Every finding on record at Villa Health Care Center

Based on interviews and record review, the facility failed to implement the abuse prevention policy and procedure for one of three sampled residents reviewed for abuse (Resident A) . The facility did not report or investigate an allegation of abuse as required.These failures increased the potential for Resident A and other residents in the facility to not be protected from abuse. A review of Resident A's admission record indicated Resident A was admitted to the facility on [DATE], with diagnoses which included depression (feeling of sadness). A review of Resident A's History and Physical, dated September 4, 2025, indicated Resident A had the ability to make own medical decisions. On August 24, 2026, at 1:59 p.m., Resident A was interviewed. Resident A stated on August 8, 2026, at 3:30 a.m., Resident B tried to get out of bed and grabbed the curtain for support. The curtain and the resident fell on Resident A's bed. Resident A asked Resident B to move away from him, and then Resident B started swinging at Resident A. On August 25, 2026, at 10:48 a.m., Certified Nurse Assistant (CNA) 1 was interviewed. CNA 1 stated she was inside the room next to Resident A's room, when the incident happened. CNA 1 heard the commotion and went out and saw Resident B on the floor and CNA 2 was assisting him to his wheelchair. CNA 2 and CNA 1 heard Resident A alleging he was hit by Resident B. CNA 1 stated a written incident report was submitted to the Director of Staff Development (DSD) and the Director of Nursing Services (DNS). On August 25, 2026, at 3:20 p.m., the Director of Nursing Service (DNS) was interviewed and stated the allegation of abuse by Resident B should have been reported immediately to the California Department of Public health and should have been investigated thoroughly and documented in the resident's record. A review of facility policy and procedure titled, Abuse, Neglect.Reporting and investigating, dated March 2026, indicated, .All reports of resident abuse.the suspicion must be reported immediately to administrator and to other officials according to state law within two hours of an allegation involving abuse.All reports of resident abuse.are investigated thoroughly.

Based on interviews and record review the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) for one of three sampled residents reviewed for abuse (Resident A), when Resident A alleged he was punched by Resident B. This failure had potential for psychosocial harm to Resident A and to other residents in the facility.A review of Resident A's admission record indicated Resident A was admitted to the facility on [DATE], with diagnoses which included depression (feeling of sadness). A review of Resident A's History and Physical, dated September 4, 2025, indicated Resident A had the ability to make own medical decisions. On August 24, 2026, at 1:59 p.m., Resident A was interviewed. Resident A stated on August 8, 2026, at 3:30 a.m., Resident B tried to get out of bed and grabbed the curtain for support. The curtain and the resident fell on Resident A's bed. Resident A asked Resident B to move away from him, and then Resident B started swinging at Resident A. On August 25, 2026, at 10:48 a.m., Certified Nurse Assistant (CNA) 1 was interviewed. CNA 1 stated she was inside the room next to Resident A's room, when the incident happened. CNA 1 heard the commotion and went out and saw Resident B on the floor and CNA 2 was assisting him to his wheelchair. CNA 1 and CNA 2 heard Resident A alleging he was hit by Resident B. CNA 1 stated a written incident report was submitted to the Director of Staff Development (DSD) and the Director of Nursing Services (DNS). On August 25, 2026, at 2:38 p.m., CNA 2 was interviewed. CNA 2 stated he just went out of the bathroom when he saw Resident B grabbing the floor by the doorway. CNA 2 stated he immediately assisted him up to his wheelchair. CNA 2 stated he heard Resident A alleging Resident B hit him and after hearing this allegation CNA 2 immediately reported the allegation to two Licensed Vocational Nurses (LVNs). On August 25, 2026, at 9:20 a.m., LVN 1 was interviewed. LVN 1 stated at around 4:30 a.m., Resident A was angry when he verbalized to us (LVN 1, LVN 2, CNA 1, and CNA 2) that he was attacked by Resident B. LVN 1 stated Resident A was cursing and stated he will never forget that. LVN 1 further stated she reported the incident in a group text to the Director of Nursing Service (DNS) & to the Administrator. On August 25, 2026, at 11:14 a.m., LVN 3 was interviewed. LVN 3 stated that she was the incoming Licensed Nurse on August 9, 2026. LVN 3 stated that she and the DNS went to see Resident A. LVN 3 stated Resident A verbalized that the guy next door ( A__H___) punched me. LVN 3 further stated that this was an allegation of abuse, and she did not report it for she was already with the DNS at the time. A review of the undated written incident report made by CNA 1 indicated .Resident A mentioned to me that he just began rigging onto the curtains and eventually went on his bed and just began punching him in the face. The incident report was submitted to the IDT (Interdisciplinary Team- a group that includes the nurse, social worker, dietician, physician, and the resident. Together, they assess, coordinate, and manage each resident's care). On August 24, 2026, at 3:46 p.m., the DNS was interviewed. The DNS stated Resident A's allegation was not reported because the IDT concluded the red mark on the left cheek was not due to the alleged altercation but a result of the curtain railing that had fallen onto his cheek. The DNS stated the allegation should have been reported regardless of whether it was true or whether the incident actually occurred. The DNS further stated it should have been reported within two hours to CDPH from the time allegation was made. A review of facility policy and procedure titled, Abuse, Neglect.Reporting and investigating, dated March 2026, indicated, .All reports of resident abuse.the suspicion must be reported immediately to administrator and to other officials according to state law within two hours of an allegation involving abuse.

