 posed a danger to self and other residents. AP 1 stated being in the facility on the morning of 7/23/25, and OOP order was discussed with the facility staff. AP 1 stated giving an OOP order but did not know Resident 199's elopement attempt on 7/16/25. 2. During a review of Resident 200's RFS, the RFS indicated Resident 200 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis (infection in the bone), severe sepsis (serious condition resulting from the body's response to infection, can lead to tissue damage and death if not treated promptly), and generalized anxiety disorder (mental health condition, persistent and excessive worry about various aspects of life). During an observation and interview on 7/22/25 at 4:42 p.m. with Resident 200, there was an open pack of cigarettes on the overbed table. Resident 200 stated going out to smoke four times a day and that the facility staff had allowed cigarettes to be kept at the bedside. During a concurrent interview and record review on 7/24/25 at 4:06 p.m. with LVN 5, LVN 5 stated Resident 200 smoked independently. LVN 5 stated the lighters and cigarettes were stored at the nurse station but was not sure if Resident 200 had some cigarettes at the bedside. LVN 5 stated a safe smoking assessment was initiated on 7/6/25 that indicated Resident 200 was a smoker but was not completed. LVN 5 also stated there was no baseline care plan completed to address Resident 200's smoking. LVN 5 stated the importance of ensuring smoking materials like cigarettes are not kept at the bedside, as residents could end up smoking in the room and potentially cause a fire. During a review of the facility's policy and procedure (P&P) titled Smoking Policy, undated, indicated a Safe Smoking Assessment is going to be completed to ensure safety or residents who may smoke and other residents other than smokers. The P&P also indicated, all residents that desire to exercise the privilege to smoke will be assessed to determine their smoking safety awareness, Interdisciplinary team (IDT, a group composed of individuals from different departments) will determine if a resident is a safe smoker, the Safe Smoking Assessment will be completed at the next morning meeting, following the resident's admission to the facility. Regardless of the Safe Smoking Assessment result, residents will need to keep smoking materials in the nurse station.

Based on interview and record review, for one of three (Resident 112) sampled residents reviewed for behavioral health services, the facility failed to follow the psychiatrist's recommendation when Complete Blood Count (CBC, a common blood test that measures various components of your blood that included red blood cells, white blood cells, hemoglobin, etc. ), Basic Metabolic Panel (BMP, blood test that measures glucose, calcium, electrolytes, etc. to detect conditions such as liver and kidney disease and diabetes) and Urinalysis (UA, used to detect and manage disorders such as urinary tract infection, kidney disease and diabetes) and Culture and Sensitivity (C&S, used to diagnose urinary tract infection and guide antibiotic therapy) were not conducted.This failure had the potential to result in undetected abnormal blood levels due to current treatment. During a review of Resident 112's Resident Face Sheet (RFS), the RFS indicated Resident 112 was admitted to the facility in July 2024 with diagnoses that included cellulitis of the left lower limb, acute kidney failure, sepsis (life-threatening condition in response to an infection) and essential hypertension (high blood pressure), prediabetes (blood sugar levels are higher than normal but not high enough to be diagnosed as type 2 diabetes), and asthma.During an interview on 7/22/25 at 3:30 p.m. with Administrator (ADM), ADM stated Resident 112 allegedly attempted to touch Resident 19's arm. Resident 19 did not like the gesture and said, Don't touch me. ADM stated the incident ended with no further issues between the two residents.During a review of Resident 112's Progress Notes dated 3/21/25, the Progress Notes indicated Resident 112 cried and was emotionally distressed after the incident.During a review of Resident 112's Physician Order Report, dated 7/24/25, the Physician Order Report indicated an order dated 3/24/25 for psychiatric evaluation related to the physical altercation. The Physician Order Report also indicated an order dated 12/5/24 for Resident 112 to receive Seroquel (treats psychosis) 50 milligrams (mg) by mouth in the morning at 9 a.m. and 100 mg. tablet in the evening at 9 p.m. for agitation.During a concurrent interview and record review on 7/24/25 at 9:14 a.m. with Minimum Data Set Coordinator (MDSC), MDSC stated that there was no documentation in the clinical record indicating Resident 112 had been seen by a psychiatrist. MDSC stated they would check with Medical Records to see if there was anything that had not been uploaded to the electronic chart.During a concurrent interview and record review on 7/24/25 at 10:52 a.m. with MDSC, MDSC provided a copy of the psychiatrist recommendation, which she said was with the Social Services Department. A review of the Psychiatrist Visit Progress Report (PVPR) indicated, There are no immediate psychiatric or behavioral concerns per staff, therefore will recommend GDR (Gradual Dose Reduction, process to slowly decrease the dosage of a medication, particularly psychotropic drugs, to determine if patient can maintain stability on a lower dose or if the drug can be discontinued altogether) trial of quetiapine [Seroquel]. Under Medication Order, the PVPR also indicated to consider obtaining blood work (CBC, BMP/UACS) to rule out underlying medical issues with behavior changes. The evaluation also included a Physician's Telephone Orders dated 6/10/25 to decrease the 50 mg. dose to 25 mg. once daily.During a review of Consultant Pharmacist's Medication Regimen Review (CPMRR) dated 6/16/25, the CPMRR indicated, I do not see any notation/document that the resident was seen by the psychiatrist. Resident [112] is on Seroquel for agitation which is not an acceptable diagnosis for the use of an antipsychotic agent. In addition, he had a recent unwitnessed fall- Seroquel may be a contributing factor. Please follow-up psych[iatric] consult to assess Seroquel order.During an interview on 7/24/25 at 11:10 a.m. with Director of Nursing (DON), DON stated she was just now looking at the psychiatrist's recommendation for the first time and would get back to this writer as soon as she found out what happened. MDSC was with DON, and both were looking into Resident 112's chart.During a concurrent interview and review of Resident 112's PVPR on 7/24/25 at 11:12 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated the PVPR dated 6/9/25 indicated GDR and laboratory tests, but the clinical record did not indicate any of the recommendations were done. LVN 4 stated the clinical record did not indicate that a GDR had been performed since Resident 112's admission to the facility in July 2024. LVN 4 stated the last laboratory test was dated 8/22/24.During a review of Resident 112's Progress Notes written by DON, with a run date of 7/24/25 at 12:17 p.m., the Progress Notes indicated an entry dated 6/12/25 at 11:46 a.m., recorded as late entry on 7/24/25 at 11:49 a.m. The Progress Notes indicated AP did not agree with the recommendation at the time due to Resident 112's behavior. Another Progress Notes written by DON indicated, Resident had been experiencing some tearfulness, and we went over the recommendations from the Psych evaluation and [AP] agreed to the GDR which I have changed as of today.During a review of Resident 112's Behavioral Monitoring Administration History from 7/1/2025-7/24/2025 (BMAH), the BMAH indicated side effects to be observed for Seroquel use that included sedation, drowsiness, dry mouth, constipation, blurred vision, extrapyramidal reaction, weight gain, seizures, urinary retention, tardive dyskinesia, and cognitive/behavior impairment. During a follow-up interview on 7/24/25 at 12:40 p.m. with LVN 4, LVN 4 stated they were not aware of the psych recommendation until today, 7/24/25.During a telephone interview on 7/25/25 at 9:36 a.m. with Attending Physician (AP) 1, AP 1 stated he was not aware of the psychiatrist's recommendation to do laboratory tests.

