Every finding on record at Valley View Care Center

Based on interview and record review, the facility failed toEnsure two of three sampled residents (Resident 1 and Resident 2) received at least thirty-day notice of transfer/discharge prior to discharge.Ensure three of three sampled residents (Resident 1, Resident 2, and Resident 3) had documentation that the Ombudsman was notified of the facility-initiated transfer/discharge.Ensure three of three sampled residents (Resident 1, Resident 2, and Resident 3) had a discharge care plan developed and implemented prior to transfer/discharge.Ensure one of three sampled residents (Resident 1) had physician's discharge orders in place prior to discharge.These failures had the potential for Resident 1, Resident 2, and Resident 3 to have an unsafe discharge.Findings:1. During a review of Resident 1's Notice of Transfer/Discharge (NTD), dated [DATE], the NTD indicated, Notification date [DATE] . Effective discharge date [DATE]. Resident 2's NTD dated [DATE], indicated, Notification Date [DATE]. Effective discharge date [DATE]. Resident 1 and Resident 2 was not provided a thirty-day notice of transfer/discharge prior to discharge. During an interview on [DATE] at 2:37 p.m. with Social Service Director (SSD), SSD confirmed Resident 1 and Resident 2 did not receive a thirty-day notice prior to discharge.2. During a review of Resident 1's NTD dated [DATE], the NTD did not have a fax confirmation of being sent to the Ombudsman. Resident 2's NTD dated [DATE], did not have a fax confirmation of being sent to the Ombudsman and Resident 3's NTD dated [DATE], did not have a fax confirmation of being sent to the Ombudsman.During an interview on [DATE] at 3:09 p.m. with SSD, SSD stated Ombudsman was not contacted when Resident 1 was discharged .During an interview on [DATE] at 3:34 p.m. with Director of Nursing (DON), DON stated only resident's responsible party are notified when a resident is discharged .During an interview on [DATE] at 2:37 p.m. with SSD, SSD stated NTD wasn't sent to Ombudsman for Resident 1, Resident 2 and Resident 3.During an interview on [DATE] at 3:32 p.m. with Medical Record Director (MRD), MRD stated she doesn't send NTD to Ombudsman when a resident is discharged .3. During a concurrent interview and record review on [DATE] at 3:09 p.m. with SSD, Resident 1's Care Plan Report (CPR) dated [DATE] was reviewed. The CPR indicated no documentation of a discharge/transfer care plan. SSD stated a discharge/transfer care plan should have been completed for Resident 1. During a concurrent interview and record review on [DATE] at 3:34 p.m. with DON, Resident 1's CPR dated [DATE] was reviewed. The CPR indicated no documentation of a discharge/transfer care plan. DON stated Resident 1 should have had a discharge/transfer care plan and did not have one completed.During a concurrent interview and record review on [DATE] at 2:37 p.m. with SSD, Resident 2 and Resident 3's CPR was reviewed. SSD was unable to find a discharge/transfer care plan for Resident 2 and Resident 3. SSD stated a discharge/transfer care plan should have been completed for Resident 2 and Resident 3. 4. During an interview on [DATE] at 3:09 p.m. with SSD, SSD stated a discharge order is needed to discharge a resident from the facility. SSD stated Resident 1 did not have discharge orders.During a concurrent interview and record review on [DATE] at 3:34 p.m. with DON, Resident 1's Order Summary Report (OSR) (OSR) dated [DATE] was reviewed. The OSR indicated, no discharge orders were documented. DON stated Resident 1 should have discharge orders and did not.During a review of the facility's policy and procedure (P&P) titled, Transfer and Discharge (including AMA) (undated), the P&P indicated, 4. Generally, the notice must be provided at least 30 days prior to a transfer or discharge of the resident. 5. The facility will maintain evidence that the notice was sent to the Ombudsman. 9. Non-Emergency Transfer or Discharges.d. The facility will provide transfer/discharge notice to the resident/representative and Ombudsman as indicated. 10.a. Facility will obtain a physician's order for transfer or discharge and instructions or precautions for ongoing care 12. Anticipated Discharge to the Community.e. The comprehensive, person-centered care plan shall contain the resident's goal for admission and desired outcome and shall be in alignment with the discharge.During a review of the facility's P&P titled, Comprehensive Care Plans, (undated), the P&P indicated, 3. The comprehensive care plan will describe, at a minimum, the following.e. Discharge plans.

Based on interview and record review, the facility failed to develop and implement care plan interventions for one of three sampled residents (Resident 1) when Resident 1's gastrostomy tube (G-tube- a tube which delivers liquid, nutrition, and medications, through a flexible tube that goes directly into the stomach) was repeatedly dislodged. This failure resulted in Resident 1 being sent to the acute hospital two times in a 24-hour period and potential for complications including severe pain and infections. Findings:During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 3/13/26, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status- standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 6 (0-7 points indicates the resident severely impaired cognition). The MDS indicated Resident 1 was dependent (helper does all the effort) for upper body dressing (the ability to dress and undress above the waist: including fasteners if applicable) and lower body dressing (the ability to dress and undress below the waist, including fasteners; does not include footwear).During a review of Resident 1's Change in Condition, (CIC) dated 5/16/26 at 1:55 p.m., the CIC indicated, GT [G-tube] dislodgement/balloon deflated . 3. Recommendation of Primary Clinician(s): send out to ER (emergency room) for replacement.During a review of Resident 1's Change in Condition, dated 5/20/26 at 6:05 p.m., the CIC indicated, [Resident 1] was found with G-Tube chewed off and pulled out . [Resident 1] had abdominal binder on and was also removed by himself. [Resident 1] was sent out for g-tube replacement.During a review of Resident 1's Change in Condition, dated 5/20/26 at 10:40 p.m., the CIC indicated, Gtube (sic) dislodged . 3. Recommendation of Primary Clinician(s): Transfer to [acute hospital] for gtube (sic)replacement.During a concurrent interview and record review, on 6/1/26 at 2:30 p.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), Resident 1's Change in Condition, dated 5/16/26 and 5/20/26 were reviewed. DON and ADON confirmed Resident 1 was sent out to the acute hospital on 5/16/26, 5/20/26 at 6:05 p.m. and 10:40 p.m. for G-tube dislodgement and being pulled out. Resident 1's G-tube s care plans were reviewed. DON and ADON stated no new intervention were developed or implemented for Resident 1 for CIC on 5/16/26. ADON stated there should have been new interventions put in place to prevent Resident 1 from pulling out his G-tube.During a review of the facility's policy and procedure (P&P) titled, Care Planning, revised 6/2020, the P&P indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. II. The Care Plan serves as a course of action where the resident (resident's family and /or guardian or other legally authorized representatives), resident's Attending Physician, IDT work to help the resident move towards resident-specific goals that address the resident's medical, nursing, mental and psychological needs. VIII. A comprehensive person-centered Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychological needs. B. Changes may be made to Comprehensive Care Plan on an ongoing basis for the duration of the resident's stay. IX. Each resident's Comprehensive Care Plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; B. Any services that would be required, but are not provided due to the resident's exercise of rights. Which includes the right to refuse treatment . X. The Comprehensive Care Plan must be completed . and must be periodically reviewed and revised by a team of qualified persons after each assessment, including the comprehensive and quarterly review assessments. V. The IDT will revise the Comprehensive Care Plan as needed at the following intervals: .B. As Dictated by changes in the resident's condition; . D. Ta address changes in behavior and care; and E. Other times as appropriate or necessary.

Based on interview and record review, the facility failed to develop a complete care plan with interventions for one of three sampled residents (Resident 1) when antibiotics was not administered as ordered. This failure had the potential for staff to be unaware of how to care for Resident 1 when the antibiotic was not administered.Findings:During a review of Resident 1's Care Plan (CP) dated 5/13/26, the CP indicated, Focus.Resident had a missed dose of Zosyn (antibiotic) on 5/11/26 Resident made a statement to staff that he felt neglected and fears that he will lose his leg.Goal. IV (intravenous-administered through a vein) antibiotic will be administered as ordered timely.Interventions/Tasks.No description provided (indicating the care plan had no interventions).During a concurrent interview and record review on 5/20/26 at 11:41 a.m., with Director of Nursing (DON), Resident 1's CP was reviewed. DON stated the CP was incomplete and should have included interventions.During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans undated, the P&P indicated, The comprehensive care plan will describe, at a minimum, the following.the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to follow physician orders when an antibiotic was not administered as ordered for one of three residents (Resident 1). This failure resulted in a missed dose of antibiotics and the potential for Resident 1's wound to worsen. Findings:During a review of Resident 1's Physician Order (PO) dated 5/6/26, the PO indicated, Zosyn Intravenous Solution.Use 50 ml (milliliters) intravenously three times a day related to local infection of the skin and subcutaneous tissue.for 14 days.During a review of the Medication Administration Record (MAR), dated 5/2026, the MAR indicated, Zosyn Intravenous Solution.three times a day related to local infection of the skin and subcutaneous (fatty layer under the skin) tissue.14 days.5/11/26.0800 (8 a.m.) .blank (indicating medication was not administered) .During a review of Resident 1's Progress Notes (PN) dated 5/11/26 at 5 p.m., the PN indicated, Followed up with resident regarding concerns about delayed IV antibiotic administration, including missed 0800 (8 a.m.) dose and delayed 1400 (2 p.m.) dose. DON became aware of missed 0800 dose at approximately 1300 (1 p.m.) and discussed continuation of antibiotic therapy with resident. DON later became aware at approximately 1630 (4:30 p.m.) that scheduled 1400 (2 p.m.) dose had not yet been administered.During a review of Resident 1's PN dated 5/11/26 at 7:17 p.m., the PN indicated, At about 7 p.m. SSA (Social Service Assistant) spoke with resident regarding a concern resident has regarding IV medication. Resident complained of missing scheduled 8AM and 2 PM IV medication. Resident stated assigned nurse, assigned CNA (certified nursing assistant), and DON were informed of questions regarding IV medications. Resident stated he was asking all day for medication, and medication was not administered at scheduled times. Resident states he feels neglected and fears that he will lose his leg.During an interview on 5/20/26 at 10:12 a.m. with Resident 1, Resident 1 stated he was being treated for a leg infection and did not receive a dose of his antibiotics on 5/11/26. Resident 1 stated the facility told him it was a miscommunication on their part.During an interview on 5/20/26 at 10:17 a.m. with DON, DON stated on 5/11/26 there was a lack of communication, and she was unaware there was not an RN available to administer Resident 1's IV antibiotic. DON stated Resident 1 missed his 8 a.m. dose of the antibiotic and that was an error on her part.During a review of the facility's policy and procedure (P&P) titled, Medication Administration undated, the P&P indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so as ordered by the physician and in accordance with professional standards of practice.