Based on interviews and record review, the facility failed to investigate an allegation of physical abuse involving Resident A, one of three sampled residents reviewed for abuse. This failure placed Resident A at continued risk of further abuse.Findings: A review of Resident A's admission record indicated Resident A was admitted to the facility on [DATE], with diagnoses which included depression (feeling of sadness). A review of Resident A's History and Physical, dated September 4, 2025, indicated Resident A had the ability to make own medical decisions. On August 24, 2026, at 1:59 p.m., during interview, Resident A stated that on August 8, 2026, at 3:30 a.m., Resident B held on to the curtain to maintain his balance as he (Resident B) tried to get out of bed; however, the curtain and the resident (Resident B) fell on his (Resident A) bed. Resident A stated he (Resident B) began swinging at him (Resident A) after being asked to move away. On August 25, 2026, at 10:48 a.m., Certified Nurse Assistant (CNA) 1 was interviewed, CNA 1 ++stated she was in the room next to Resident A's room, when she heard the commotion. She (CNA 1) stated she exited the room and observed CNA 2 assisting Resident B into his wheelchair. CNA 1 stated she and CNA 2 heard Resident A alleged that he was hit by Resident B. CNA 1 stated she completed an incident report and submitted the report to the Director of Staff Development (DSD) and the Director of Nursing Service (DNS). She further stated that no one asked her about the incident. On August 25, 2026, at 11:48 a.m., Licensed Vocational Nurse (LVN) 3 was interviewed, LVN 3 stated she was the incoming nurse, on the day of and the day following the incident. She also stated that she was with the DNS on August 9, 2026, when they spoke with Resident A, who stated he had been hit by the guy next door (referring to Resident B). She (LVN 3) stated that no investigation had been conducted to determine whether the allegation was true or was just a false allegation. On August 25, 2026, at 3:20 p.m., during a concurrent interview and record review with the Director of Nursing Service (DNS), the DNS stated the allegation of abuse involving Resident B and Resident A should have been thoroughly investigated and documented in the residents' record. A review of facility policy and procedure titled, Abuse.Reporting and Investigating., dated March 2026, indicated .All reports of resident abuse.are investigated thoroughly.All allegations are thoroughly investigated.the individual conducting the investigation as a minimum review the documentation and evidence.interviews the person(s) reporting the incident.interviews any witnesses to the incident.interview the resident or the resident representative.interview the resident roommate.documents the investigation completely and thoroughly.The administrator or his/or her designee, provide the appropriate agencies a written report of the findings of the investigation within 5 working days of the occurrence of the incident.

Based on interviews and record review, the facility failed to develop a care plan addressing the allegation of physical abuse involving Resident A, one of three sampled residents reviewed for abuse. This failure had the potential to negatively affect the psychosocial well-being of Resident A.Findings: A review of Resident A's admission record indicated Resident A was admitted to the facility on [DATE], with diagnoses which included depression (feeling of sadness). A review of Resident A's History and Physical, dated September 4, 2025, indicated Resident A had the ability to make own medical decisions. On August 24, 2026, at 1:59 p.m., during interview, Resident A stated that on August 8, 2026, at 3:30 a.m., Resident B held on to the curtain to maintain his balance as he (Resident B) tried to get out of bed; however, the curtain and the resident (Resident B) fell on his (Resident A) bed. Resident A stated he (Resident B) began swinging at him (Resident A) after being asked to move away. On August 24, 2026, at 3:46 p.m., during a concurrent interview and record review with the Director of Nursing Services (DNS), the DNS stated that all allegations should be reported as a change in condition and addressed in the care plan. The DNS further stated that care plans should be developed for both the alleged victim and the alleged aggressor. The DNS confirmed that no care plans had been initiated. On August 25, 2026, at 9:20 a.m., during an interview with a Licensed Vocational Nurse (LVN 1), LVN 1 stated that at around 4:30 a.m., on August 8, 2026, Resident A appeared angry and reported to them (LVN 1, LVN2, CNA1, and CNA 2) that he was attacked by Resident B. LVN 1 stated Resident A was cursing out while making the report and said that he would never forget that incident. LVN 1 further stated she reported the incident via a group text to the Director of Nursing Service (DNS) and to the Administrator. On August 25, 2026, at 10:48 a.m., Certified Nurse Assistant (CNA) 1 was interviewed, CNA 1 stated she was in the room next to Resident A's room, when she heard the commotion on August 8, 2026. She (CNA 1) stated she exited the room and observed CNA 2 assisting Resident B into his wheelchair. CNA 1 stated she and CNA 2 heard Resident A alleged that he was hit by Resident B. CNA 1 stated she completed an incident report and submitted the report to the Director of Staff Development (DSD) and the Director of Nursing Service (DNS). She further stated that no one asked her about the incident. A review of facility policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated November 2025 indicated .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.Assessments of residents are on-going, and care plans are revised as information about the residents and the residents' conditions change.