Based on observations, interviews and record reviews the facility failed to ensure Resident 91 was updated regarding the status of her power wheelchairThis deficient practice had the potential to result in a significant impact on the resident's independence, quality of life, physical and mental health. During a review of Resident 91's Face sheet, dated 7/24/25, the Face sheet indicated, an initial admission date of 11/3/2018 and latest return date of 7/20/25. During a review of Resident 91's Face sheet, dated 7/24/25, the Face sheet indicated, Resident 91 had diagnoses to include: chronic obstructive pulmonary disease (COPD-chronic lung disease that makes it hard to breathe), diabetes mellitus type 2 (body either doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), chronic pain, anxiety disorder (excessive, persistent, and unreasonable fear and worry, often interfering with daily life), Major Depressive Disorder (MDD,persistent sadness, loss of interest, and other symptoms that significantly impair daily life), hypertension (high blood pressure), osteoarthritis (condition that causes joints to become painful and stiff), generalized muscle weakness and severe morbid obesity (a severe form of obesity characterized by a Body Mass Index (BMI) of 40 or higher, or a BMI of 35 or higher with obesity-related health complications. This condition significantly increases the risk of various health problems and can reduce life expectancy) During a review of Resident 91's Minimum Data Set (MDS-standardized assessment tool used to evaluate the health and functional status of residents), dated 4/22/25, the MDS indicated, the following: Section C (Cognitive Patterns-way of thinking) show a Brief Interview for Mental Status (BIMS-cognitive screening measure that focuses on orientation and short-term word recall) score was 15 (cognitively intact per BIMS score scale). The MDS Section GG (Functional Abilities) noted Dependent to moderate assist. During an interview on 7/21/25 at 3:56 p.m. with Resident 91, Resident 91 stated that she recently came back from the hospital. Resident 91 also stated that her electric wheelchair has been broken for about a year and that she has not been able to go out and do the things she like to do, like go to Dollar Tree or Ross right down the street. Resident 91 stated that she has not heard anything back regarding the power wheelchair and is using the manual wheelchair she is currently in but it is difficult to be as mobile as was when she had her power wheelchair. During a concurrent interview and record review on 7/23/25 at 12:36 p.m. with Social Worker (SW), Resident 91's Progress Notes dated 8/30/24, 12/10/24, 2/7/25 and 2/28/25 were reviewed. The Progress Notes for each date indicated: 8/30/24: Restorative Nursing Assistant (RNA) to weigh resident 91 in order to move forward with power wheelchair, 12/10/24: Facility received call from Durable Medical Equipment (DME) facility requesting resident 91 power wheelchair paperwork to be faxed on 11/25/24 that was refaxed 12/10/24, 2/7/25: A written order from provider was faxed to DME facility, 2/2/28/25: Facility received call from DME facility that resident 91 has an appointment in the facility 3/13/25 at 12:00 p.m. to assess her power wheelchair and resident 91 was made aware. SW stated the dates 8/30/24, 12/10/24, 2/7/24 and 2/28/25 were the only dates that could be found regarding the power wheelchair. SW stated that could not find documentation regarding 3/13/25 DME visit to the facility. The SW also stated that there should be document in the chart for this visit but I don't see it. During a concurrent interview and record review on 7/23/25 at 3:24 p.m. with SW, Resident 91's Insurance Letter, dated 4/30/25, was reviewed. The Insurance Letter indicated, that resident 91 was denied authorization for a power chair and that there was no follow up that can be found after that. SW also stated that resident 91 was informed at that time that authorization for the power wheelchair. During an interview on 7/23/25 at 3:49 p.m. with resident 91, resident 91 stated that it was as I told you before, I was not aware of any denial letter and nobody told me anything. Resident 91 also stated that I thought that they was still working on getting my power chair. During a review of the facility's policy and procedures (P&P) titled, Social Services, [undated], the P&P indicated, .2. The director of social services is responsible for.maintaining records related to social services.meeting or assisting with the medically-related social service needs of residents.3.Medically-related social services are provided to maintain or improve each resident's ability to control everyday physical needs (e.g. appropriate adaptive equipment for eating, ambulation, etc); and mental and psychosocial needs (e.g. sense of identity, coping abilities, and sense of meaningfulness or purpose.5. The social worker/social services staff are responsible for.making referrals and obtaining needed services from outside entities. During a review of the facility's policy and procedures (P&P) titled, Resident Rights, [undated], the P&P indicated, .Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care.