Based on observation, interview, and record review, the facility failed to ensure the annual performance evaluation (A written demonstration of nursing staff's knowledge, skills, and techniques necessary to care for residents' needs safely and effectively) was up to date for one of five sampled staff (Certified Nursing Assistant [CNA]). This failure had the potential to result in CNA providing care that does not meet the residents' needs.Findings: During a concurrent interview and record review on 3/20/26 at 11:04 a.m. with Director of Staff Development (DSD), CNA personnel file (PF), dated 8/10/20, was reviewed. The PF indicated CNA the annual performance review was last conducted on 12/28/24. DSD stated an annual performance evaluation was not done for 2025.During a review of the facility's policy and procedures (P&P) titled, Performance Evaluations, undated, the P&P indicated, Policy Statement, The job performance of each employee shall be reviewed and evaluated at least annually. 9. The completed performance evaluation will be sent by the director or supervisor to the HR Director to be placed in the employee's personnel record.

Based on interview and record review, the facility failed to implement their policy and procedure on Drug Diversion, for three of four sampled residents (Resident 2, Resident 3, Resident 4) to ensure secure storage, accurate documentation, proper administration, monitoring, and accountability of all narcotic controlled substances (a powerful, prescription-only drug used to treat moderate to severe pain). This failure resulted in narcotic diversion (the illegal transfer, theft, or misuse of prescription drugs from their intended medical path) and had the potential to cause pain induced harm to residents.Findings:During an interview and record review on 2/11/26 at 3:05 p.m. with Administrator, Resident 2's, Resident 3's, and Resident 4's narcotic log (NL), electronic medical record (EMR), and the facility five-day report (F5R) were reviewed. Administrator stated on 2/3/26 at approximately 2:30 p.m. Licensed Vocational Nurse (LVN) 1 was starting his evening shift (2 p.m. to 10:30 p.m.) when he noticed Resident 2's hydrocodone (narcotic pain medication) 10/325 milligrams (mg - a unit of measurement) bubble-pack (a, clear plastic, organized card that holds pills in individual, sealed compartments labeled by day and time) with 28 pills was missing along with the inventory sheet (a sheet that describes the amount of product was released to the facility). Administrator stated LVN 1 knew Resident 2's hydrocodone was missing because he had provided Resident 2's hydrocodone from the bubble-pack on 2/1/26. Administrator stated the facility expanded their search to other residents to see if they had missing narcotics. Administrator stated Resident 3 and Resident 4 had one bubble-pack of hydrocodone 5/325 mg which contained 28 pills missing each (56 narcotic pills total plus the 28 for Resident 1) along with their inventory sheets. Administrator stated they looked further back into Resident 2's medication and found three more hydrocodone 10/325 mg bubble-packs missing with their inventory sheets. Administrator stated the inventory sheets missing were the main reason the hydrocodone was not noticed to be gone for Resident 2, Resident 3, and Resident 4 due to the narcotic count appearing to be correct. Administrator stated copies of the inventory sheet for resident narcotics are not taken to keep track when they were delivered. Administrator stated the F5R indicated a total of 164 hydrocodone pills were diverted.During an interview on 2/11/26, at 4 p.m. with LVN 1, LVN 1 stated on 2/3/26 he had come in to work his evening shift (2 p.m. to 10:30 p.m.) and conducted his resident narcotic count with LVN 2. LVN 1 stated the narcotic count was correct but knew Resident 2's Hydrocodone bubble-pack was missing because he had seen it on 2/1/26 during his shift. LVN 1 stated he also noticed the inventory sheet was missing for Resident 2's Hydrocodone which had led staff to think the narcotic count was correct.During a review of the facility's policy and procedure (P&P) titled, Drug Diversion, undated, the P&P indicated, It is the policy of this Skilled Nursing Facility to ensure the secure storage, accurate documentation, proper administration, monitoring, and accountability of all narcotic controlled substances. The facility maintains zero tolerance for narcotic drug diversion and will take immediate action to investigate, report, and mitigate any suspected or confirmed diversion to protect resident safety and comply with all federal and state regulations. All narcotic administrations must be documented immediately in . Electronic or paper Medication Administration Record (MAR) . Controlled Substance Record .

Based on interview and record review, the facility failed to implement their policy and procedure on Use of Psychotropic Medication(s) (medication that affects brain activity, resulting in changes in mood, behavior, thoughts, and perception) for one of four sampled residents (Resident 1). This failure resulted in Resident 1 to be on psychotropic medication without IDT (Interdisciplinary team- a collaborative group of healthcare professionals, including nurses, doctors, therapists, social workers, and the resident/family, who work together to create and implement personalized care plans) approval, and to be without behavioral monitoring to see if the medication was effective. Findings:During an review of Resident 1's admission RECORD (AR), dated 2/11/26, the AR indicated, Resident 1 was admitted to the facility on [DATE] with a diagnoses including major depressive disorder (a common, serious mental health condition characterized by persistent, intense feelings of sadness, hopelessness, and a loss of interest in activities), history of falling, shortness of breath, and muscle weakness.During a review of Resident 1's physician order sheet (POS), dated 1/29/26, the POS indicated, Resident 1 was to start on Depakote (medication used for depression) 250 milligrams (mg - a unit of dosage) by mouth two times a day for mixed mania (a severe state where symptoms of mania [high energy, racing thoughts] and depression [sadness, hopelessness] occur simultaneously or in rapid succession) and bipolar due to aggressive behaviors.During a review of Resident 1's MEDICATION ADMINISTRATION RECORD (MAR), dated 1/2026, the MAR indicated, Resident 1 had started Depakote 250 mg on 1/29/26 at 6 p.m. and continued to take Depakote 250 mg the rest of the month at 8 a.m. and 6 p.m. The MAR indicated Resident 1 was not on behavior monitoring for his Depakote usage.During a review of Resident 1's MAR, dated 2/2026, the MAR indicated, Resident 1 had taken Depakote 250 mg twice a day at 8 a.m. and 6 p.m. from 2/1/26 until 2/28/26. The MAR indicated the facility did not start behavior monitoring for Resident 1 Depakote usage until 2/11/26.During a concurrent interview and record review on 2/11/26 at 11:04 a.m. with Social Services Director (SSD), Resident 1's electronic medical chart (EMR) was reviewed. SSD stated Resident 1 was started on Depakote 250 mg twice daily on 1/29/26. SSD stated there has not been an IDT conducted to determine if it was appropriate to start Resident 1 on Depakote 250 mg for twice a day for his depression. SSD stated facility staff are supposed to be monitoring Resident 1's behavior while on Depakote but that was not being done. SSD stated the purpose of monitoring behaviors is to determine if the medication and/or its dosage was appropriate for use. SSD stated an IDT, and behavioral monitoring should have been initiated once Resident 1 had the order for Depakote 250 mg for depression but was not done.During a review of the facility's policy and procedure (P&P) titled, Use of Psychotropic Medications, dated 2025, the P&P indicated, It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. 'Adequate indications for use' refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and after any other treatments have been deemed clinically contraindicated. For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for use is inadequate. Also, adequate indication for use means that the medication administered is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence based review of articles that are published in medical and/or pharmacy journals. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. The indications for initiating, maintaining, or discontinuing medications(s), as well as the use of nonpharmacological approaches, will be determined by evaluating the resident's physical, behavioral, mental, and psychosocial signs and symptoms in order to identify and rule out any underlying medical conditions, including the assessment of relative benefits and risks, and the preferences and goals for treatment. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use . The resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record.During a review of the facility P&P titled, The Psychotropic Drug Committee (PDC), undated, the P&P indicated, The objectives of the Psychotropic Committee are . To utilize an IDT framework with additional disciplines to develop multidisciplinary non-drug interventions and strategies to address mood and behavioral issues of long term care residents . To utilize different disciplines, expertise and experience to recommend the least restrictive and most beneficial psychotropic drugs to the primary physician . To ensure that the facility is in compliance with the regulatory guidelines . The committee shall thoroughly review the [NAME] owing areas for each resident who is on psychoactive medications . appropriate diagnosis for the medication used . accurate and appropriate target behaviors for treatment being provided .