Based on interview and record review, the facility did not ensure timely delivery and administration of the medication Trelegy (medication used to treat Chronic Obstructive Pulmonary Disease {COPD - a progressive inflammatory lung disease that obstructs airflow}) as ordered by the physician for one of three residents reviewed (Resident 1) for pharmacy services. This failure resulted in resident not receiving medication as ordered by the physician to manage and treat the medical condition. Findings:On June 2, 2026, at 1130 a.m., an interview was conducted with Resident 1. Resident 1 stated the following:- She was transferred to the acute hospital on May 16, 2026 and was re-admitted back to the facility on May 20, 2026;- She was prescribed Trelegy as a discharge medication order for her COPD; and- The facility staff did not give the medication as ordered by the physician when she was readmitted back to the facility.On June 4, 2026, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses including COPD.The acute hospital document titled, (Name of Acute Hospital).Discharge Medication List.Current Medication as of 05/20/2026.Trelegy Elliipta 100 MCG (microgram - unit of measurement).Inhalation Powder.How to take.1 INHALATION DAILY.The document titled, Progress Notes, dated May 21, 2026, and signed by Resident 1's physician indicated, .On 05/16/2026, patient with COPD exacerbation (a sudden, sustained worsening of respiratory symptoms like increased breathlessness, coughing, or mucus changes that requires a change in medication) and was transferred to (Name of Acute Hospital) for further evaluation. Patient discharged back to (Name of Facility) on 05/20/2026.with new med Trelegy Ellipta.daily for chronic COPD.The electronic Medication Administration Record dated May 1 to 31, 2026, indicated a physician's order to give Trelegy Ellipta Inhalation Aerosol Powder Breath Activated for COPD to start on May 21, 2026. The eMAR indicated Trelegy was not administered on May 21 or 22, 2026. Resident 1 received the initial dose on May 23, 2026.On June 4, 2026, at 1540 pm, an interview with a record review was conducted with Licensed Vocation Nurse (LVN) 2. LVN 2 stated the following:- Resident 1 had a discharge order from the hospital, dated May 20, 2026, for Trelegy Ellipta one inhalation daily for COPD;- Resident 1's May 2026 eMAR indicated the medication Trilogy was ordered on May 20, 2026, and the first dose was supposed to be given on May 21, 2026, at 9 a.m.;- Resident 1 did not receive the first dose of Trelegy until May 23, 2026. LVN 2 stated the eMAR indicated the medication Trelegy was not given on 05/21/2026 and 05/22/2026 due to its unavailability.- Resident 1 should have received the first dose of Trelegy on May 21, 2026,, as ordered by the physician; and- There was no record indicating that the pharmacy and physician were contacted about the medication unavailability on May 21 and 22, 2026. LVN 2 stated, the licensed nurse should have documented that pharmacy and physician were contacted when medication is missed.On June 4, 2026, at 4:34 p.m., the interim Director of Nursing (DON) was interviewed. The DON stated:- Resident 1 had a physician's order for Trelegy dated May 20, 2026, with a start date of May 21, 2026;- The medication Trelegy was not given on May 21 and 22, 2026 because of pending pharmacy delivery; and- There was no documentation from the licensed nurses that Resident 1's physician and the pharmacy were notified of the medication unavailability on May 21 and 22, 2026. The DON stated the licensed nurse should document why a medication was unavailable, notify the physician, and follow up with the pharmacy. The DON stated this should have been done.The facility' policy and procedure titled, Pharmacy Services Overview dated, November 2025, indicated, .The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist . resident have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner . Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting pharmacy if a resident's medication is not available for administration.

Based on observation, interview, and record review, the facility failed to ensure timely response to call lights for one out of five residents (Resident 2), who waited approximately 15 minutes for assistance. This failure had the potential to place the resident at risk for unmet care needs and increased the risk for unsafe self-mobility and potential falls. Findings: On March 5, 2026, at 10:13 a.m., an unannounced visit to the facility on a complaint investigation for quality-of-care issues was initiated. A review of Resident 2's admission Records indicated resident was admitted on [DATE], with diagnoses of fracture of right ulna, (a partial or complete break in the ulna, the long bone on the pinky side of the forearm extending from the elbow to the wrist), subsequent encounter for closed fracture with routine healing, fracture of the lower end of right radius, (a break in the right forearm bone near the wrist joint), subsequent encounter for closed fracture with routine healing, multiple fractures of ribs, (a break or crack in one or more of the 12 pairs of bones forming the rib cage), right side. A review of Resident 2's history and Physical dated February 17, 2026, indicated resident had the capacity to make decisions. On March 5, 2026, at 12:08 p.m., an observation and interview were conducted with Resident 2. Resident 2 was standing at the bedside, wearing a clean gown and shorts, with a long arm splint and sling of the right arm. Resident 2 stated that she was right-handed and the splint and sling made it difficult to do normal daily tasks. Resident 2 stated she required assistance with dating her food and was waiting for staff to come and help. Resident 2 further stated that call lights were answered between five and 30 minutes. On March 5, 2026, at 12:17 p.m., during the interview, Resident 2 in her room activated the call light. At 12:32 p.m., the Treatment Nurse (TN) responded approximately 15 minutes after Resident 2 activated the call light. On March 5, 2026, at 12:34 p.m., an interview was conducted with TN. The TN stated that all staff are responsible for answering call lights. The TN stated that the call light should be answered as soon as possible and residents should not wait 15 minutes. On March 5, 2026, at 1:02 p.m., an interview was conducted with the Certified Nursing Assistant (CNA). The CNA stated that call lights should be answered within five to 10 minutes. On March 5, 2026, at 1:35 p.m., an interview was conducted with the Licensed Vocational Nurse (LVN). The LVN stated that call lights should be answered immediately. The LVN further stated delays of up to 15 minutes could result in the resident's needs not being met and increase the risk of falls. A review of Resident 2's Care Plan dated February 18, 2026, indicated .Focus The resident is at low risk for falls.Interventions/Tasks Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. A review of the facility's policy and procedure titled Answering the Call Light undated, indicated The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Steps in the Procedure1. When answering from the call light station, turn off the signal light.2. Identify yourself and politely respond to the resident by his/her name. a. If the resident needs assistance, indicate the approximate time it will take for you to respond. b. If the resident's request requires another staff member, notify the individual. c. If the resident's request is something you can fulfill, complete the task within five minutes if possible. d. If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance.3. If assistance is needed when you enter the room, summon help by using the call signal.