Based on observation, record review and interviews, the facility failed to provide call system (allows patients to request assistance from healthcare staff, typically nurses, by activating a call button or other alerting device. These systems are crucial for patient safety and efficient care delivery, enabling patients to quickly summon help when needed) to Resident 107.This deficient practice had the potential to result in resident having trouble accessing help for medication needs basic comfort or hygiene needs to prevent falls.Findings:During a review of Resident 107's Face sheet, [undated], the Face sheet indicated, Resident 107 was admitted to the facility 4/9/24 and has diagnoses to include Chronic Obstructive Pulmonary Disease (COPD- condition caused by damage to the airways or other parts of the lung), Fracture of Left and Right Humerus (break in the upper arm bones), Vertigo (sensation that you or your surroundings are spinning or moving) Anxiety (feelings of worry, nervousness, or unease) and Depression (mood disorder that can affect how you think, feel, and handle daily activities). During an observation on 7/24/25 at 12:32 p.m. in Resident 107's room, above Resident 107's bed, there was no call light observed attached to the wall or at the bedside. There was also no call bell observed on the bedside table. During an interview on 7/24/25 at 12:32 p.m. with Resident 107, Resident 107 stated that he had not had a call bell for a long time. Resident 107 also stated that if he needed medications such as his pain or sleep medication, he would have to use his wheelchair to wheel himself to the nurses station to request them.During an interview on 7/24/25 at 12:34 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated that it is important for the resident to have a call light because what if he can't get up. LVN 4 stated that will contact Maintenance to have a call light installed into the wall but will get bedside table call bell in the meantime.During a review of the facility's policy and procedure (P&P) titled, Resident Call System, [undated], the P&P indicated, Residents are equipped with a communication system allowing them to request assistance by contacting either a staff member directly or a centralized work station.3. The resident call system remains functional at all times.5. The resident call system is routinely maintained and tested by the maintenance department.

Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from abuse when Resident 1, a vulnerable resident, unable to protect himself, was roomed with Resident 2, an ambulatory resident with a history of impulsive aggressive behavior, and Resident 2 hit Resident 1 with a quad cane (a device used for walking that has a metal base on the bottom with four small feet that extend from the base). This failure resulted in Resident 1 sustaining a scalp laceration (a tear, cut, or opening in the skin covering the head caused by an injury) from Resident 2 hitting him with the quad cane. Resident 1's scalp laceration required placement of two staples (metal devices used to hold wound edges together) at the emergency department of an acute care hospital. Resident 2's unprovoked attack of Resident 1 also had the potential to result in emotional/psychological injury to Resident 1. Findings: A review of Resident 1's Face Sheet, undated, indicated Resident 1 was admitted to the facility in 2015 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/1/22, indicated Resident 1 had unclear speech, was usually understood, and sometimes understood others. The MDS indicated Resident 1 was impaired on both upper and lower extremities, on one side of his body. The MDS indicated Resident 1 required extensive assistance from one person for bed mobility, dressing, and personal hygiene; total assistance from one person for locomotion; and total assistance from two people for transfer between surfaces. The MDS indicated Resident 1 used a wheelchair for locomotion. A review of Resident 2's Face Sheet indicated Resident 2 was originally admitted to the facility in February 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's MDS dated [DATE], indicated Resident 2 had unclear speech, was usually understood, and usually understood others. The MDS indicated Resident 2 used a walker or wheelchair for locomotion, and was not steady, but was able to stabilize himself without staff assistance. The MDS indicated Resident 2 had no impairment to either upper or lower extremities. A review of Resident 2's care plan dated 8/26/21, for the problem of negative behavioral symptoms of rejection of care, wandering, and physical abuse to others, indicated a goal of Resident 2 having more productive and meaningful activity and less negative behavioral symptoms occurrence. Interventions to achieve the goals included: observe for pain/discomfort that might trigger negative behavior; remove from triggering environment to a calm and quiet place with supervision; and monitor for behavior not easily altered. A review of Resident 2's care plan, dated 4/22/22, indicated a problem of physical aggression: Resident 2 hit a staff member in the neck on 4/22/22 at 6 p.m. The care plan indicated a goal of Resident 2 displacing physical aggression to meaningful activities. Interventions to achieve the goals included: coach and train resident to respond assertively rather than aggressively; develop behavioral management plans that include rules, expectations, and consequences and implement consistently; and enhance feeling of self-control by assisting in identifying available resources and personal strengths. A review of the facility form, Notification of Room Change, dated 4/22/22, indicated Resident 1 was relocated in the facility to share a room with Resident 2 on 4/22/22 at 12 noon. The Notification of Room Change indicated the reason Resident 1 was relocated was for the resident's psychosocial well-being. A review of Resident 1's clinical record titled, Situation, Background, Assessment, Recommendation (SBAR) - General, dated 4/27/22, indicated Resident 2 stated he had hit his roommate Resident 1, with a quad cane (a cane with four short legs on the base) for no apparent reason. The SBAR indicated Resident 1 was transferred to the hospital via 9-1-1 for treatment. A review of Resident 1's Emergency Department (ED) Provider Notes, After Visit Summary, dated 4/27/22, the Notes indicated