Based on interview and record review, the facility failed to follow its policy and procedure on Background Investigations, for one of three licensed vocational nurses (LVN 2). This failure had the potential to expose residents to abuse, neglect, and mistreatment.Findings:During an interview and record review on 2/12/26 at 3:52 p.m. with Administrator, LVN 2's employee file (EF), was reviewed. The EF indicated LVN 2's reference check was not completed. According to the EF, LVN 2 had been working for the facility since 2/13/24. Administrator stated LVN 2's reference check should have been done prior to her working at the facility per policy and procedure.During a review of the facility's policy and procedure (P&P) titled, Background Investigations, undated, the P&P indicated, Job reference checks, drug screenings, licensure verifications and criminal conviction record checks are conducted on all personnel making application for employment with this company. Driving record checks are conducted when the job in question requires the employee to drive as part of their assigned duties. Persons applying for employment and current employees will be informed of this policy. The company will not conduct a background investigation without an applicant's or employee's advance consent. Applicants or employees who do not consent to a background investigation will, however, not be considered for positions that the company has determined to require the completion of a background investigation.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled Influenza (Flu- contagious respiratory disease) Vaccine when:1. The Infection Preventionist (IP) did not provide and document the education of explanation of risks and benefits for the flu vaccine for four of five sampled Residents (Resident 9, Resident 10, Resident 5, and Resident 2). 2. The IP did not contact Resident 53's representative (RP) for Resident 53 to receive the flu vaccine.These failures resulted in inaccurate documentation, and had the potential to spread infectious diseases.Findings:1. During a concurrent interview and record review on 12/17/25 at 8:49 a.m. with IP, Resident 9's Vaccine Consent Form. (VCF), dated 7/14/25 and Progress Note (PN), dated 7/14/25 were reviewed. The VCF indicated Resident 9's vaccine consent was signed on 7/14/25 by the RP. The PN did not indicate there was any education provided to Resident 9's RP about the risk and benefits of the flu vaccine. IP stated there was no documentation of education provided to Resident 9's RP for the flu vaccine. During a concurrent interview and record review on 12/17/25 at 8:53 a.m. with IP, Resident 10's VCF, dated 7/14/25 and PN, dated 7/14/25 were reviewed. The VCF indicated Resident 10's vaccine consent was signed on 7/14/25 by the RP. The PN did not indicate there was any education provided to Resident 10's RP about the risk and benefits of the flu vaccine. IP stated there was no documentation of education provided to Resident 10's RP, but the RP should have been educated on the risks and benefits of the Flu vaccine. During a concurrent interview and record review on 12/17/25 at 9:00 a.m. with IP, Resident 5's VCF, dated 7/14/25 and PN, dated 7/14/25 were reviewed. The VCF indicated Resident 5's vaccine consent was signed on 7/14/25 by the RP. The PN did not indicate there was any education provided to Resident 5's RP about the risk and benefits of the flu vaccine. IP stated there was no documentation of education provided to Resident 5's RP for the flu vaccine. During a concurrent interview and record review on 12/17/25 at 9:03 a.m. with IP, Resident 2's VCF, dated 11/21/25 and PN were reviewed. The VCF indicated Resident 2's vaccine consent was signed on 11/21/25 by Resident 2. The PN did not indicate there was any education provided to Resident 2 about the risk and benefits of the flu vaccine. IP stated there was no documentation of education provided to Resident 2 because he is Spanish speaking and another staff member translated for me. IP stated Resident 2's language barrier was not an excuse to not provide education about the risk and benefits of the flu vaccine. 2. During a concurrent interview and record review on 12/17/25 at 9:06 a.m. with IP, Resident 53's VCF and PN were reviewed. The VCF and PN did not indicate Resident 53 was offered the flu vaccine. IP stated Resident 53 did not receive his flu vaccine and there was no documentation Resident 53's RP was contacted for the flu vaccine. IP stated, I should have documented I called the RP, and followed up. During an interview on 12/17/25 at 10:23 a.m. with IP, IP stated there is no policy for contacting Resident's RP for immunizations. IP stated the process was to continue to call the Resident's RP or notify the medical doctor to ensure Resident 53 was offered the flu vaccine. During a review of the facility's P&P titled, Influenza Vaccination, undated, the P&P indicated, Policy: It is the policy of the facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents.annual immunization.Policy Explanation and Compliance Guidelines.3. Additionally, influenza vaccinations will be offered to residents.5. Prior to the administration of the influenza vaccine, the person receiving the immunization, or his/her legal representative, will be provided with a copy of the CDC's current vaccine information statement relative to the influenza vaccination. 6. The vaccine information statement (VIS) will, as appropriate, be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding the benefits and potential side effects of the influenza vaccine.9. The resident's medical record.will include documentation that the resident and/or the representative was provided education regarding the benefits and potential side effects of immunizations, and that the resident received or did not receive the immunizations due to medical contraindication or refusal.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Food Preparation Guidelines, for eight of eight sampled residents (Resident 4, Resident 16, Resident 23, Resident 29, Resident 34, Resident 37, Resident 39, and Resident 49) when food was not mechanical soft to meet their diet orders. This failure had the potential for undesired outcomes such as weight loss or chocking. Findings:During an observation on 12/16/25 at 12:05 p.m. in the kitchen during tray line, lunch meals were prepared. Dietary Aide (DA/C-Cook as needed) served Resident 4, Resident 16, Resident 23, Resident 29, Resident 34, Resident 37, Resident 39, and Resident 49 garlic bread, lasagna, broccoli, and a parsley garnish. During an interview and record review on 12/16/25 at 12:24 p.m. with Dietary Manager (DM), Resident 4, Resident 16, Resident 23, Resident 29, Resident 34, Resident 37, Resident 39, and Resident 49 meal tickets and Winter Menu (spreadsheet), dated 2025, were reviewed. Resident 4, Resident 16, Resident 23, Resident 29, Resident 34, Resident 37, Resident 39, and Resident 49 indicated mechanical soft texture. The Winter Menu indicated lasagna chopped with no hard edges, broccoli chopped and soft, no parsley garnish, and chop/soak/drain garlic bread. DM stated Resident 4, Resident 16, Resident 23, Resident 29, Resident 34, Resident 37, Resident 39, and Resident 49 lunch trays needed to be corrected for mechanical soft texture.During a review of the facility's P&P, titled, Food Preparation Guidelines, dated 2025, the policy indicated, Policy: It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. Policy Explanation and Compliance Guidelines: 1. The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes. 4. Food shall be provided in a form (i.e. regular, cut, chopped, ground, pureed) that meets each resident's individual needs in accordance with his or her assessment and care plan.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered (CCP) for three of six sampled residents (Resident 6, Resident 21, and Resident 32) when:Resident 21's CCP titled, Resident 21 is on Prophylactic Antibiotic Therapy [medications to prevent disease] r/t [related to] diagnosis of latent [inactive] tuberculosis (TB - a serious, contagious bacterial infection that usually attacks the lungs with two forms: latent and active [disease]) was not followed. Resident 32 did not have CCPs developed for anxiety (feelings of unease) and use of hydrOXYzine (medication to help reduce anxiety).These failures had the potential for Resident 6, Resident 21, and Resident 32 to have a delay in care. Findings:1. During a review of Resident 21's CCP titled, Resident 21 is on Prophylactic Antibiotic Therapy r/t diagnosis of latent tuberculosis, dated 11/4/25. The CCP indicated, Goal: Resident 21 will be free of any s/s (sign and symptoms) of TB with intervention of Any antibiotic may cause diarrhea, nausea, vomiting, anorexia [low appetite], and hypersensitivity/allergic reactions. Monitor q-shift [every shift] for adverse reaction.During a concurrent interview and record review on 12/17/25 at 1:47 p.m. with Infection Preventionist (IP), Resident 21's Physician Orders (PO), dated 12/17/25, and Medication Administration Record (MAR), dated November and December of 2025, were reviewed. The PO indicated, monitor vital signs and s/s of respiratory illness: 0. none observed, 1. fever or chills, 2. cough, 3. shortness of breath, 4. fatigue, 5. muscle or body aches, 6. headache, 7. new loss of taste or smell, 8. sore throat, 9. congestion or runny nose, 10. nausea or vomiting, and 11. diarrhea, three times a day for respiratory illness monitoring. IP stated Resident 21's MAR does not have records of s/s of respiratory illness. IP stated the PO indicated Resident 21's s/s of respiratory illness should be monitored.2. During a record review of Resident 32's Order Summary Report (OSR), dated 12/18/25, the OSR indicated hydrOXYzine HCl Oral [by mouth] Tablet 10 MG [milligrams-unit of measure] (Hydroxyzine HCl) Give 1 tablet by mouth every 24 hours as needed for anxiety with order date of 11/6/25. During a concurrent interview and record review on 12/17/25 at 3:49 p.m. with Health Information (HI), Resident 32's CCPs were reviewed. HI stated Resident 32 does not have CCP for anxiety or use of hydrOXYzine.During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 2001, the P&P indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition change.

Based on interview and record review the facility failed to follow its policy and procedure (P&P) titled Infection Prevention and Control Program when three of five sampled residents (Resident 9, Resident 10, and Resident 5)'s representatives (RP) were not explained of risks and benefits of the Covid-19 vaccines (Coronavirus disease- a highly contagious respiratory disease). This failure had the potential for inaccurate medical records and spread of infectious diseases to staff and visitors. Findings:During a concurrent interview and record review on 2/17/25 at 8:49 a.m. with Infection Preventionist (IP), Resident 9's Vaccine Consent Form (VCF), dated 7/14/25 and Progress Note (PN), dated 7/14/25 were reviewed. The VCF indicated Resident 9's VCF was signed on 7/14/25 by the RP. The PN did not indicate there was any education provided to Resident 9's RP about the risk and benefits of the COVID-19 vaccines. IP stated there was no documentation of education provided to Resident 9's RP for the COVID-19 vaccines. During a concurrent interview and record review on 12/17/25 at 8:53 a.m. with IP, Resident 10's VCF, dated 7/14/25 and PN, dated 7/14/25 were reviewed. The VCF indicated Resident 10's VCF was signed on 7/14/25 by the RP. The PN did not indicate there was any education provided to Resident 10's RP about the risk and benefits of the COVID-19 vaccines. IP stated there was no documentation of education provided to Resident 10's RP, but the RP should have been educated on the risks and benefits of the vaccine. During a concurrent interview and record review on 12/17/25 at 9:00 a.m. with IP, Resident 5's VCF, dated 7/14/25 and PN, dated 7/14/25 were reviewed. The VCF indicated Resident 5's VCF was signed on 7/14/25 by the RP. The PN did not indicate there was any education provided to Resident 5's RP about the risk and benefits of the COVID-19 vaccines. IP stated there was no documentation of education provided to Resident 5's RP for the Covid-19 vaccines. During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 7/1/25, the P&P indicated, Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.8. COVID-19 Immunizations.c. Education about the vaccine, risks, benefits, and potential side effects will be given to residents or resident representatives.g. The resident's medical record includes documentation that indicates, at minimum, the following: i. That the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, FOOD PREFERENCES, for 20 of 21 sampled residents (Resident 32, Resident 1, Resident 2, Resident 4, Resident 7, Resident 9, Resident 21, Resident 22, Resident 36, Resident 37, Resident 44, Resident 48, Resident 49, Resident 50, Resident 55, Resident 12, Resident 17, Resident 34, Resident 41, and Resident 6) when residents' meals ticket did not have likes and/or dislikes completed. This failure had the potential for food requests to not be honored. Findings:During an interview on 12/15/25 at 10:07 a.m. with Resident 32, Resident 32 stated he does not really like the food but will eat food to not lose weight. Resident 32 stated he has told staff (unknown) multiple times he wants his eggs well done, and it has not been accomplished. Resident 32 stated he has told them multiple times he does not like gravy and still it's being served. Resident 32 stated he wants fresh fruit and not canned fruit.During a record review on 12/15/25 at 12:09 p.m. Resident 1, Resident 2, Resident 4, Resident 7, Resident 9, Resident 21, Resident 22, Resident 36, Resident 37, Resident 44, Resident 48, Resident 49, Resident 50, and Resident 55, meal tickets were reviewed. Their meal tickets indicated missing likes, dislikes, or both.During an interview on 12/15/25 at 12:10 p.m. with Resident 1, Resident 34, Resident 44, Resident 50, and Resident 9, Resident 1 stated he ordered a chocolate pudding and did not receive it. Resident 34 stated he has not been asked regarding his food preferences. Resident 44 stated she has not been asked regarding her food preferences and the food is repeated often and would like to eat something different. Resident 50 stated she has not been asked regarding her food preferences. Resident 9 stated he has not been asked regarding his food preferences. During a review of Resident 32's meal ticket, dated 12/15/25, the meal ticket did not have any listed likes (such as likes eggs well done and fresh fruit).During a review of Resident 12's meal ticket, dated 12/15/25, the meal ticket did not indicate any dislikes and likes.During a review of Resident 17's meal ticket, dated 12/15/25, the meal ticket did not indicate any dislikes and likes.During a review of Resident 34's meal ticket, dated 12/15/25, the meal ticket did not indicate any dislikes and likes.During a review of Resident 41's meal ticket, dated 12/15/25, the meal ticket did not indicate any dislikes and likes.During a concurrent observation and interview on 12/15/25 at 12:25 p.m. with Resident 6 in the dining room, Resident 6 had pureed fish on his lunch plate, and he ate part of it. Resident 6 stated he has not been asked regarding his food preferences and he is vegetarian. Resident 6 stated he does not want fish, eggs and cheese.During an interview on 12/16/25 at 3:31 p.m. with Dietary Manager (DM), DM stated she does not document resident's food preferences in the electronic health record. During a review of the facility's P&P titled, FOOD PREFERENCES, dated 2023, the P&P indicated, POLICY: Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group. PROCEDURE: Food preferences will be obtained as soon as possible through the initial resident screen. Updating of food preferences will be done as the resident's needs change and/or during the quarterly review.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Food Safety Requirements, when molded bread was not thrown out. This failure had the potential for residents to acquire foodborne illness. Findings:During an observation on 12/15/25 at 8:42 a.m. in the kitchen's storage room, there was sandwich breads with handwritten date R [received by]: 11/26/25 and UB [use by] 12/2/25. The storage room contained a bag of English muffins with two muffins green in colored. During an interview on 12/15/25 at 8:45 a.m. with Dietary [NAME] (DC), DC stated there should not be any expired food. DC stated storage food should be checked daily and expired food thrown away in the trash. DC stated these breads are dated incorrectly and she is unsure of its manufactured expiration date. DC stated the English muffins where overlooked. During a review of the facility's P&P titled, Food Safety Requirements, dated 2025, the policy indicated, Policy. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Policy Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following. b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Hemodialysis [HD - a life-sustaining treatment that filters blood when failing kidneys cannot], for one of one sampled resident (Resident 56) when blood pressure (BP) was taken on the dialysis access arm. This failure had the potential for Resident 56 to acquire complications such as clotting, damage to the access, and increase risk of infection. Findings: During a review of Resident 56's admission RECORD (AR), dated 12/18/25, the AR indicated, END STAGE RENAL [kidney] DISEASE. During a review of Resident 56's Nursing - Pre Dialysis Evaluation & Communication (NPDEC), dated November and December 2025, the NPDEC indicated left AV shunt (a surgically created connection between an artery and a vein to provide reliable, long-term access for HD). The NPDEC indicated BP was taken on the left arm on 11/21/25 and 12/1/25. During a review of Resident 56's Nursing - Post Dialysis Evaluation (NPDE), dated November and December 2025, the NPDE indicated BP was taken on the left arm on 12/10/25, 12/12/25, and 12/15/25.During an interview on 12/18/25 at 9:24 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the HD access was on Resident 56's left arm. LVN 2 stated BP should not be taken on the HD access site. LVN 2 stated he did not know what could happen if BP is taken on the arm with HD access. During a P&P titled, Hemodialysis, dated 2025, the P&P indicated, Policy: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. Compliance Guidelines. The resident will not receive blood pressures or laboratory sticks on the arm where the dialysis access device is located.