Based on interview and record review, the facility failed to ensure for one of seven sampled residents (Resident 1), the medication Eliquis (a prescription medication that functions as a blood thinner to prevent and treat various types of blood clots) was reconciled with the physician.This failure resulted in Resident 1 receiving four doses at twice the strength, placing her at risk for bleeding and other adverse effects.Findings: A review of Resident 1's medical records indicated Resident 1 was admitted on [DATE], and discharged on July 10, 2024, with diagnoses of infected amputated stump, renal dialysis, (treatment removes waste products and excess fluids from the bloodstream, while maintaining the proper chemical balance of the blood), diabetes mellitus type 2, (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), peripheral vascular disease (PVD - is a slow and progressive circulation disorder), and left and right below the knee amputations.A review of Resident 1's history and Physical dated July 1, 2024, indicated Resident 1 had the capacity to make decisions.On July 15, 2025, at 10:33 a.m., during an interview with the Licensed Vocational Nurse, (LVN), stated that when a resident returns from the General Acute Care Hospital (GACH), the medications list from the GACH is reviewed and sent to the physician for reconciliation. The LVN stated for residents prescribed Eliquis, signs and symptoms for bleeding were assessed and documented every shift. A review of Resident 1's Discharge Medication List from the hospital, dated June 29, 2024, indicated .Medication. Eliquis. 5MG Oral Tablet. How to take. TAKE 2.5 Milligrams ORAL TWICE A DAY. A review of Resident 1's Order Summary dated June 29, 2024, indicated .Eliquis Oral Tablet 5 MG (Apixaban [an anticoagulant]) Give 1 tablet by mouth two times a day for ANTICOAGULANT. and discontinued on July 1, 2024.A review of Resident 1's Order Summary dated July 1, 2024, at 11:53 p.m., indicated Communication Method: Phone.Order Summary: Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day related to PERIPHERAL VASCULAR DISEASE.A review of Resident 1's Medication Administration Record indicated:-Dated June 2024, indicated Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for ANTICOAGULANT . -Dated July 2024, indicated .Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for ANTICOAGULANT .Further review of Resident 1's MAR for June and July 2024, indicated that on June 30 and July 1, 2024, Resident 1 received Eliquis 5 mg twice daily, rather than the intended 2.5 mg twice daily. On July 15, 2025, at 1:08 p.m., an interview and record review of Resident 1's Discharge Medication List dated June 29, 2024, MAR, and Order Summary were conducted with the Director of Nursing (DON). The DON stated the correct dose should have been Eliquis 2.5 MG two times a day. The DON stated Resident 1 received Eliquis 5 mg twice daily for a total of four doses before a telephone order confirmed Eliquis at 5 MG. A review of the facility's policy and procedure titled Reconciliation of Medications on Admission revised July 2024, indicated .1. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. 3. Using an approved medication other, list all medications from the medication history, the discharge summary, and the previous MAR (if applicable) . 4. List the dose, route and frequency for all medications. 5. Review the list carefully to determine if there are discrepancies/conflicts.

Based on interview, and record review, the facility failed to follow policy and procedure for safe use of the Hoyer lift, (a portable total patient lifting tool to assist in transferring patients in and out of bed), for one of seven sampled residents, (Resident 2). This failure had the potential to cause injury and resulted in Resident 2 feeling unsafe.Findings:A review of Resident 2's medical records indicated Resident 2 was admitted on [DATE], with diagnoses of orthopedic aftercare, left displaced trimalleolar fracture, (broken ankle bone that the pieces have moved apart, creating a gap), displaced comminuted fracture of shaft of right fibula, (the smaller bone in the lower leg is broken into multiple pieces, and these pieces have moved out of their normal alignment), fracture of manubrium, (broken breastbone), nondisplaced fracture of seventh cervical vertebra, (broken neck bone), multiple left and right rib fractures (broken rib bones), wedge compression fracture of third lumbar vertebra, (broken bone in the lower back), pneumothorax, (a collapsed lung), wedge compression fracture of first thoracic vertebra, (broken upper back bone), and bed sore of the left heel. A review of Resident 2's History and Physical dated July 14, 2025, indicated resident had capacity to make decisions.On July 14, 2025, at 2:48 p.m., an interview was conducted with Resident 2. Resident 2 stated she did not want to discuss the incident with the Hoyer lift again. Resident 2 stated it is in the records. On July 14, 2025, at 3:08 p.m., an interview was conducted with the Physical Therapist, (PT). The PT stated that on July 2, 2025, Resident 2 was non-weight bearing, and the Hoyer lift was required for out of bed transfers. On July 15, 2025, at 10:35 a.m., an interview was conducted with the Registered Nurse. The RN stated that on July 2, 2025, Resident 2 reported that Certified Nursing Assistant (CNA) used the Hoyer lift without a second staff member. The RN stated the strap slipped out of place, and Resident 2 fell onto the bed. The RN stated she assessed Resident 2 for injuries, and found none. The RN confirmed that the Hoyer lift requires at least two people. On July 15, 2025, at 11:12 a.m., an interview was conducted with CNA 1. CNA 1 stated on July 2, 2025, during her morning shift, CNA 2 requested her assistance with using the Hoyer lift for Resident 2's shower. CNA 1 stated that when she entered Resident 2's room, CNA 2 was lifting Resident 2 without assistance. CNA 1 stated, one of the straps snapped loose, and Resident 2 was lowered back onto her bed. CNA 1 stated, Resident 2 requested not to be lifted again, however, she observed CNA 2 lifted Resident 2 with the Hoyer lift again. CNA 1 stated that at least two staff members are required to use the Hoyer lift. On July 15, 2025, at 11:39 a.m., a telephone interview was conducted with CNA 2. CNA 2 stated, she was aware that two staff members are required to use the Hoyer lift. CNA 2 stated she started lifting Resident 2 with the Hoyer lift without CNA 1. CNA 2 stated one of the straps snapped out of place and she lowered Resident 2 onto the bed. On July 15, 2025, at 11:51 a.m., a telephone interview was conducted with the Director of Staff Development, (DSD). The DSD stated, CNA 1 reported the incident on July 2, 2025. The DSD stated, Resident 2 was upset and did not want CNA 2 to assist her in the future. The DSD stated, CNA 1 informed that CNA 2 had used the Hoyer lift by herself and Resident 2 was upset and did not want CNA 2 to assist her. The DSD stated that CNA 2 was given a verbal warning, and provided education that the Hoyer lift required two people to operate. A review of the facility's document titled Performance Improvement Plan dated July 2, 2025, indicated .Employee Name [name of CNA 2].Type of warning.verbal.Performance/Behavior to be Addressed.EMPLOYEE FAILED TO PERFORM 2 PERSON CARE DURING HOYER LIFT TRANSFER.A review of the facility's policy and procedure titled Lifting Machine, Using a Mechanical revised July 2024, indicated The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device.General Guidelines. 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.2. Mechanical lifts may be used for tasks that require.e. Toileting or bathing.