Resident 1 obtained a scalp laceration which required two staples to close. The Notes indicated Resident 1 would require physician follow-up for removal of the sutures in five to seven days. During an interview on 4/28/22, at 11:35 a.m., with the Director of Nursing (DON), the DON stated the Interdisciplinary Team (IDT, professionals from various disciplines within the facility, who discuss treatment plans for resident care) had daily discussions about resident room assignments. The DON stated IDT considered residents' behaviors and potential compatibility when deciding on room assignments. The DON stated Resident 1 had been in quarantine in a COVID positive area, but was released from quarantine on 4/22/22, and so he was placed in the non-quarantine area room with Resident 2. The DON stated placement was difficult as the facility had fewer male rooms available. The DON was unable to provide documentation that indicated an IDT discussion about resident compatibility of Resident 1 and 2 had occurred before Resident 1 was moved into the room with Resident 2. During an interview on 4/28/22, at 12:37 p.m., with the Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she had been working yesterday around noon when she saw Resident 2 standing in the hall next to the entry to his room. CNA 1 stated Resident 2 asked her to call 9-1-1 (emergency call) because he wanted food. CNA 1 stated she had entered the shared room of Resident 1 and 2, to do a routine check of Resident 1, and saw Resident 1 in bed with blood rolling down from his forehead to his nose. CNA 1 stated she went outside the shared room to call Licensed Vocational Nurse 1 (LVN 1) for help, and when she turned back around CNA 1 saw Resident 2 standing next to Resident 1's bed, holding a quad cane up in the air. CNA 1 stated she took the cane away from Resident 2. During an interview on 4/28/22, at 1:30 p.m., with LVN 1, LVN 1 stated he was at the nursing station next to the shared room of Resident 1 and 2, when CNA 1 called for him. LVN 1 stated he entered the shared room of Resident 1 and 2 and saw Resident 1 lying in bed, swearing, and bleeding from his head. LVN 1 stated 9-1-1 was called and Resident 1 went to the acute care hospital. During an interview with Resident 2 on 4/28/22, at 1:47 p.m., Resident 2 sat in a wheelchair, with a staff member seated within arm's reach from Resident 2. Resident 2 stated he had hit Resident 1's head three times with a hammer because Resident 1 lied to him about Resident 1's life. During an observation and concurrent interview on 5/5/22, at 2:15 p.m., with Resident 1, Resident 1 had two staples on top of a black colored oblong scab (approximately one inch by ½ inch) on the top of his head. Resident 1 did not respond when asked how he obtained the injury to his head. A review of the facility policy and procedure titled, Abuse and Neglect Prohibition, dated October 2004, indicated, Each resident has the right to be free from mistreatment, neglect, abuse . A review of the facility policy and procedure titled, Abuse and Neglect Prohibition Policy and Procedure California Facility Addendum, dated 4/15/2001, indicated, Physical abuse means any of the following: assault, battery; assault with a deadly weapon or force likely to produce great bodily injury .

Based on interview and record review, the facility failed to notify the physician of one (Resident 1) of two sampled residents after Resident 1 fell , which resulted in Resident 1 having treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: During a review of Resident 1's facility document titled, Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility in 2019. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool use to guide care) dated 2/9/21, the MDS indicated Resident 1 had a score of six on the Brief Interview for Mental Status exam. (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status; a score of six is an indication of severe impairment.) The MDS indicated Resident 1's preferred language was Spanish, and she needed/wanted an interpreter for communication with health care staff but was able to make herself understood using verbal and nonverbal expression. The MDS also indicated Resident 1 was unsteady during transfer and required total assistance from two or more staff for transfer between surfaces. During an interview on 2/23/21 at 1:35 p.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated on the evening shift (3 p.m. to 11:30 p.m.) of 2/16/21, she was assigned to care for Resident 1. CNA 3 stated before dinner on that evening, CNA 3 saw Resident 1 take off her blankets, and move her feet off the bed toward the floor. CNA 3 stated LVN 3 responded to her calls for assistance, and the two of them were able to control Resident 1's descent to the floor at the side of Resident 1's bed. During an interview on 2/25/21 at 3:44 p.m., with LVN 3, LVN 3 stated on 2/16/21, Resident 1 had been restless; Resident 1 had pointed to the floor mat as if she wanted to go to the floor, and tried to climb out of bed. LVN 3 stated he and a certified nursing assistant eased Resident 1 to the floor mat. LVN 3 stated he was not familiar with Resident 1, as he usually worked in a different unit. LVN 3 further stated he documented the eased down incident two days after the event occurred. During a review of Resident 1's Physical Therapy (PT) Treatment Encounter Notes, by Physical Therapist Assistant 1 (PTA 1), dated 2/16/21 at 7:24 p.m., the Encounter Notes indicated Resident 1 had complained of hip pain, and held her right hip while lying on the floor mat next to her bed. The notes reflected Resident 1 was unable to do physical therapy tasks, so physical therapy was not done the evening shift of 2/16 21. The notes reflected PTA 1 had reported Resident 1's condition to Licensed Vocational Nurse 3 (LVN 3). During a review of Resident 1's nursing Progress Notes dated 2/16/21 at 3 p.m., to 2/17/21 at 7:30 a.m., there were no documented pain assessments, no documentation of Resident 1's assisted fall to the floor, no documentation that PTA 1 had reported to nursing staff that Resident 1 seemed to be in pain. The notes further indicated an entry dated 2/19/21 at 5:32 p.m., as a late entry for 2/16/21 at 4:50 p.m., by LVN 3, Resident 1 eased herself down the Charge Nurse from her bed to the impact pad, gave gesture that she wanted to be on the floor. During an interview