Based on observation, interview, and record review, the facility failed to ensure one of 27 twenty-seven sampled residents' (Resident 48) medication was ordered. This failure resulted in the delay of administering medication and potential for Resident 48 experiencing adverse health outcomes. During a concurrent observation and interview on 12/16/25 at 7:59 a.m. in the hallway, with Licensed Vocational Nurse (LVN) 1, LVN 1 was passing medication, she searched for Resident 48's Pantoprazole (stomach acid reducing medication) medication. LVN 1 was unable to locate Resident 48's medication in the medication cart.During a concurrent interview and record review on 12/16/25 at 8:06 a.m. with LVN 1, Resident 48's Medication Administration Record (MAR), dated December 2025 was reviewed. The MAR indicated, on 12/15/25 code 9 other see nursing notes.During a review of Resident 48's Order Summary (OS), dated 12/16/25 the OS indicated Protonix Tablet Delayed Release 40 mg (milligrams- unit of measure) (Pantoprazole Sodium) Give 1 tablet by mouth two time a day for GERD (medication used to treat heartburn) administer 30 to 60 minutes before a meal.During a concurrent interview and record review on 12/17/25 at 1:18 p.m. with Director of Nursing (DON) Resident 48's Progress Note (PN), dated 12/14/25 to 12/16/25 were reviewed. The PN indicated the following:12/14/25 at 5:53 p.m. Protonix Tablet Delayed Release 40 mg (milligrams- a unit of measure). Give 1 tablet by mouth two times a day for GERD.12/15/25 at 9:01 a.m. Protonix Tablet Delayed Release 40 mg, Give 1 tablet by mouth two times a day for GERD. Med [medication] is not available.12/16/25 at 8:13 a.m. Protonix Tablet Delayed Release 40 mg, Give 1 tablet by mouth two time a day for GERD. Med unavailable.12/16/25 at 8:42 a.m. Protonix Tablet Delayed Release 40 mg (Pantoprazole Sodium) Give 1 tablet by mouth two times a day for GERD. Received Interim Medication Regimen Review and recommended to be given 30 to 60 minutes before a meal. MD in agreement to change the order.12/16/25 at 9:34 a.m. Protonix Tablet Delayed Release 40 mg (Pantoprazole Sodium). Give 1 tablet by mouth two times a day for GERD administer 30 to 60 minutes before a meal. DON followed up with [pharmacy] to expedite the process to send the medication and anything he needs approval and ok to bill to facility.12/16/25 at 4:57 p.m. Protonix Tablet Delayed Release 40 mg. Medication is unavailable; pending pharmacy delivery. MD was notified and was ok to hold until mediation is available. No new orders. DON stated the nurses should not have run out of Resident 48's medication. During a review of facility's policy and procedure (P &P) titled Medication Administration, Review, dated 7/21, the P &P indicated, Keep medication cart clean, organized, and stocked with adequate supplies.

Based on interview and record review, the facility failed to:1.Follow its policy and procedure (P&P) titled, Nursing Care of the Older Adult with Diabetes Mellitus [a condition where the body cannot properly control blood sugar (glucose) levels], for one of one sampled resident (Resident 56). This failure had the potential for Resident 56 to experience hyperglycemia (blood sugar above target levels) symptoms (such as increase thirst, fatigue, headache, and blurred vision) and complications (such as heart disease, stroke, kidney disease, diabetic eye disease, foot complications, and nerve damage [neuropathy]).2.Follow its policy and procedure (P&P) titled, Lab and Diagnostic Test Results-Clinical Protocol, when a physician failed to review one of two sampled residents (Resident 30)'s test results in a timely manner and provide treatment to Resident 30. This failure had the potential for a delay in care and experience adverse health outcomes. 1.During a record review of Resident 56's admission RECORD (AR), dated 12/18/25, the AR indicated on admission date of 11/19/25 a diagnosis of Diabetes Mellitus Type 2 (DM2) with hyperglycemia and unspecified DM2 neuropathy.During an interview and record review on 12/17/25 at 2:35 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 56's Weights and Vital Summary (WVS) and Progress Notes, dated December and November 2025, were reviewed, the WVS indicated the following blood sugar levels by month:November 2025 11/23: 4:32 p.m. - 299 mg/dL (milligram per deciliters-unit of measurements, normal blood sugar level should be below 140 mg/dL) 11/23: 4:57 p.m. - 299 mg/dL 11/24: 10:03 a.m. - 259 mg/dL 11/24: 4:05 p.m. - 344 mg/dL 11/28: 9:45 a.m. - 235 mg/dL 11/28: 4:54 p.m. - 307 mg/dL11/29: 4:34 p.m. - 251 mg/dL11/30: 5:01 p.m. - 287 mg/dLDecember 2025 12/1: 5:23 p.m. - 236 mg/dL12/2: 9:08 a.m. - 218 mg/dL12/2: 4:54 p.m. - 274 mg/dL12/3: 5:03 p.m. - 346 mg/dL12/4: 9:10 a.m. - 242 mg/dL12/5: 5:37 p.m. - 341 mg/dL12/7: 4:28 p.m. - 337 mg/dL12/8: 5:05 p.m. - 294 mg/dL12/9: 9:59 a.m. - 207 mg/dL12/10: 5:13 p.m. - 336 mg/dL12/11: 8:41 p.m. - 381 mg/dL12/12: 4:52 p.m. - 324 mg/dL12/13: 8:12 a.m. - 250 mg/dL12/13: 5:35 p.m. - 340 mg/dL12/14: 8:32 a.m. - 249 mg/dL12/14: 4:36 p.m. - 326 mg/dL12/15: 4:09 p.m. - 284 mg/dL12/16: 9:08 a.m. - 237 mg/dL12/16: 6:10 p.m. - 294 mg/dL12/17: 9:50 a.m. - 311 mg/dLLVN 1 stated there are no notifications to medical doctor of Resident 56's blood sugar levels of 200s and 300s.During a review of the facility P&P titled, Nursing Care of the Older Adult with Diabetes Mellitus, dated 2001, the P&P indicated the following, Purpose: To provide an overview of diabetes in the older adult, its symptoms and complications, and the principles of glucose monitoring. Complications associated with diabetes can be attributed to: (1) uncontrolled hyperglycemia and subsequent damage to the vasculature. 6. Establish provider notification protocols, for example. b. Call as soon as possible when. (2) blood glucose values are > [greater than] 250 mg/dL more than once within a 24-hr [hour] period (3) blood glucose values are > 300 mg/dL more than once over two consecutive days. 2 During a review of Resident 30's Progress Notes (PN), dated 12/11/25 at 12:04 a.m., the PN indicated, monitor for left lower lobe diminished [quiet] with crackles [snapping sound] and episodes of being lethargic [drowsy].Resident has a low Oxygen saturation [O2 sat- a measurement of how much oxygen the blood is carrying as a percentage] reading.During a review of Resident 30's PN, dated 12/11/25 at 12:50 p.m. the PN indicated, resident [30] is lethargic but responds to painful stimuli.breath sounds in the upper and lower lobes [parts of the lungs] are coarse [rattling noise].During a review of Resident 30's PN, dated 12/10/25 at 2:30 p.m. the PN indicated, Change of Condition.noted with LLL [left lower lobe] diminished with crackles.follows simple commands but lethargic.Recommendations: chest x-ray [picture of the lungs].During a review of Resident 30's Radiology Results Report (RRR), dated 12/11/25, the RRR indicated, Examination Date: 12/11/25 15:39 [3:39 p.m.]. Reported Date: 12/11/25 17:28 [5:28 p.m.] .Conclusion: Bibasilar airspace disease [air sacs in the lower parts of the lungs are filled with fluid, pus or blood].During a review of Resident 30's PN, dated 12/11/25 at 11:14 p.m. the PN indicated, RT [respiratory therapist-healthcare professional who helps patients who are having trouble breathing] assessed PT [patient], coarse and gurgling [lung sounds]. During a review of Resident 30's PN, dated 12/12/25 at 12:22 a.m., the PN indicated, placed pt on 1L [one liter] NC [nasal cannula- a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen] due to saturation being below 90% [low oxygen saturation considered a medical concern] .During a review of Resident 30's PN, dated 12/12/25 at 1:03 a.m., the PN indicated, Received resident's Chest Xray result for examination date 12/11/25.Awaiting further orders at this time.During a review of Resident 30's PN, dated 12/12/25 at 6:39 a.m., the PN indicated, At approximately 2300 [11:00 p.m.] assigned CNA reported resident had gurgling breath sounds.During a concurrent record review and interview on 12/17/25 at 8:23 a.m. with Infection Preventionist (IP), Resident 30's PN, dated 12/10/25 through 12/14/25 were reviewed. The PN indicated Resident 30 had a change in condition on 12/10/25 when his lung sounds were noted as diminished (quieter). The PN indicated a chest x-ray was ordered on 12/11/25. The PN indicated the results of the chest x-ray were placed in the medical record on 12/11/25 at 5:28 p.m. The PN indicated the physician did not read the results and order antibiotics (medication to treat an infection) until 12/14/25. The IP stated Resident 30 had a chest x-ray completed on 12/11/25 and the physician did not read the results until 12/14/25, three days later.During an interview on 12/17/25 at 9:27 a.m. with Director of Nursing (DON), DON stated the nursing staff notified the physician by fax on 12/11/25; however, the physician did not review and respond until 12/14/25. The DON stated when the physician does not respond the staff should have called the physician to ensure he received the test results. During a review of the facility's P&P titled, Lab and Diagnostic Test Results-Clinical Protocol, dated 11/2018, the P&P indicated, Assessment and Recognition: 1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests.Review by Nursing Staff: 1. When test results are reported to the facility, a nurse will first review the results.3. A nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality, and the individual's current condition.b. To assess a condition change or recent onset of signs and symptoms.Identifying Situations that Warrant Immediate Notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results.Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change. Physician Responses: 1. Time frames. A physician will respond within an appropriate time frame, based on the request from nursing staff and the clinical significance of the information. a. A physician should respond within one hour regarding a lab test result requiring immediate notification, and by the end of the next office day to a non-emergency message regarding non-immediate lab test notification with a request for response.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P & P) titled, Safe and Homelike Environment, for one of six sampled residents (Resident 13), when cold air entered the room from the closed sliding door. This failure resulted in Resident 13 feeling cold in her room and had the potential for Resident 13 to become hypothermic (extreme cold temperature). Findings:During a concurrent observation and interview on 12/15/25 at 11:21 a.m. with Resident 13 in Resident 13's room, a piece of plastic was covering bottom of the closed patio sliding door. Resident 13 stated the air leaking from under the sliding door made her feel cold. Resident 13 stated the room was freezing cold.During an interview on 12/18/25 at 11:57 a.m. with Environmental Supervisor (ES), ES stated Resident 13 complained about being cold in her room. ES was unable to provide documentation a door company was contacted regarding Resident 13's patio door leaking cold air.During a review of the facility's Policy and Procedure (P&P) titled, Safe and Homelike Environment, (undated), the P&P indicated, Comfortable and safe temperature levels, means that the ambient temperature should be in a relatively narrow range that minimizes residents' [sic] susceptibility to loss of body heat and risk of hypothermia/ hyperthymia[sic] and is comfortable for the residents.