5. On June 10, 2025, at 11:41 a.m., an interview was conducted with Resident 37. Resident 37 stated she was not sure if she had an AD and would like more information. A review of Resident 37's admission Record indicated Resident 37 was admitted to the facility on [DATE], with diagnoses which included dysphasia (difficulty to speak or understand speech) following cerebral infarction (stroke). A review of Resident 37's Advance Directive/POLST Acknowledgment Form, dated November 6, 2024, indicated, .I have not executed an Advance Directive for Health Care .I do not wish to do so at this time . A review of Resident 37's POLST, dated November 6, 2024, did not indicate Resident 37 had an AD. A review of the Social Services Assessment, dated May 6, 2025, indicated Resident 37 did not have an AD. A review of Resident 37's IDT Care conference, dated May 9, 2025, indicated Resident 37 did not have an AD. A review of Resident 37's MDS, dated May 12, 2025, indicated Resident 37 had a BIMS score of 13 (intact cognitive response). There was no documented evidence Resident 37 or RP were provided follow up information or education about the right to formulate an AD. On June 12, 2025, at 2:10 p.m., a concurrent interview and record review of Resident 37's Social Services Assessment and Care Conference forms was conducted with the SSD. The SSD stated residents in the facility were provided an acknowledgement form upon admission and if they had an AD, they would request a copy to be available in the facility. The SSD stated if they did not have one, they would provide a handout with information and provide education on how to formulate one. SSD stated if the resident did not wish to have an AD, a follow up with the resident or RP about AD would be conducted quarterly during a resident's care conference. The SSD stated there was no documentation which indicated Resident 37 and/or RP were provided follow up information during the care conference on May 9, 2025. The SSD stated if there was no AD on file there was a potential for the facility to not be able to honor their wishes for care. A review of the facility's policy and procedure titled, Advance Directives, revised January 2023, indicated, .the resident will be provided with written information concerning the right to refuse or accept .and to formulate an advance directive if he or she chooses to do so .prior to or upon admission of a resident, the social services director or designee will inquire of the resident, his/her family members and /or his or her legal representative, about the existence of any written advance directives .information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record .if the resident indicates that he or she has not established advance directive, the facility will offer assistance in establishing advance directives . Based on interview and record review, the facility failed to ensure, five of seven residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 26, 30, 34, 35, and 37) a copy of the AD was available and the resident or their resident representative (RP) had been provided follow up information regarding the formulation of an AD. These failures had the potential to result in the ADs for Residents 26, 30, 34, 35, and 37 not being readily accessible to staff and physicians, which could lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored. Findings: 1. Resident 26's admission record was reviewed. Resident 26 was admitted to the facility on [DATE], with diagnosis which included chronic obstructive pulmonary disease (progressive lung disease that causes obstructed airflow making it hard to breath) and diabetes mellitus (abnormal blood glucose level). A review of the Advance Directive / Physician Orders for Life-Sustaining Treatment (POLST) Acknowledgment Form, dated April 14, 2023, indicated, .I have not executed an Advance Directive for Health Care .I do not wish to do so at this time . A review of Resident 26's Minimum Data Set (MDS - an assessment tool), dated April 26, 2025, indicated Resident 26 had Brief Interview of Mental Status (BIMS - a tool to assess cognitive function of an individual) score of 11 (moderate cognitive response). A review of Resident 26's IDT (Interdisciplinary Team - MDS Licensed Vocational Nurse, Social Service Director, Director of Rehab, Activities Director, and Certified Nurse Assistant) Care Conference, dated April 28, 2025, indicated, Resident 26 did not have an AD. There was no documented evidence Resident 26 or RP were provided follow up on the right to formulate an AD. On June 12, 2025, at 2 p.m., a concurrent interview and record review of Resident 26's IDT Care Conference form was conducted with the Social Services Director (SSD). The SSD stated residents in the facility were provided an acknowledgement form upon admission and if they had an AD, they would request a copy to be available in the facility. The SSD stated if they did not have one, they would provide a handout with information and provide education on how to formulate one. The SSD stated if the resident did not wish to have an AD, a follow up with the resident or RP about AD would be conducted quarterly during a resident's care conference. The SSD stated there was no documentation which indicated Resident 26 and/or RP were provided follow up information during the care conference on April 28, 2025. The SSD stated if there was no AD on file there was a potential for the facility to not be able to honor their wishes for care. 2. On June 9, 2025, at 9:59 a.m., an interview was conducted with Resident 30. Resident 30 stated she was unsure if she has an AD. Resident 30's admission record was reviewed. Resident 30 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (a type of stroke) without residual effects and dysphagia (difficulty in swallowing). A review of the Advance Directive / POLST Acknowledgment Form, dated October 16, 2024, indicated, .I have not executed an Advance Directive for Health Care .I do not wish to do so at this time . A review of Resident 30's POLST, dated October 16, 2024, did not indicate Resident 30 had an AD. A review of Resident 30's IDT (Interdisciplinary Team - MDS Licensed Vocational Nurse, Social Service Director, Director of Rehab, Activities Director and Certified Nurse Assistant) Care Conference, dated May 9, 2025, indicated, Resident 30 did not have an AD. A review of Resident 30's MDS, dated May 10, 2025, indicated Resident 30 had BIMS score of 11 (moderate cognitive response). There was no documented evidence Resident 30 or RP were provided follow up on the right to formulate an AD. On June 12, 2025, at 2:02 p.m., a concurrent interview