on 2/25/21 at 2:24 p.m., with Physical Therapist Assistant 1 (PTA 1), PTA 1 stated he had gone to Resident 1's room to provide physical therapy around dinner time on 2/16/21. PTA 1 stated he found Resident 1 lying on the fall mat next to her bed, holding her hip and grimacing. PTA 1 stated Resident 1 appeared to be in pain, so he left the room and told Licensed Vocational Nurse 1 (LVN 1) that Resident 1 was on the floor, on the fall mat, and seemed to be in pain. LVN 1 accompanied PTA 1 back to Resident 1's room, and they transferred Resident 1 back into bed. PTA 1 stated he attempted to perform sit-to-stand exercises with Resident 1, but she refused to participate and kept rubbing her right hip. PTA 1 stated he left Resident 1's room and again told LVN 1 that Resident 1 seemed to be in pain. LVN 1 told him she was not in charge and he should make his report to Licensed Vocational Nurse 2 (LVN 2). PTA 1 stated he then told LVN 2 about Resident 1's pain, but LVN 2 told him she was not Resident 1's nurse, and she had referred him to LVN 3. PTA 1 stated he found LVN 3 and reported he had found Resident 1 on the floor, and she appeared to be in pain, as she was holding her right hip, and refused to do physical therapy. PTA 1 stated LVN 3 told him Resident 1 preferred to lay on the floor mat. During an interview on 2/25/21 at 3:44 p.m., with LVN 1, LVN 1 confirmed PTA 1 had told him Resident 1 was on the floor fall mat, pointing at her hip, and seemed to be in pain. LVN 1 stated PTA 1 had reported he had not been able to do physical therapy with Resident 1 and thought Resident 1 should have an Xray. LVN 1 stated she told PTA 1 she was currently doing overtime, but only to help with medication administration, and PTA 1 should speak to LVN 2. During a telephone interview on 2/25/21 at 8:29 p.m., Licensed Vocational Nurse 2 (LVN 2) stated she recalled PTA 1 had told her of Resident 1's pain and she referred PTA 1 to LVN 3. During an interview on 2/25/21 at 11:45 a.m., with LVN 3, LVN 3 stated he did not recall PTA 1 reporting Resident 1 was in pain on 2/16/21. During an interview on 2/23/21 at 1:10 p.m., with LVN 2, LVN 2 stated she had gone to Resident 1's room on 2/17/21, between 8 a.m. and 9 a.m., and Resident 1 was screaming in a non-English language and pointing to her back and right hip. LVN 2 stated she called Certified Nursing Assistant 3 (CNA 3) into Resident 1's room to translate. During an interview on 2/23/21 at 1:37 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated on 2/17/21 around 9 a.m., LVN 2 called her into Resident 1's room to act as a translator for Resident 1. CNA 1 stated when she entered the room, Resident 1 was screaming words. CNA 1 stated she translated the words as, I have pain! I have pain! During a telephone interview on 3/25/21 at 1:45 p.m., with the Director of Nursing (DON), the DON stated Resident 1's pain was first reported to the Nurse Practitioner on 2/17/21. During a review of Resident 1's facility document titled, Observation Detail List Report, dated 2/17/21 at 6:30 p.m., the Report indicated Resident 1's Nurse Practitioner/Physician was notified 2/17/21 at 9 a.m., that Resident 1 was complaining of hip pain upon movement. During a review of Resident 1's, Radiology Order, dated 2/17/21 at 9:00 a.m., the order indicated stat (immediate or urgent) X-R (x-ray) . of both right and left hips, and pelvis. During a review of Resident 1's acute care Hospital Discharge Summary dated 2/19/21, the discharge summary indicated Resident 1 was admitted to the hospital for a right hip fracture on 2/18/21, had surgery of the right hip on 2/18/21, and was discharged back to the facility on [DATE]. During a telephone interview with Resident 1 and the Language Interpreter Services representative on 3/5/21 at 3:47 p.m. Resident 1 stated she had gone to the hospital, but she was feeling really bad and did not want to talk.

Based on observation, interview, and record review, the facility failed to: 1. provide adequate monitoring and supervision systems during an extended fire watch, 2. while the fire alarm system was malfunctioning; 3. submit a request for an emergency fire alarm panel for ten days after the fire panel malfunction; and, 4. establish effective monitoring and supervision procedures for prevention/identification of intentional fire setting. These failures had the potential to result in injury, or loss of life, for all residents in the facility in the event of an uncontrollable fire in the facility. On 3/3/2020 at 4:06 p.m., the facility Administrator and Director of Nursing was informed of an Immediate Jeopardy situation (IJ - a situation in which the provider's noncompliance with requirements has caused or is likely to cause serious injury, harm, impairment, or death to a resident), for failure to implement adequate protective measures in a timely manner against the threat of fire from both accidental and deliberate causes. Through observation, interview, and record review, the facility demonstrated they had initiated the plan of action for providing monitoring and supervision against the threat of fire. The Immediate Jeopardy was lifted on 3/13/2020 at 2:03 p.m. Findings: During a review of the facility license, expiration date of 4/15/2020, the license indicated the facility was licensed for 202 beds. During a review of a fax signed by the Administrator (ADM), with a transmission date of 2/19/2020, at 6:18 p.m., the fax indicated the fire alarm system had an uncorrectable issue identified, and was currently nonfunctional. The fax indicated the facility had implemented a fire watch until the system was completely restored. During review of two voice messages on 2/20/2020 at 12:09 p.m., and 1:58 p.m., from the ADM, the ADM stated there was a small fire in a resident room, which was extinguished before the Fire Department arrived. The Fire Department told the ADM the fire appeared to be accidental. During a review of a fax signed by the ADM, with a transmission date of 2/24/2020 at 6:40 p.m., the fax indicated facility staff discovered a fire on 2/24/2020, at 11:44 a.m., by Bed C, in room [ROOM NUMBER], a three-bed room. At that time, two residents occupied the room: Resident 1, who was sleeping in Bed A, and Resident 2, who was in Bed C, and was not alert. The fax indicated both residents were evacuated, and staff had extinguished the fire before arrival of the Fire