Based on interview and record review the facility failed to follow its policy and procedure (P&P) titled, Resident Participation- Assessment/Care Plans, when one of one sampled resident (Resident 10)'s representative (RP) was not followed up to attend the Interdisciplinary Team Meetings (IDT-a meeting where professionals meet to collaborate, develop, review, and coordinate a care plan) to participate and follow-up after those meetings when the RP was not in attendance for the last six months. This failure had the potential to result in Resident 10's unmet care needs. Findings: During an interview on 12/15/25 at 3:03 p.m. with Family Member (FM) 1, FM 1 stated she has never been asked to participate in care planning or care conferences to discuss the care provided to Resident 10. FM 1 stated she had concerns about the care being provided to Resident 10 that had not been addressed by the facility. During a concurrent interview and record review on 12/17/25 at 9:32 a.m. with Director of Nursing (DON), Resident 10's IDT Care Conference Summary (IDTCCS), dated 6/19/25 and 9/11/25 were reviewed. The IDTCCS indicated Resident 10's RP [FM 1] had not been attending the quarterly meetings. The IDTCCS indicated there was no follow up to Resident 10's FM 1 to discuss the meeting and care provided to Resident 10. DON stated the FM 1 was not answering when we called. DON stated we should have followed up and called the FM 1 again. DON stated the importance of the FM 1 being a part of the IDT meetings was because it provides them with updates on care and for them to provide any further guidance in the care, they want the resident to receive. DON stated Social Services should be sending a letter to the FM 1 to indicate the date and time of the next meeting. DON stated there was no follow-up with the FM 1 from the last two care conferences. During an interview on 12/17/25 at 9:39 a.m. with Social Services Director (SSD), SSD stated she sends out a certified letter to the representative a week before the IDT meeting. During a concurrent interview and record review on 12/17/25 at 9:40 a.m. with SSD, Resident 10's IDTCCS, dated 6/16/25 and 9/11/25 were reviewed. The IDTCCS indicated there was no follow up to the FM 1 after the meeting. SSD stated the RP did not participate in the meeting and there was no follow-up to the FM 1 after the meeting. SSD stated a certified letter was not sent to the FM 1 indicating the next meeting date and time prior to the IDT Care Conference. SSD stated she should have continued to call the FM 1 the next few days to follow up. SSD stated the IDT Care Conferences are not completed until the RP is notified. SSD stated the IDT Care Conferences held in June and September have not been completed. SSD stated the last time she spoke with FM 1 was in March 2025, six months ago. SSD stated FM 1 not participating in the IDT care conferences is a concern and should have followed up.During a review of the facility's P&P titled, Resident Participation- Assessment/Care Plans, dated 2/2021, the P&P indicated, Policy Statement: The resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. Policy Interpretation and Implementation: 1. The resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan.5. Facility staff supports and encourages resident/representative participation in the care planning process by.b. holding care planning meetings at times of day when the resident, representative and family members can attend and are functioning at their best; c. providing sufficient notice in advance of the meeting.9. The social services director or designee is responsible for notifying the resident/ representative and for maintaining records of such notices.

Based on interview and record review the facility failed to provide activities which reflected two of five sampled residents' (Resident 5 and Resident 53) choices and/or interests. This failure had the potential to negatively impact mental and psychosocial well-being of Resident 5 and Resident 53. Findings: 1a. During a review of Resident 5's Quarterly Activities Participation Review (QAPR), dated 11/9/25, the QAPR indicated, [Resident 5] needs encouragement and assistance during activities. [Resident 5] likes to play ball/balloon toss and sensory touch materials.Resident is up daily in his wheelchair and is dependent on staff to take him to activities. Activity staff will continue to provide assistance and encouragement during activities. During a review of Resident 5's Care Plan (CP), dated 2/3/25, the CP indicated, [Resident 5] is dependent on staff for meeting emotional, intellectual [related to thinking], physical, and social needs.Provide 1:1 [one-to-one] room visit if unable to attend group activities to monitor activity needs and offer activity materials and socialization. Resident enjoys: playing ball/balloon toss.sensory touch items.The resident needs assistance/escort to activity functions.During an observation on 12/15/25 at 10:00 a.m. the activities schedule posted in the hallway outside the activity/dinning room showed balloon volleyball at 10:00 a.m. During an observation on 12/15/25 at 10:02 a.m. staff are setting up the activities room for balloon volleyball. Six residents participated in balloon volleyball. Resident 5 was not in attendance. During an interview on 12/16/25 at 2:38 p.m. with Activities Assistant (AA) 1, AA 1 stated one activities assistant is assigned to room visits to see residents daily who do not participate in activities in the activity room. AA 1 stated activity documentation is completed in the activity's binder. During an interview on 12/16/25 at 3:01 p.m. with Activities Director (AD), AD stated her expectation for staff is to notify all residents of the activities that are happening daily and complete room visits for those residents who did not participate in the group activities daily. AD stated room visits should include activities such as coloring, word search, sudoku, dominos, and magazines. AD stated room visits should last between 10-15 minutes for each resident. AD stated staff should assist Resident 5 daily to join group activities in the activities room. AD stated if Resident 5 did not participate in the group activity, then a room visit should be provided to Resident 5. AD stated some room visit activities for Resident 5 could include providing lotion and/or sensory toys for stimulation. During a concurrent record review and interview on 12/16/25 at 3:06 p.m. with AD, Resident 5's Activity Attendance Record (AAR), dated 12/1/25 through 12/15/25 was reviewed. The AAR indicated Resident 5 only had room visits during the reviewed dates and the activities were social contact and hand massage only. AD stated, we could do more for him [Resident 5]. AD stated staff should have provided more engaging activities for Resident 5 using objects or games. AD stated there is no time or length of stay documented, but room visits should be 10-15 minutes long. AD stated because the time is not documented she cannot verify the staff completed the room visits per policy. 1b. During a review of Resident 53's QAPR, dated 12/11/25, the QAPR indicated, [Resident 53] enjoys playing bingo and Loteria [Spanish BINGO], ball/balloon toss, exercises, watching TV, singing. [Resident 53] uses a wheelchair at times and depends on staff to take him to the dining room for activities. Activity staff will continue 1:1 room visits to monitor his activity needs and provide materials and socialization.During a review of Resident 53's CP, dated 12/11/25, the CP indicated, [Resident 53] is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t [related to] Physical limitations.Resident likes to: play bingo and Loteria, play ball/balloon toss, exercises, watch tv.singing. The resident needs 1:1 bedside/in-room visits and activities if unable to attend out of room events.Ensure that the activities the resident is attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences.Compatible with individual needs and abilities; and Age appropriate. During a concurrent record review and interview on12/16/25 at 3:11 p.m. with AD, Resident 53's AAR, dated 12/1/25 through 12/15/25 was reviewed. The AAR indicated Resident 53 had room visits eleven days out of fifteen days and was only given hand massages for his room activities. AD stated the activity staff could provide better room activities for Resident 53. During a review of the facility's P&P titled, Activity Evaluation, dated 2/2023, the P&P indicated Policy Statement: In order to promote the physical, mental, and psychosocial well-being of residents, a activity evaluation is conducted to maintained for each resident at least quarterly and with any change of condition that could affect his/her participation in planned activities. Policy Interpretation and Implementation: 1. An activity evaluation is conducted as part of the comprehensive assessment to help develop an activities plan that reflects the choices and interests of the resident.4. The resident's lifelog interests, spirituality, life roles, goals, strengths, needs and activity pursuit patterns and preferences are included.The activity evaluation is used to develop an individual activities care plan.that will allow the resident to participate in activities of his/her choice and interests