and record review of Resident 30's IDT Care Conference form was conducted with the SSD. The SSD stated residents in the facility were provided an acknowledgement form upon admission and if they had an AD, they would request a copy to be available in the facility. The SSD stated if they did not have one, they would provide a handout with information and provide education on how to formulate one. The SSD stated if the resident did not wish to have an AD, a follow up with the resident or RP about AD would be conducted quarterly during a resident's care conference. The SSD stated there was no documentation which indicated Resident 30 and/or RP were provided follow up information during the care conference on May 9, 2025. The SSD stated if there was no AD on file there was a potential for the facility to not be able to honor their wishes for care. 3. On June 9, 2025, at 10:41 a.m., an interview was conducted with Resident 34. Resident 34 stated he was unsure if he has an AD. Resident 34's admission record was reviewed. Resident 34 was admitted to the facility on [DATE], with diagnoses which included hypertensive heart disease (heart problem caused by high blood pressure that's been going on for a long time) and major depressive disorder (persistent and intense feeling of sadness or loss of interest). A review of the Advance Directive / POLST Acknowledgment Form, dated June 30, 2024, indicated, .I have not executed an Advance Directive for Health Care .I would like more information .7/1/24 discussed and resources given . A review of Resident 34's POLST, dated June 30, 2024, did not indicate Resident 34 had an AD. A review of Resident 34's MDS, dated April 13, 2025, indicated Resident 34 had BIMS score of 13 (intact cognitive response). A review of the Social Services Assessment, dated April 14, 2025, indicated Resident 34 did not have an Advance Directive. A review of Resident 34's IDT (Interdisciplinary Team - MDS Licensed Vocational Nurse, Social Service Director, Director of Rehab, activities Director and Certified Nurse Assistant) Care Conference, dated April 15, 2025, indicated, Resident 34 did not have an AD. There was no documented evidence Resident 34 or RP were provided follow up on the right to formulate an AD. On June 12, 2025, at 2:04 p.m., a concurrent interview and record review of Resident 34's IDT Care Conference form was conducted with the SSD. The SSD stated residents in the facility were provided an acknowledgement form upon admission and if they had an AD, they would request a copy to be available in the facility. The SSD stated if they did not have one, they would provide a handout with information and provide education on how to formulate one. The SSD stated if the resident did not wish to have an AD, a follow up with the resident or RP about AD would be conducted quarterly during a resident's care conference. The SSD stated there was no documentation which indicated Resident 34 and/or RP were provided follow up information during the care conference on April 15, 2025. The SSD stated if there was no AD on file there was a potential for the facility to not be able to honor their wishes for care. 4. On June 9, 2025, at 11:10 a.m., an interview was conducted with Resident 35. Resident 35 stated was unsure if he has an AD. Resident 35's admission record was reviewed. Resident 35 was admitted to the facility on [DATE], with diagnoses which included hypertensive chronic kidney disease (high blood pressure has been damaging the kidneys over a long period of time) and moderate protein-calorie malnutrition (the body is not geeing enough protein and calories). A review of the Advance Directive / POLST Acknowledgment Form, dated September 27, 2024, indicated, .I have not executed an Advance Directive for Health Care .I do not wish to do so at this time . A review of Resident 35's POLST, dated November 15, 2024, did not indicate Resident 35 had an AD. A review of Resident 35's IDT (Interdisciplinary Team - MDS Licensed Vocational Nurse, Social Service Director, Director of Rehab, activities Director and Certified Nurse Assistant) Care Conference, dated April 15, 2025, indicated, Resident 35 did not have an AD. A review of Resident 35's MDS, dated April 17, 2025, indicated Resident 35 had BIMS score of 13 (intact cognitive response). A review of the Social Services Assessment, dated May 23, 2025, indicated Resident 35 did not have an Advance Directive. There was no documented evidence Resident 35 or RP were provided follow up on the right to formulate an AD. On June 12, 2025, at 2:06 p.m., a concurrent interview and record review of Resident 35's IDT Care Conference form was conducted with the SSD. The SSD stated residents in the facility were provided an acknowledgement form upon admission and if they had an AD, they would request a copy to be available in the facility. The SSD stated if they did not have one, they would provide a handout with information and provide education on how to formulate one. The SSD stated if the resident did not wish to have an AD, a follow up with the resident or RP about AD would be conducted quarterly during a resident's care conference. The SSD stated there was no documentation which indicated Resident 35 and/or RP were provided follow up information during the care conference on April 15, 2025. The SSD stated if there was no AD on file there was a potential for the facility to not be able to honor their wishes for care.

Based on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when five large plastic basins used for ice and food items were stacked and stored wet. This failure had the potential to cause foodborne illnesses in 52 medically vulnerable resident population who consumed food in the facility. Findings: During the initial tour in the kitchen, an observation and concurrent interview with the Dietary Services Supervisor (DSS) on June 9, 2025, at 9:05 a.m. was conducted. Five large plastic basins were observed stacked wet and stored on a metal storage shelf. The DSS stated the plastic basins were wet and stacked on top of each other. He stated that all dishes, pots, and pans should be air-dried and completely dried before stored away in their designated area. During an interview on June 11, 2021, at 3:15 p.m., the Registered Dietitian (RD) stated all dishes, pots, pans, and utensils needed to be air-dried before stored away. She stated the moisture environment could induce bacteria or mold growth. According to FDA Federal Food Code 2022, Section 4-901.11 Equipment and Utensils, Air-Drying Required, after cleaning and sanitizing, equipment, and utensils .shall be air-dried .before contact with food .