Department. At 11:56 a.m., with the Fire Department on site, facility staff discovered a fire in room [ROOM NUMBER], a two-bed room. room [ROOM NUMBER] had no occupants in the room at the time of the fire; the fire was contained and extinguished. The fax indicated the Fire Department Fire Investigator deemed the causes of the two fires as suspicious, and would investigate further. The fax indicated the Plan of Action was: notifications to (local) Fire Department, CDPH (California Department of Public Health), ombudsman, Medical Director, and physicians; fire watch in place; Fire Investigator in facility to investigate fire as they were treating the fires as suspicious and continuing their investigation; monitor residents for respiratory or emotional distress; social services to meet with residents to provide emotional support, with referral to psychological services for affected residents; and isolation and cleaning of the affected rooms by a Restoration Management Company. During an observation in room [ROOM NUMBER] on 2/24/2020, at 2:10 p.m., room [ROOM NUMBER] smelled of smoke, and had a blackened foam-like material on the floor by Bed C. The bedside table at 19C had a blackened area approximately four inches wide running the entire length of the bedside table back; the baseboard and wall adjacent to the bedside table was blackened. The electrical cord for the bed of 19C was partially melted. During an observation in room [ROOM NUMBER] on 2/24/2020, at 3:10 p.m., room [ROOM NUMBER] smelled of smoke; the mattress of bed 40B had a blackened area on the right hand side in the middle of the mattress. During an interview on 2/24/2020, at 4:10 p.m., with the Vice President of Operations (VPO), the VPO stated the fire alarm system was still not in service for one side of the building, but was expected to be repaired by 2/25/2020. The VPO stated until the fire alarm system was completely functional, the facility would be completing fire watch rounds on a continual basis, utilizing two staff members. The VPO stated the facility would be applying to the Office of Statewide Health Planning and Development (OSHPD) for an emergency fire panel permit. During a telephone interview on 3/3/2020 at 10:35 a.m., with the ADM, the ADM stated the facility was still on fire watch because the fire system had not been completely repaired yet on both floors of the two floors of the facility, with further repair work not scheduled until 3/10/2020. The ADM stated the facility was still on fire watch, which meant each room and area was checked on an ongoing basis. The ADM stated the facility tried to schedule two dedicated personnel for the fire watch each shift, but sometimes were only able to schedule one fire watch person per shift. During a review of the facility Fire Watch Patrol Log Sheets dated 2/28/2020, 2/29/2020, 3/1/2020, and 3/2/2020, the Log Sheets indicated only one person was on fire watch: 2/28/2020, from 3 p.m., until 2/29/2020, at 7 a.m.; 2/29/2020, from 11 a.m., to 12 p.m.; 2/29/2020, from 3 p.m., until 3/1/2020, at 7 a.m.; and 3/1/2020, at 11 p.m., until 3/2/2020, at 7 a.m. During a telephone conference on 3/5/2020 at 1:05 p.m., with OSHPD District Structural Engineer (DSE) and the facility-contracted architect (ARC), ARC stated the request for the emergency fire panel was sent to OSHPD on 2/29/2020. DSE stated OSHPD had received the facility request for a special urgent fire panel permit on 3/2/2020. During a conference on 3/5/2020 at 1 p.m. attended by the ADM, the VPO, and the facility Attorney (AAL), the ADM, the VPO and the AAL, all stated they had timed how long it took to do a fire watch covering all areas of the facility, and it had taken staff a total of 60 to 64 minutes for completion of the circuit of all patrolled areas. During a review of the facility policy and procedure (PNP), Fire Watch Procedures, dated 11/5/13, the PNP indicated the Uniform Fire Code required the facility to establish and maintain a fire watch when fire protection equipment/system/sprinklers were rendered inoperable. The PNP indicated the fire watch included assignment of a qualified person or persons whose sole responsibility was a continuous patrol of the building/premises. The fire watch patrol rounds included, check the entire building-all rooms, offices, storage areas, and areas outside the building. The PNP indicated the patrol rounds should be completed every thirty minutes, with documentation of the history of the rounds maintained in a log book. During an interview on 3/6/2020, at 11:41 a.m., Fire Department Inspector 1 (FD 1), FD 1 stated the fires on 2/24/2020 were a result of arson. During a review of a fax with a transmission date of 3/10/2020, at 2:53 a.m., signed by the ADM, the fax indicated on 3/9/2020, at 11:30 p.m., the facility remained on fire watch. The fire watch personnel had just completed a patrol in room [ROOM NUMBER] a few minutes earlier, when Certified Nursing Assistant 1 (CNA 1) passed the doorway of room [ROOM NUMBER], and saw a fire in the two-bed room. The fax indicated a bed-bound resident occupied Bed A, and Bed B was unoccupied at the time of the fire. Facility staff evacuated the resident in Bed A, and extinguished the fire before the arrival of the Fire Department. A review of the Fire Watch Log Sheet dated 3/9/2020, for the area of Station 1A and Station 1B, the log indicated Security Guard 1 (SG 1), patrolled the area for the time period of 3/9/2020, at 10 p.m., to 3/10/2020 at 2 a.m., with an average time per round of 19 minutes. For the same time period, the log indicated in the column labeled, Finding, of smoke in room [ROOM NUMBER]. During an interview on 3/13/2020 at 8:20 a.m., with Security Guard 1 (SG 1), SG 1 stated he had been doing continuous fire watch rounds, on a fifteen minutes per round schedule. SG 1 stated he had patrolled room [ROOM NUMBER], and had only seen one resident in Bed A. SG 1 stated he had been out of room [ROOM NUMBER] for three to five minutes, when he heard there was a fire in room [ROOM NUMBER], and went to assist. During an interview on 3/13/2020, at 8:32 a.m., with CNA 1, CNA 1 stated he had passed by room [ROOM NUMBER], and noticed a fire behind the nightstand between Bed A and B. CNA 1 stated he called out to alert staff of the fire, and went into the room to extinguish the fire, while other staff evacuated the resident in Bed A. During an interview