Based on observation, interview, and record review, the facility failed to prevent an avoidable fall (move downward, typically rapidly and freely without control from a higher to a lower level) for one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNA 1) and CNA 2 failed to implement the care plan (CP- a document that outlines a resident's needs, treatment, and expected outcomes) to use a Hoyer lift (a mechanical device that helps move people with limited mobility) in transferring Resident 1 from the bed to the wheelchair. This failure resulted in Resident 1 sustaining a fall and experiencing pain to the left foot. Resident 1 was transferred to the acute hospital where the resident was found to have varus deformity (a condition characterized by an inward angulation or bending of a bone or joint) of the second metatarsophalangeal (the joints connecting the long bones of the foot and bones of the toes) joint. A nondisplaced (a break in the bone where the original bones remain in their original position) proximal phalangeal (the toe bones closest to the ankle and metatarsals [the five long bones in the foot]) fracture (a break in the bone) cannot be entirely excluded. Findings: During a review of Resident 1's ADMISSION RECORD (AR), dated 1/29/25, the AR indicated, Resident 1 was admitted to the facility on [DATE]. The AR indicated, Resident 1 diagnoses including repeated falls, difficulty in walking, spinal stenosis (a narrowing of the spinal column (backbone) that occurs over time and can put pressure on the spinal cord [a tube-shaped bundle of nerves that runs from the brain to the lower back]) lumbar region (lower back) with neurogenic claudication (a condition that causes pain, weakness, or numbness in the legs while walking or standing), and need for assistance with personal care. During a review of Resident 1's quarterly Minimum Data Set (MDS- an assessment tool) dated 1/10/25, under the section Brief Interview for Mental Status (BIMS- an assessment of cognition [how well a person thinks, remembers, and learns]), the BIMS indicated, Resident 1 had a score of 13 (cognition [how well a person thinks, remembers, and learns] intact). The MDS under the section GG (an assessment of the level a care a resident required), indicated, Resident 1 was dependent on staff for transferring from bed to chair/chair to bed. During a review of Resident 1's Care Plan dated 6/23/24, the CP indicated, Resident 1 had self-care performance issues secondary to impaired balance, limited mobility, and limited ROM (range of motion- how far you can move a joint [where two or more bones connect] in your body). CP intervention indicated under transfer to use a Hoyer lift with two staff members for any transfers Resident 1 required. During an observation and interview on 1/29/25 at 12:16 p.m. with Resident 1, in Resident 1's room, Resident 1 was sitting in her wheelchair and stated on 1/16/25, Certified Nursing Assistant (CNA 1) and CNA 2 attempted to transfer her from the bed to the wheelchair. Resident 1 stated she was not able to bear weight (to support or withstand the weight of the body) in her legs. Resident 1 stated, They (CNA 1 and CNA 2) picked me up (using a bath towel) and they (CNA 1 and CNA 2) dropped me, they used a (bath) towel to pick me up not the Hoyer lift. Resident 1 stated she experienced left foot pain (no detailed information about the pain) after the fall incident. During a review of Resident 1's Progress Notes (PN), dated 1/16/25, the PN indicated the following: a. At 12:30 p.m.- Nursing observations, evaluation, and recommendations . Staff (not indicated who) reported resident (1) had an assisted fall. When resident (1) was asked, she stated that staff (not indicated who) dropped her on the floor while being transferred. She also stated that she fell on both her knees. Spoke to staff (not indicated who) and one of the CNA (not indicated who) stated that her partner lost grip of the towel under resident's (1) legs, and she had to be assisted to the floor. b. At 4:15 p.m.- On time of fall (no indicated time), no swelling noted to left great toe. At approximately (4:20 p.m.), redness, and swelling to left great toe was noted. During a review of Resident 1's Nursing- Pain Evaluation (NPE), dated 1/16/25, the NPE indicated, Resident 1 complained of pain after her fall to the floor on a scale of five out of 10 (moderate pain, distracting or interfering with activities) .to the left great toe. During a review of Resident 1's Interdisciplinary Post Event Note (IDT- Interdisciplinary Team- group of professionals who assess, coordinate, and manage each resident's comprehensive needs), dated 1/20/25, the IDT indicated, Resident 1 had an x-ray (medical imaging technique that uses radiation to create a picture of the inside of the body) of the left foot (on 1/17/25). The x-ray results indicated Resident 1 had a possible fracture (break) in her left great toe. The IDT indicated Resident 1 had an order for Norco (a narcotic medication for pain) 5/325 mg (milligram- a unit of measurement) every eight hours for pain (routinely given). During a review of Resident 1's Physician Orders (PO), dated 1/21/25, the PO indicated, Resident 1 was to be sent out to the hospital to confirm a possible fracture to the left great toe. During a review of the acute hospital Emergency Department Notes (EDN), dated 1/21/25, the CN indicated, Resident 1 was sent to the acute hospital with a left great toe injury after a fall. The EDN indicated a left foot x-ray was performed, and Resident 1 was found to have a nondisplaced fracture (a break in the bone where the original bones remain in their original position) of the proximal phalangeal (the toe bones closest to the ankle and metatarsals [the five long bones in the foot]). During an interview on 1/29/25 at 1:48 p.m. with Director of Nursing (DON), DON stated on 1/16/25 Resident 1 fell to the floor while being transferred by CNA 1 and CNA 2 from the bed to the wheelchair using a (bath) towel. DON stated Resident 1 was to be transferred from the bed to the wheelchair using a Hoyer lift, but CNA 1 and CNA 2 did not use the Hoyer lift. During an interview on 2/5/25 at 2:31 p.m. with CNA 1, CNA 1 stated on 1/16/25 at approximately 11 a.m. she asked CNA 2 to assist her with transferring Resident 1 from the bed to the wheelchair. CNA 1 stated she and CNA 2 did not use the Hoyer lift to transfer Resident 1. CNA 1 stated she and CNA 2 used a bath towel underneath Resident 1's legs to lift her up to transfer from the bed to the wheelchair. CNA 1 stated she and CNA 2 lost control of the bath towel and Resident 1 fell to the floor. CNA 1 stated after the fall incident Resident 1 started complaining of pain to her left foot. CNA 1 stated no staff trained her to use a bath towel to transfer Resident 1 and it was dangerous to do so. CNA 1 stated she used a bath towel in the past (no dates given) to transfer Resident 1. CNA 1 stated she was aware she should use the Hoyer lift (as indicated in the CP). During an interview on 2/5/25 at 3:20 p.m. with CNA 2, CNA 2 stated on 1/16/25 at approximately 11 a.m. she and CNA 1 transferred Resident 1 from the bed to the wheelchair using a bath towel. CNA 2 stated she and CNA 1 lost control of the bath towel and Resident 1 fell to the floor. CNA 2 stated Resident 1 was dead weight (when a person is unable to assist with movement and their full weight is felt by the persons assisting) and had fallen into a position in which her foot (left) was possibly crushed by her weight. CNA 2 stated Resident 1 was visibly upset (could not describe what this meant other than upset) and yelling at them (CNA 1 and CNA 2) about the fall incident. CNA 2 stated, She (Resident 1) required a Hoyer lift . we (CNA 1 and CNA 2) did not use it. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, dated 11/2024, the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.The comprehensive care plan will describe, at a minimum, the following .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. During a review of the facility's P&P titled, Safe Resident Handling/Transfers, dated 11/2024, the P&P indicated, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used.Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting except in medical emergencies.Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment.Resident lifting and transferring will be performed according to the resident's individual plan of care.

Based on interview and record review, the facility failed to supervise one of three sampled residents (Resident 1) while he smoked. This failure resulted in Resident 1 falling and sustaining an injury and pain to bilateral [MEDICAL CONDITION] (BKA-surgical removal of the leg below the knee) stump sites. As a result of the fall Resident 1 was transferred to the Emergency Department for treatment of [REDACTED]. Findings: During a review of the clinical record for Resident 1, the NURSING - FALL RISK OBSERVATION/assessment dated [DATE], indicated Resident 1 scored a fall risk assessment of 20 (high risk for falls). The smoking care plan dated 9/1/19, indicated Resident 1 had a potential for burn and injury while smoking. The interventions listed included, (Resident 1) is provided supervision while smoking in designated area. The goal for Resident 1's plan of care was, Will have no injuries. The NURSING - SMOKING OBSERVATION/assessment dated [DATE], at 7:44 PM, indicated Resident 1 had a BIMS (brief interview for mental status- an assessment tool for cognition) score of 8 (mildly-impaired cognition) and required supervision for smoking as well as assistance with going to designated smoking area. During a review of the clinical record for Resident 1, the Progress Notes dated 9/24/19, at 4:54 PM, indicated 11:00 (AM) resident (1) was taken outside to smoke by CNA (Certified Nursing Assistant, 1) . and was left outside by himself smoking. Maintenance came in alert this nurse the (sic) there was a resident on the floor. Resident (1) was sitting on the floor with wheel chair behind and him leaning against wheelchair. Was trying to get cigarette from his shirt pocket, while sliding out of the chair. Resident (1) was assessed for injuries; bilateral BKA avulsion (skin torn from body due to trauma) of surgical incisions . Medicated for pain 8/10 (severe) to bilateral BK[NAME] Given (pain narcotic medication) . was sent out to (acute care hospital emergency room ) for further evaluation and treatment. During a review of the acute care hospital clinical record for Resident 1, the ED (Emergency Department) Note dated 9/24/19, indicated The patient (Resident 1) presents following fall. Additional history: (Resident 1) sent from (facility) for sliding out of his wheelchair earlier today while trying to grab cigarette in his shirt. Left BKA stump pain and bleeding since then. Physical Examination . Bilateral BK[NAME] Left stump with dehiscence and oozing. Diagnosis. Wound dehiscence. The record indicated Resident 1's BKA were dressed with a blood-clot inducing material and discharged back to the facility the same day. During a review of the clinical record for Resident 1, the Progress Notes dated 9/25/19, at 12:04 AM, indicated Resident 1 continued to have bleeding complications from his 9/24/19 fall. The record indicated Assigned CNA reports that (Resident 1) dressings to both of his (BKA stumps) are bleeding. Both stumps are checked. Left stump dressing is intact and re-enforced . Right stump stapled healed wound noted to be completely open (dehiscence). Dressing removed and wound cleansed. Left stump continue to bleed moderately. (Doctor) notified and sent (Resident 1) to (Emergency Department) for evaluation and treatment. During a review of the acute care hospital clinical record for Resident 1, the Emergency Dept. (Department) Documents dated 9/25/19, indicated (Resident 1) was sent back over by (emergency medical services) for excessive bleeding to the left lower stump. left (stump) has blood soaked gauze and removed there was active bleeding from the edge of the stump wound had completely dehisced. Due to excessive bleeding I (physician) closed the wound with staples. Description. Laceration 14 cm (centimeters - a unit of measurement) in length. Left BK[NAME] muscle involvement. During an interview with Licensed Vocational Nurse (LVN) 1, on 10/7/19, at 3 PM, she stated Resident 1 fell on [DATE]. LVN 1 stated she was informed by maintenance staff that Resident 1 fell outside in the smoking area of the facility. LVN 1 stated she went out to assess Resident 1, and noted there was no staff with him. LVN 1 stated Resident 1's bilateral stumps were bleeding, and he needed to be sent to the hospital. LVN 1 stated she asked the Certified Nursing Assistant (CNA) 1 assigned to Resident 1, why did she leave him outside by himself and she responded that Resident 1 wanted to stay outside to smoke. LVN 1 stated Resident 1 was not to be left alone outside. LVN 1 stated the facility has a policy that staff need to be with residents whenever they are smoking. During an interview with LVN 2, on 10/7/19, at 3:35 PM, he stated on 9/24/19, he assisted LVN 1 in assessing Resident 1 when he was found on the ground by himself in the smoking area. LVN 2 stated Resident 1's BKA sites were bleeding. LVN 2 stated Resident 1 had gone outside with CNA 1 in order to smoke. LVN 2 stated Resident 1 should not be left alone when taken out to smoke. During a review of the facility policy and procedure titled Smoking Policy - Residents dated 7/2017, indicated The facility shall establish and maintain safe resident smoking practices. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include. Ability to smoke safely with or without supervision. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.