Based on observations, interviews, and record review, the facility failed to ensure proper medication administration practices were followed when the licensed nurse did not observe the resident take the medication and left the medication at bedside for one of five residents (Resident 26). This failure had the potential for the resident to not consume the medication as ordered and experience adverse effects as a result of not consuming the medication. Findings: During a concurrent observation and interview on June 9, 2025, at 9:45 a.m. with Resident 26 in her room, one clear medication cup filled halfway with orange liquid was observed on top of Resident 26's bedside table. Resident 26 acknowledged the liquid was her medication. During a concurrent observation and interview on June 9, 2025, at 9:46 a.m. with Licensed Vocational Nurse (LVN) 1 inside Resident 26's room, LVN 1 verified the orange liquid medication at Resident 26's bedside was potassium chloride which was Resident 26's scheduled 9 a.m. medication. LVN 1 stated the medication should not have been left at the bedside and stated she should have observed Resident 26 take the medication. LVN 1 stated it was important to observe the resident take the medication to ensure the effectiveness of the medication for their health and safety. During an interview on June 12, 2025, at 10:21 a.m. with the Director of Nursing (DON), the DON stated nursing staff were expected to observe residents take their medications and medications should not be left at the bedside. The DON stated it was important to make sure the resident received the medication as ordered and to prevent any adverse effects related to not receiving the medication. A review of the facility's policy and procedure titled, Administering Oral Medications, dated September 2023, indicated, .remain with the resident until all medications have been taken .

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when nursing staff did not clean and disinfect a shared blood pressure cuff and stethoscope according to the disposable wipe manufacturer's specified contact time (the time the resident equipment was to remain wet to kill micro-organisms [germs]) for one of four residents reviewed for medication administration (Resident 31). This failure had the potential to expose vulnerable residents to cross-contamination and increased the risk of infection. Findings: During a medication pass observation on June 11, 2025, at 8:04 a.m., LVN 2 was observed wiping a shared manual blood pressure cuff and stethoscope with a germicidal disposable wipe. LVN 2 did not leave the blood pressure cuff and stethoscope visibly wet for at least two minutes, as required. In a concurrent interview with LVN 2, LVN 2 stated the equipment needed to remain wet for one minute. LVN 2 stated, the manufacturer's instructions from germicidal disposable wipe container indicated to leave wet for two minutes. LVN 2 stated she should have kept the equipment wet for two minutes. LVN 2 stated it was important to follow the manufacturer's instructions to effectively kill bacteria and prevent the spread of infection. During an interview on June 11, 2025, at 12:25 p.m. with the Infection Preventionist (IP), the IP stated the staff are expected to disinfect shared equipment, such as blood pressure cuffs and stethoscopes, after each use. The IP stated nursing staff should have followed the manufacturer's instructions and the resident shared equipment should have remained visibly wet for two minutes. The IP stated it was important to follow manufacturer's instructions to prevent the spread of infection. During an interview on June 12, 2025, at 10:14 a.m. with the Director of Nursing (DON), the DON stated the expectation was for nursing staff to follow the germicidal disposable wipe manufacturer's instructions regarding the recommended contact time. The DON stated it was important to follow the manufacturer's instructions to properly disinfect and prevent the spread of infection. A review of the facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated September 2024, indicated, .reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturer's instructions . A review of the manufacturer's instructions for disinfecting time for the [brand name] Germicidal Disposable Wipes provided by the facility, indicated, .to disinfect .thoroughly wet surface .allow surface to remain wet for two (2) minutes .

Based on observation, interview, and record review, the facility failed to ensure multi-resident bedrooms provided the required minimum of 80 sq ft (square feet - unit of measurement) per resident in 16 out of 22 rooms (Rooms 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 21, 22, 23, 24, and 25). This failure had the potential to negatively affect the residents' quality of life. Findings: A review of facility document titled, SQUARE FOOTAGE STATISTICS FOR RESIDENT ROOMS, dated July 5, 2012, indicated a list of rooms with less than 80 sq ft per resident. The document indicated the room measurements, square footage, and the approved maximum capacity for each room: - room [ROOM NUMBER] (three-bed) - total of 220 sq ft (73.3 sq ft per resident) - room [ROOM NUMBER] (three-bed) - total of 216 sq ft (72 sq ft per resident) - room [ROOM NUMBER] (three-bed) - total of 218 sq ft (72.7 sq ft per resident) - room [ROOM NUMBER] (three-bed) - total of 218 sq ft (72.7 sq ft per resident) - room [ROOM NUMBER] (three-bed) - total of 216 sq ft (72 sq ft per resident) - room [ROOM NUMBER] (three-bed) - total of 218 sq ft (72.7 sq ft per resident) - room [ROOM NUMBER] (three-bed) - total of 216 sq ft (72 sq ft per resident) - room [ROOM NUMBER] (three-bed) - total of 216 sq ft (72 sq ft per resident) - room [ROOM NUMBER] (three-bed) - total of 218 sq ft (72.7 sq ft per resident) - room [ROOM NUMBER] (two-bed) - total of 144 sq ft (72 sq ft per resident) - room [ROOM NUMBER] (three-bed) - total of 218 sq ft (72.7 sq ft per resident) - room [ROOM NUMBER] (three-bed) - total of 215 sq ft (71.7 sq ft per resident) - room [ROOM NUMBER] (three-bed) - total of 215 sq ft (71.7 sq ft per resident) - room [ROOM NUMBER] (three-bed) - total of 218 sq ft (72.7 sq ft per resident) - room [ROOM NUMBER] (three-bed) - total of 216 sq ft (72 sq ft per resident) - room [ROOM NUMBER] (three-bed) - total of 221 sq ft (73.7 sq ft per resident) During the survey days from June 9, 2025, to June 12, 2025, observations were made of care provided in rooms with less than 80 sq ft per resident. The room sizes did not appear to limit the provision of care. No negative impacts on the health, safety, and comfort of the residents were observed. Residents interviewed stated they were comfortable in their rooms and had no concerns related to space or privacy. On June 12, 2025, at 12:55 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated some facility rooms were smaller than than the required 80 sq ft per resident. The DON stated there have been no complaints or concerns from staff and residents regarding space and privacy. The DON further stated staff kept the rooms clutter free and did not leave any equipment in residents' rooms. On June 12, 2025, at 1:15 p.m., an interview was conducted with the Administrator (ADM). The ADM stated, per policy, the facility was required to provide at least 80 square feet per resident in multi-resident rooms. The ADM stated there had been no complaints regarding room size or barriers to care provision and that the facility was requesting a continued room waiver for Rooms 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 21, 22, 23, 24, and 25. A review of facility's policy and procedure titled, Room Measurement, dated July 2023, indicated, . it is the policy of this facility to ensure that resident is comfortable with the living space in his/her room .the required room measurement is [sic] least 80 square feet per resident in multiple resident bedrooms and at least 100 square feet in single resident rooms .facility will assess an adverse effect on the resident's health and safety or if it impedes the ability of any resident in that room to attain his or her highest practicable well-being .resident will be offered for [sic] room change if the room size affects resident's comfort level .