on 3/11/2020, at 8:30 a.m., with the ADM, the ADM stated six cars were set on fire this morning at 5:35 a.m., on a street adjacent to the facility. The ADM stated the facility had not been physically damaged, but the smoke from the fires necessitated evacuation of 38 residents to dining areas of the facility for three hours. During an interview on 3/13/2020, at 2:03 p.m., with the ADM, and Director of Nursing (DON), the ADM stated on the morning of 3/11/2020, at 5:35 a.m., facility staff had responded to a loud noise, which sounded like an explosion at the north side of the building. The ADM stated the responding staff were at the intersection of two streets, by the northwest corner of the building. The staff saw that cars parked along the curb of the sidewalk adjacent to the building were on fire, and gasoline was running downhill in the gutter, toward the northwest corner. The responding staff extinguished the gasoline fire at the corner, but the smoke from the burning cars continued to enter the facility. The ADM stated at the time of the car fires, the facility had patrol areas along the building perimeter, including the smoking area, but no designated patrols or fire watch of the sidewalks surrounding the building. During a concurrent observation and interview on 3/13/2020, at 3:03 p.m., with the ADM, and Maintenance Supervisor (MS), the north side of the facility had a resident and staff smoking area along the length of the building, bordered on the north by a concrete wall, and on the south, by the building. Unlocked metal gates closed the eastern and western ends, and separated the resident and staff smoking areas. Two streets intersected at the northwest corner of the facility; the northern street came to a dead end at its eastern end, and sloped downhill toward the western street. The western street sloped downhill toward the south and the southern side of the building. The smoking area was below the street level on both the north and west street sides, with variable depth due to the sloping of the streets. The north concrete wall varied in height on the sidewalk side between three and five feet, with the shortest height at the uphill, eastern end. The sidewalk curb along the north side of the facility had a black discoloration roughly the length of the building. MS measured the following distances, which were confirmed by the ADM: from the northwest edge of the facility roof, to the street side of the top of the concrete wall was 8 feet and 4 inches; from the exterior north wall of the facility to the exterior edge of the concrete wall was 11 feet and 10.5 inches; from the curb of the north street sidewalk to the concrete wall was 5 feet and 5.5 inches.

Based on observation, interview and record review, the facility failed to prevent one of one sampled residents (1) from injury during a transfer from the bathroom onto his motorized wheelchair. For Resident 1, Certified Nursing Assistants (CNA) 1 and CNA 4 lifted him under his arms and Resident 1's feet dragged along the floor as he was moved from the commode to his wheelchair located outside of the bathroom. Resident 1's feet became entangled as he was being turned in order to sit in the wheelchair. This failure resulted in Resident 1 sustaining multiple fractures in both of his lower legs. Findings: Review of Resident 1's medical record, on 4/8/14, at 3 p.m., showed the facility admitted Resident 1, on 4/29/09, with multiple medical [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set (MDS) an assessment tool), dated 10/17/13, indicated Resident 1 was unable to stand or walk or transfer between surfaces, without total assistance from two staff. Resident 1 did not use the bathroom to toilet. He was incontinent of bowel and bladder and used adult briefs. During an observation and concurrent interview, on 4/8/14, at 2:15 p.m., Resident sat up in bed with both his legs out straight in soft braces from thigh to ankle. There was a pillow between his knees to prevent him from crossing his legs and a foot cradle at the bottom of the bed to lift the weight of the blankets from his feet. There was an electric wheel chair parked at the foot of his bed. Resident 1 stated, "I can't use my chair at all since this (pointed to his legs) happened. I sure want to. I'd go outside and listen to the birds. I'm used to being up and around. I'm an outside person." Resident 1 explained how his 3/24/14 injury occurred during a transfer from the commode in the bathroom to the wheelchair outside of the bathroom. He stated, "The two people (Certified Nursing Assistants, CNA 1 and CNA 4) worked to try to get me in my chair. It was a slip not a fall." A review of the nurses notes for Resident 1, dated 3/25/14, at 8:30 p.m., showed Registered Nurse 2 (RN 2) wrote, "Pt (patient) has multiple intact blisters on bilateral lower extremities. Skin discolorations surrounding the blisters also noted." Nurses notes dated 3/26/14, at 2 p.m., showed RN 1 recorded, "Received x-ray results from imaging services...multiple fractures on bilateral lower extremities." A review of Resident 1's x-ray results, dated 3/26/14, indicated: "1. Femur (thigh bone, right), comminuted (crushed or splintered into pieces) and impacted (wedged together) distal (farthest down) femoral shaft fracture; 2. Ankle (right), non-displaced fracture of the distal tibial (shin bone) shaft in addition to the spiral fracture of the mid to distal tibia shaft 3. Femur (left) comminuted anterior (front) apex (summit or extremity) angulated and impacted distal femoral shaft fracture; 4. Knee (left) fracture of the proximal (nearest the knee) tibial shaft and fibular (fibula; outer, smaller bone, alongside the tibia) neck without significant displacement." Review of Resident 1's Doctor's progress notes, dated 3/28/14, indicated, "Patient is extremely osteoporotic (had weakened bones, a frequent consequence of quadriplegia) - subject to fractures, even with minor trauma." In an interview, on 4/8/14, at 2:30 p.m., (CNA 1) stated, "I am his regular CNA. Usually, Resident 1 is incontinent or just passed gas." CNA 1 did not have an explanation for why Resident 1, who was always incontinent and never used the commode, was in the bathroom using one that day. CNA 1 went on to say that on 3/24/14, after lunch, she helped get Resident 1 off the shower chair commode in Resident 1's bathroom. CNA 1 was on Resident 1's left