Based on interview and record review, the facility failed to implement their abuse policy and procedure when three of 12 sampled residents' (2, 4, and 12) and eight random residents (13, 14, 15, 17, 18, 19, 20, and 21) reported accusations that included elements of potential abuse that were not addressed, documented or reported to the Department. These failures have caused embarrassment, anxiety, and fear to these residents and had the potential for abuse to be widespread to other residents in the facility. Due to the facility's failure to implement their policy and procedure for resident abuse, the Administrator and the Director of Nursing (DON) were verbally notified of an Immediate Jeopardy (IJ) situation on [DATE] at 4:32 PM. The facility's failure to take appropriate corrective action to protect residents from abuse, the facility's failure to thoroughly investigate allegations of abuse and the facility's failure to report allegations of abuse and investigate results of alleged abuse within five working days placed residents at risk for real or potential abuse. These failures constituted an Immediate Jeopardy situation. With onsite confirmation the immediacy was removed due to the following Plan of Correction being confirmed: 1. In-service regarding abuse reporting; 2. Random rounds (observing care); 3. In-service re: handling difficult patients; 4. Abuse investigation; 5. Interviews of residents and families by Social Worker; 6. Psychiatric referral 7. Suspension of two staff. The Administrator and the DON were notified the IJ was removed on [DATE], at 6:35 PM. Findings: 1. During an interview with Resident 12's daughter, on [DATE], at 4:20 PM, she stated, My mother made an allegation about sexual abuse that occurred early 2016 (January) or late 2015 (December). She told me that a Certified Nurse's Assistant (CNA) came up behind her and hugged her, the CNA's hands cupped my mother's breasts, then moved her hands down to my mother's privates. I don't believe it. Nobody saw anything. During a record review and interview with the Administrator and the DON, on [DATE], at 5:20 PM, they stated, That didn't actually occur. We investigated this inappropriate hugging and determined the allegation was not true. The DON stated, It was not a sexual abuse allegation after I spoke with her. I met with the daughter. It was care planned. We didn't report the incident to the Department because we didn't think it happened. The Administrator provided a document she identified as the facility's investigation dated [DATE]. It indicated: Resident (unnamed) made a complaint that they (unknown) hug her to (sp) tight, they push against her 'pecho' (chest) and she felt that is not good. During the night shift (no date, no time). Notified (DON) of this (DON) talked to resident and had resident show them (unidentified) how they (unidentified) hugged her. It was asked if resident felt like it was wrong or she felt violated, 'No' When (DON) spoke to nursing assistant (unnamed) she said she gave her (unnamed) a hug, and resident was grabbing everyone's (staff) buttocks when they walked by. It was not an allegation so there was no need to be concerned. Spoke to R/P (responsible party) and she spoke to her mom and felt the same. Resident was asked several times during the day and there was no allegation. Resident has a history of making false statements for 'Attention' Has to be the center of attention. The Administrator stated, The DON investigated the allegation and I wrote it because he doesn't like to write. The document was unsigned. The Administrator stated she had not spoken with Resident 12 about the alleged incident. The Administrator identified the previously unnamed CNA as CNA 19. CNA 19 was not suspended during the investigation. During a review of the clinical record for Resident 12, the Minimum Data Set (MDS, an assessment tool used to identify care needs), dated [DATE], indicated Resident 12 had a BIMS score of 15 (Brief Interview for Mental Status (BIMS-a cognitive assessment tool with a score from ,[DATE].) A score of 0 is severe mental impairment compared to a score of 15 with no mental impairment). The Behavioral Symptoms care plan, not dated, indicated False accusations about sexual things hx (history). During an interview with Resident 12, on [DATE], at 11:58 AM, she was asked about her care plan indicating accusations about sexual things. She stated Oh my goodness .(her eyes opened wide, lowered her head as she covered her face). Resident 12 stated that back around December at approximately 4 AM, she was standing facing the nurses' station waiting for her medications and suddenly someone hugged her from behind and squeezed both of her breasts. Resident 12 stated, I got so scared, I turned and looked at her . Her face was on my shoulder. Resident 12 stated that (CNA 19) then held both of her hands and placed them on her private area (Resident 12 cupped her hands and placed on her vaginal area) and squeezed. Resident 12 stated, Then she (CNA 19) took my hands and put them on her (CNA 19) private area (Resident 12 point to vaginal area) and she (CNA 19) squeezed. I was shaking and scared, I was speechless, shocked and very embarrassed . The other girls (staff) saw it and laughed out loud. I went back to my room .When I got back to my room I was shaking so bad, I couldn't stand . I was so scared and embarrassed. I stayed in my room all day. That evening (Licensed Vocation Nurse (LVN) 3), came into my room, I told her . I also told my daughter. Resident 12 stated that LVN 3 told her that she would talk to her (CNA 19) and that she (CNA 19) should not play with the residents like that. Resident 12 stated that a few weeks prior to the sexual touching CNA 19 would slap her butt as she walked down the hallway. Resident 12 stated that she was uncomfortable with the slapping of the butt. Resident 12 stated that (CNA 19) works at night. She stated, She's a Filipino lady .has a round face and light skin. Resident 12 was asked to identify the staff member from a facility wall of employee pictures. Resident 12 stated, I'm scared the staff will see me showing you. I'm scared! Resident 12 covered her face and her body started trembling. Resident stated that her (CNA 19's) picture was on the bottom row. She stated, She (CNA 19) is the one wearing a yellow top, her picture is the fifth picture on the bottom row. Count from the right to the left, it's the fifth picture. The picture Resident 12 identified was CNA 19. She stated that neither the DON nor the Administrator talked to her about the incident. She stated that a few weeks after the touching incident the DON stopped to ask her how the night shift behaved. When Resident 12 shook and covered her face the DON stated, I heard that they don't behave at night and walked away. Resident 12 stated, So I never told him. I was so embarrassed, I'm still embarrassed. That should never happen to anyone. Resident 12 stated after she talked to the evening nurse about the touching CNA 19 does not talk to her anymore. She stated, They (staff) must of talked to her. During an interview with LVN 3, on [DATE], at 2:38 PM, when asked about Resident 12 reporting the sexual touching LVN 3 stated, I don't remember her (Resident 12) ever reporting anything to me. During a second interview with Resident 12's daughter, on [DATE], at 12:30 PM, she stated, I walked into my mother's room while she was telling the Social Services Designee (SSD) about the incident. After she left the room, I spoke with my mom about the incident. When I left her room, the SSD and the DON were waiting for me and we discussed it. After I spoke with you, I thought really hard about when the incident occurred. I'm not exactly sure, but March or April. During an interview with CNA 19 on [DATE], at 8:56 AM, CNA 19, stated, Yes, I hugged her out in the hallway by the nurses station . Back in March the Administrator and the DON talked to me about hugging her (Resident 12) and they told me to never hug her again . I kept working my regular schedule. They never removed me from the schedule until now . She (Resident 12) does not come out of her room in the mornings anymore . Before I hugged her she used to come out to the nurses station for her medications and for a snack, but she doesn't do that anymore. During an interview with the Administrator on [DATE], at 10:55 AM, she stated, I am the Abuse Coordinator. I didn't get the 'hands on breasts and private area'. I thought I did investigate it at the time, but now I realize the investigation was insufficient. The Administrator verified there was no documentation of the alleged incident within Resident 12's clinical record and no notation of the alleged incident in CNA 19's personnel file. She stated, I'm going to do that. The Administrator checked her records and stated the facility had not reported any allegations of abuse to the Department since [DATE] through [DATE]. During an interview and record review with the DON, on [DATE], at 2:13 PM, the Behavioral Symptoms Care Plan, last re-evaluated ,[DATE], for Resident 12 was reviewed. The care plan indicated: False accusations about sexual things hx (history of). The DON stated he had not dated this notation he wrote on the behavior care plan, therefore he could not identify what had occurred that would justify 'false allegations' to be documented on the care plan. The Interdisciplinary Team Meeting (IDT) dated [DATE] was reviewed. It indicated: Topic Behaviors IDT met to discuss R (Resident 12) hx and false accusations, gossiping, and drug seeking behavior. Team has spoke with R R/P and R has a long hx of this behavior . R will spread false rumors, feign medical symptoms . threaten to call state if her wants are not met immediately. R R/P states she will continue to speak to her about this behavior . The DON stated, We discussed her behaviors at that meeting; we should have documented inappropriate hugs---the incident that caused the meeting. During a concurrent interview and clinical record review with the DON, on [DATE], at 5:28 PM, he reviewed the clinical record and was unable to find documented evidence of Resident 12's report of sexual touching. The DON stated, I did the care plan but we did not report it to the Department .we determined that's not abuse . We (DON and Administrator) spoke to CNA 19 and told her not to hug the resident anymore. I also spoke with the daughter. That's why I didn't consider that as abuse. 2. During an interview with Resident 2, on [DATE], at 11:58 AM, Resident 2 was asked about the phrase used in her care plan, last reviewed ,[DATE], indicating accusations of staff . She stated, It was about three or four weeks ago, I don't remember exactly. It was night time, I was sleeping and woke up because I felt someone touching my part (she pointed to her vaginal area). Resident 2's face began to frown, her voice cracked and she lowered her tone of voice. She turned and looked around her. Resident 2 stated, I'm scared to go to sleep, because I'm scared those two girls are coming back to my room. One girl grabbed my hands, I couldn't move . I had a bruise on my wrist, the bruise went away. I told my husband and the DON. I also told the skinny activity girl and she told the DON. The DON and the skinny girl came to talk to me. I was crying (Resident 2 lowered her head and held her hands together, her voice cracked.) I cry all the time now since it happened. I'm scared, I'm so scared. I cry all the time. That should only happen between a man and a woman, not between two women. That's not right, I'm so scared, I'm so nervous. Resident 2 was asked about staff performing incontinent care. She stated, That's different they just clean me, I'm okay with that. Resident 2 was asked to identify the staff member she notified of the incident. Resident stated, Yes she pointed to the SSD. During a review of the clinical record for Resident 2, the Behavioral Symptoms care plan, last reviewed ,[DATE], indicated Resident stated false accusations, accusations of people slapping her . Accusations of slap to resident face from staff . Resident states she wish she dies . The clinical record for Resident 2, the Social Work Progress Notes dated [DATE], indicated SSD notified resident daughter of (Resident 2) accusations and asking that her family take her home . The social service note did not describe Resident 2's specific (sexual abuse) accusation. During a concurrent interview and clinical record review with the SSD, on [DATE], at 3:32 PM, the SSD stated, Yes, (Resident 2) did tell me about two weeks ago that two girls (unidentified) went into her room and touched her privates. I asked her if she was soiled and needed to be cleaned when the staff touched her . I told her that staff have to touch her when they have to clean her. I told the DON and we went to talk to her, he asked her the same thing . I called the daughter . I did not document the accusation . I could have done a better job . we did not investigate. During a concurrent interview and review of the clinical record for Resident 2 with the DON, on [DATE], at 5:43 PM, the DON reviewed the clinical record and was unable to find documented evidence of any sexual abuse allegation, investigation, resident protection, or reporting to the Department. He stated, I did not do an investigation because I did not consider that as abuse . I spoke with the resident and explained to her that staff have to touch her to clean her . I did the care plan. 3. During an interview with the DON on [DATE], at 2:13 PM, he was asked about the number of resident care plans implemented for false accusations. The DON stated, We have a high incidence of false (verbal) accusations---there is a lot of this behavior here. During a follow-up interview and review of nine clinical records (Resident 4, Random Residents 13, 14, 15, 17, 18, 19, 20, 21) with the DON on [DATE], at 5:20 PM, he stated he was the staff member who primarily added the false accusations . to the behavior care plans of residents. The DON acknowledged he did not initial his additions to the care plans reviewed. He stated he usually did not document a date as to when he added the false accusations . to an existing care plan, making it difficult to understand the specific incident, event or behavior that preceded the care plan notation. He acknowledged he should have dated the care plan additions. The DON was asked to identify the criterion or process of how he determined false accusations should be added to the resident care plans. The following resident care plans were reviewed: Resident 4's Mood and Behavior care plan, undated when initiated and added to, last reviewed ,[DATE], indicated: R (Resident) will make false accusations (secondary) to reliving past traumatic experiences . possible verbal and physical abuse? The DON stated he did not feel Resident 4 was making any allegations of abuse and that he had not investigated any physical or verbal abuse involving her. Resident 13's Behavioral Symptoms care plan, initiated [DATE], last reviewed ,[DATE], indicated, False accusations accuses facility of taking her SS (Social Security) check. The DON stated, I don't think it's abuse. We have not investigated anything about her checks. Resident 14's Mood and Behavior care plan, initiated [DATE], last reviewed ,[DATE], indicated, False statements of people are talking about her. False statement that people don't like her. The DON was asked how he determined these statements were false. He did not respond. Resident 15's Noncompliance care plan, initiated [DATE], last reviewed ,[DATE], indicated, Makes false accusations of care for attention seeking purposes. Makes false accusations about not participating in activities Will state she has not had brief changed all day falsely. The DON stated he did not feel any of these accusations indicated abuse and had not investigated any of them. Resident 17's Noncompliance Care Plan, last reviewed ,[DATE], indicated, Makes false accusations that staff are mad at him and/or people do not want to be around him. His Behavior care plan, last reviewed ,[DATE], indicated: R (Resident 17) will make false accusations regarding care provided by staff then tell R/P (Responsible Party) he made false accusations because he wants a different aide The DON stated, He (Resident 17) has an anxiety disorder, he misinterprets the time it takes to answer his lights. I don't think this is abuse. There has been no investigation regarding these complaints. Resident 18's Behavior care plan, last reviewed ,[DATE], indicated, 1. Makes allegations that staff is beating him up The DON stated, That was an allegation of abuse. We did not investigate, report or document the specific allegation. Resident 19's Mood and Behavior care plan, no date initiated, no previous review, re-evaluation date due ,[DATE], indicated, False statements of people are talking about her. False statement that people don't like her. The DON stated, She's gossiping with false accusations. A relative of hers was in room X and she told them that everybody died in that room. We used it for hospice but the way she portrayed the story was not all right. That's why I documented the care plan as making false allegations. Resident 20's Behavioral Symptomscare plan, last re-evaluation ,[DATE], indicated, Falsely reports falls for attention seeking purposes. The DON stated, He does do that. I have not investigated any falls. Resident 21's Mood and Behavior care plan, last re-evaluation ,[DATE], indicated, Makes false accusations to staff in regards to other R not getting care. The DON stated, We haven't investigated. The facility policy and procedure titled Abuse Policy dated ,[DATE], indicated: Policy The facility will prohibit abuse . for all patients through the following: Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; Protection of patients during investigations; and Reporting of incidents, investigations and facility response to the results of their investigations . Abuse is defined as the willful infliction of physical pain, injury, or mental anguish . Sexual Abuse includes, but is not limited to, sexual assault. Physical Abuse includes hitting, slapping . Mental Abuse includes, but is not limited to, humiliation, 5.1.1 The notified supervisor will report the suspected abuse immediately (not to exceed 24 hours) to the Administrator or designee and other officials in accordance with state law. 5.1.2 The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation . 6.2 If serious bodily injury . 6.2.2 Send a written report within two (2) hours to the local law enforcement agency, the L&C Program (CDPH) District Office . 6.3 If no serious bodily injury . 6.3.2 Provide a written report the L&C Program District Office . 6.7. Initiate an investigation within 24 hours of an allegation of abuse .6.8 The investigation will be thoroughly documented on the facility's investigation form and log. Ensure that documentation of witnessed interviews is included . 7. The facility will protect patients from further harm during an investigation . 8. The Administrator or designee will report findings of all completed investigations to the L&C Program District Office and other officials in accordance with state law within five (5) working days of the incidents