arm. Another CNA (CNA 4) was on his right arm. The Restorative Nurse Assistant (RNA 1) was supposed to pull up Resident 1's pants and get the (motorized) chair into position at the bathroom door. "We hoisted him up under his armpits. RNA 1 took longer than expected to pull up his pants, they got stuck or something. We pulled him out to the door frame. The pants got twisted and one of his legs was crossed under his other knee. When I felt him slipping I said, 'Let's just get him back in the (wheel) chair.' I was holding onto the pants. I felt he was slipping." CNA 1 stated, "I could have taken the wheeled commode, with Resident 1 on it, out of the bathroom and placed it next to his wheel chair. We could have more safely transferred Resident 1 out there in the room." During an interview, on 4/10/14, at 9:30 a.m., RNA 1 stated, "My job was to bring up the wheel chair and pull up his pants once they had him (Resident 1) standing. They pivoted and brought him out, bottom first. I was attempting to work the electric wheel chair controls. It had been left in the rabbit mode (rapid acceleration). It came out of the corner quicker than I was prepared. I had to get it into turtle mode (slow speed) to put it in the doorway. I guess I fidgeted with it longer than I should. It seemed to me they were trying to dead lift him (lift a person who is completely unable to bear weight) (Resident 1) and carry him to the chair." In an interview and concurrent record review, on 4/9/14, at 12:15 p.m., the Director of Nursing (DON) looked through Resident 1's clinical record for a care plan for transferring between surfaces. The DON stated, "There isn't one. All I could find is the ADL (Activities of Daily Living) care plan. It says Resident 1 requires extensive assistance with ADL's and transfer." In an interview, on 4/10/14, at 9:45 a.m., the DON stated Resident 1 had osteoporosis. "It's probably because of his quadriplegia. Staff needed to take care with anyone with long term quadriplegia. Staff needed to take extra careful precautions for osteoporosis." In an interview, on 5/21/14, at 1 p.m., the Unit Manager at Station 2 (RN 1) explained that the instructions on how to transfer Resident 1 were on the Kardex. RN 1 stated, "He was a two person lift but now he is a mechanical lift (using a machine with a sling to lift the Resident operated by 2 staff.)" RN 1 went on to explain why Resident 1 hadn't been out of bed since his legs were broken, "They didn't know if he could use a manual wheel chair because he had always refused to try to get up." During a telephone interview on 7/17/14, at 11:30 a.m., Resident 1 said of his legs, "They are still there. They are still hurting. They are not knitting back together. The pain is still a real problem. The pain is around both knees, like I was being stung by ten thousand red ants, or wasps, or bees. They didn't hurt at all until they were broken. The pain I had before was in my back, but now that is overshadowed by my legs. Also, my legs have contracted-stiff like. They don't bend any more like they did (before fractures). They don't fit solidly in the foot rest on my wheel chair; they stick out about six inches. I have to watch where I'm going so as not to get caught."

Based on interview, and record review, the Facility failed to implement their procedures that prohibit the misappropriation of resident property for one, Resident 1, of one sampled resident. Facility staff used Resident 1's credit card to purchase $6,000 worth of items for personal use. This failure resulted in Resident 1 being, "Extremely upset." In an interview on 10/1/13 at 1:13 p.m., the Social Services Assistant, (SSA), was asked to describe the incident with Resident 1. The SSA stated that she had used Resident 1's credit card to purchase several personal items for herself and not for the resident. The SSA stated that she, "Knew it was not okay, but I did it and I feel bad. I felt weak. I feel so bad." In an interview on 9/26/13 at 10:25 a.m., Resident 1 was asked to describe the incident with the SSA. Resident 1 stated that she, (the SSA), "stole from me. I did not know it until the Credit Union called the police. It was extremely upsetting. I understood it was $6,000. She tried to get me to say that I gave her permission. She got me to where I trusted her. I gave her the credit card to buy things for me." In an interview on 10/1/13 at 12:33 p.m., The Director of social Services, (DSS), was asked to describe what the SSA's knowledge was in regards to accepting gifts or using Resident's credit cards for their own personal use. The DSS stated that she had, "Never had a discussion with her, (the SSA), regarding not accepting gifts or taking money. I knew she understood. I basically trusted her." In a concurrent interview and record review on 10/1/13 at 12:03 p.m., the ADM was asked to describe the training that staff recieve in regards to accepting gifts from residents. The ADM stated that each staff person is required to, "Sign a Code of Conduct." Record Review of the Code of Conduct showed that employees and contractors may not accept any gifts or gratuities from residents, their families, or their visitors. In an interview on 10/2/13 at 11:05 a.m., the Facility Administrator, (ADM), stated that the facility did not know that Resident 1 had access to a personal credit card. The ADM was asked why the SSA was aware that Resident 1 had a credit card but not the facility administration. The ADM stated that the SSA, "Never said anything about it. She only told us that she was helping Resident 1 open a new bank account. She never mentioned the credit card. I did not know that they went to Walmart. Now I will go through the whole house to see who has credit cards to see how we can safeguard these items." Record review of the Inventory of Personal Effects document, (document used to itemize all personal belongings upon admission), on 10/2/13 at 11:05 a.m., showed that Resident 1 was admitted with a wallet. There was no description of what was inside the wallet. the ADM was asked why the contents of the wallet were not addressed. The ADM stated that yes, Resident 1, "May have had the credit card with him on admission. We should have looked." Record review of the facility's policy and procedure entitled, Residents' Personal Property, and dated 4/15/2001, showed that the residents' property will be kept in a safe location.