Based on interview and record review, the facility failed to implement it's policy and procedure for abuse prevention for two of 12 sampled residents (2 and 12) when four staff (Administrator, Director of Nursing (DON), Social Services Designee (SSD) and Licensed Nurse (LN) 3) were made aware of allegations of sexual abuse. The allegations of abuse were not investigated, not reported, and the residents were not protected. This failure resulted in Resident 2 and Resident 12 suffering emotional fear and mental anguish. These failures have the potential for abuse to be widespread, unrecognized, not investigated or reported. Due to the facility's failure to implement their policy and procedure for resident abuse, the Administrator and the DON were verbally notified of an Immediate Jeopardy (IJ) situation on 5/17/16 at 4:32 PM. The facility's failure to take appropriate corrective action to protect residents from abuse, the facility's failure to thoroughly investigate allegations of abuse and the facility's failure to report allegations of abuse and investigate results of alleged abuse within five working days placed residents at risk for real or potential abuse. These failures constituted an Immediate Jeopardy situation. With onsite confirmation the immediacy was removed due to the following Plan of Correction being confirmed: 1. In-service regarding abuse reporting; 2. Random rounds (observing care); 3. In-service re: handling difficult patients; 4. Abuse investigation; 5. Interviews of residents and families by Social Worker; 6. Psychiatric referral 7. Suspension of two staff. The Administrator and the DON were notified the IJ was removed on 5/18/16, at 6:35 PM. Findings: 1. During an interview with Resident 12's family member on 5/11/16, at 4:20 PM, she stated, My mother made an allegation about sexual abuse that occurred early 2016 (January) or late 2015 (December). She told me that a CNA (Certified Nurse's Assistant) came up behind her and hugged her, the CNA's hands cupped my mother's breasts, then moved her hands down to my mother's privates . During a record review and interview with the Administrator and the DON, on 5/11/16, at 5:20 PM, they stated, That didn't actually occur. We investigated this inappropriate hugging and determined the allegation was not true. The DON stated, It was not a sexual abuse allegation after I spoke with her. I met with the daughter. It was care planned. We didn't report the incident to the Department because we didn't think it happened. The Administrator provided a document she identified as the facility's investigation dated 3/18/15. The Administrator stated, The DON investigated the allegation and I wrote it because he doesn't like to write. The document was unsigned. The Administrator stated she had not spoken with Resident 12 about the alleged incident. The Administrator identified the previously unnamed CNA as CNA 19. CNA 19 was not suspended during the investigation. During a review of the clinical record for Resident 12, the Minimum Data Set (MDS, an assessment tool used to identify care needs), dated 4/6/16, indicated Resident 12 had a BIMS score of 15 (Brief Interview for Mental Status (BIMS-a cognitive assessment tool with a score from 0-15.) A score of 0 is severe mental impairment compared to a score of 15 with no mental impairment). The Behavioral Symptoms care plan, not dated, indicated False accusations about sexual things hx (history). During an interview with Resident 12, on 5/12/16, at 11:58 AM, she was asked about her care plan indicating accusations about sexual things. She stated that back around December at approximately 4 AM, she was standing facing the nurses' station and all of a sudden someone hugged her from behind and squeezed both of her breasts. Resident 12 stated, I got so scared, I turned and looked at her. Her face was on my shoulder. She, (CNA 19), then held both of my hands and put my hands to my private (Resident 12 placed her hands cupped on her vaginal area) and squeezed. Then she (CNA 19) took my hands and put them on her (CNA 19's) private area . That evening (LVN (Licensed Vocational Nurse) 3), came into my room, I told her . I also told my daughter. Resident 12 stated that LVN 3 told her that she would talk to her (CNA 19). Resident 12 identified CNA 19 and stated that neither the DON nor the Administrator talked to her about the incident. During a second interview with Resident 12's daughter, on 5/15/16, at 12:30 PM, she stated, I thought hard about the date after we spoke. It was later than what I told you . I am not exactly sure, but the incident occurred sometime in March or April, 2016. I walked into my mother's room while she was telling the SSD about the incident. During an interview with CNA 19 on 5/16/16, at 8:56 AM, CNA 19, stated Yes, I hugged her out in the hallway by the nurses station . Back in March the Administrator and the DON talked to me about hugging her (Resident 12) and they told me to never hug her again . I kept working my regular schedule. They never removed me from the schedule until now . During an interview with the Administrator on 5/16/16, at 10:55 AM, she stated, I am the Abuse Coordinator. I didn't get the 'hands on breasts and private area'. I thought I did investigate it at the time, but now I realize the investigation was insufficient. The Administrator verified there was no documentation of the alleged incident within Resident 12's clinical record and no notation of the alleged incident in CNA 19's personnel file. She stated, I'm going to do that. The Administrator checked her records and stated the facility had not reported any allegations of abuse to the Department since 3/10/15 through 5/10/16. During a concurrent interview and clinical record review with the DON, on 5/16/16, at 5:28 PM, he reviewed the clinical record and was unable to find documented evidence of Resident 12's report of sexual abuse. The DON stated, I did the care plan but we did not report it to the Department because we (DON and Administrator) determined that's not abuse . We (DON, and Administrator) spoke to CNA 19 and told her not to hug the resident anymore . 2. During an interview with Resident 2 on 5/12/16, at 11:58 AM, she was asked about her care plan indicating accusations of staff . She stated, It was night time and I was sleeping and woke up because I felt someone touching my part (she pointed to her vaginal area). Resident 2's face began to frown, her voice began to crack and lowered her tone of voice. She turned and looked around her. She stated, I'm scared to go to sleep, because I'm scared that those two girls (unidentified) are coming back to my room. One girl grabbed my hands, I couldn't move . I told my husband and the owner (DON) . I also told the skinny activity girl. She pointed to the Social Service Designee (SSD). During a review of the clinical record, the MDS, dated [DATE], indicated Resident 2 had a BIMS score of 9. The Behavioral Symptoms care plan, not dated, indicated Resident stated false accusations, accusations of people slapping her . Accusations of slap to resident face from staff . Resident states she wish she dies . The Social Work Progress Notes, dated 4/28/16, indicated SSD notified R (resident's) daughter of R accusations and asking that her family take her home. During a concurrent interview and clinical record review with the SSD, on 5/16/16, at 3:32 PM, the SSD stated, .Yes, she (Resident 2) did tell me about two weeks ago that two girls went into her room and touched her private . I told the DON . I did not document her accusations, I just documented accusations on my note . we did not investigate. During an interview with the DON, on 5/16/16, at 5:43 PM, he stated, I didn't do an investigation because I did not consider that as abuse . I did the care plan of 'false accusations'. The facility policy and procedure titled Abuse Policy dated 7/2015, Indicated The facility will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients through the following: 1. Screening of potential hires; 2. Training of employees (both new employees and ongoing training for all employees); 3. Prevention of occupancies; 4. Identification of possible incidents or allegations which need investigation; 5. Investigation of incidents and allegations; 6. Protection of patients during investigations; and, 7. Reporting of incidents, investigations, and facility response to the results of their investigations. Purpose: to ensure that facility staff are doing all that is within their control to prevent occurrences of abuse . Process: The Administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse .5.1.1 The notified supervisor will report the suspected abuse immediately (not to exceed 24 hours) to the Administrator or designee and other officials in accordance with state law . 5.1.2 The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. 5.1.3 All reports of suspected abuse must also be reported to the patient's family and attending physician . 6.1 Enter allegation into the abuse tracking form.