Based on interview and record review, the facility failed to ensure an alleged physical abuse was reported to the California Department of Public Health (CDPH) and other officials immediately, but not later than 2 hours after the allegation was made. The facility was made aware of the alleged physical abuse of a facility staff to a resident on August 26, 2024. This failure had the potential to cause a delay in investigation of the alleged abuse and to expose residents in the facility to further abuse. Findings: On August 28, 2024, at 07:05 a.m., an unannounced visit was conducted at the facility to investigate an abuse allegation. On August 28, 2024, Resident 1 ' s record was reviewed. Resident 1 was admitted to the facility on [DATE], with Huntington ' s Disease (a progress disease and results in progressive, involuntary movements, thinking and psychiatric symptoms) and muscular weakness. A review of Resident 1's Minimum Data Set (MDS - an assessment tool) dated July 13,2024, indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a cognitive screening tool) score of 05 (cognitively severely impaired). A review of Resident 1's progress notes dated August 26 and August 27, 2024, indicated no change in physical or behavioral well-being. A review of the progress notes and care plans did not indicate documentation and interventions related to the alleged physical abuse. On August 28, 2024, at 0730 a.m., during a concurrent observation and interview with Certified Nurse (CNA) 3, CNA 3 stated she has not witnessed any verbal or physical abuse of staff or residents in her four years working at the facility. CNA 3 further stated if she did witness any kind of abuse, she would make sure resident is safe and she would report the incident immediately to the licensed nurse. On August 28, 2024, at 07:37 a.m., during a concurrent observation and interview with Resident 2, the roommate of the Resident 1, the resident stated the staff have not verbally or physically mistreated him or any of the roommates. Resident 2 further stated he would have reported immediately because that would be important to him. On August 28, 2024, at 7:50 a.m., during an interview with Resident 1 with a Spanish interpreter, Resident 1 denied being slapped or hit by anyone, by shaking his head. On August 28, 2024, at 8:00 a.m., during a concurrent observation and interview with the RN Supervisor, the RN Supervisor stated she attended several in-services on ABUSE reporting, documentation, and procedures to follow. She stated if there were incidents of a resident to resident or a staff and resident altercations, she would make sure both parties are separated and assessed. In addition, she stated she would immediately notify Administration, the Director of Nursing, physicians, family, the Ombudsman, CDPH and sheriff. The RN Supervisor stated she would document and then update the care plan. On August 28, 2024, at 8:00 a.m., during an interview and concurrent chart review with the Director of Nursing (DON) in the DON ' s office, the DON stated she had the two student nurses and the Director of the Training facility on August 26, 2024, at approximately 1:00 p.m. expressed concerns of a witnessed physical abuse on Resident 1, who was slapped on the leg by CNA 1, when Resident 1 was being transferred to a shower chair. The DON further stated she immediately began an investigation of the alleged abuse, removed the CNA from work and interviewed CNA 1 and CNA 2 (assisting with the resident ' s transfer the time of the incident). The DON stated both the CNAs denied doing or seeing Resident 1 being slapped. CNA 1 explained the method of gentle tapping or patting the extremity to calm the resident ' s chorea movements and when the resident focused on the gentle tapping, the movements lessen. The DON stated CNA 1 was suspended pending investigation. The DON stated that the initial meeting with the students and the staff were also attended by the Social Services Director (SSD) and the Director of Staff Developement (DSD). The DON stated after the investigation of the incident, it was determined that there was a misunderstanding of the calming methods used and CNA 1 was allowed to return to work the next shift, though not to care for Resident 1. The DON further stated the alleged incident was not reported as it was found to be unsubstantiated. On August 28, 2024, at 11:05 a.m., an interview with the SSD to review incident and the meetings that were attended. She stated the student expressed concern of abuse when CNA 1 slapped the leg of Resident 1, and the student explained that Resident 1 was trying to hit and kick the CNA. The SSD stated CNA 2 did not see any slapping and explained the resident has continuous movements because of his disease. The SSD stated CNA 2 further explained CNA 1 was tapping on the resident ' s leg, in a rhythmic way, which usually calms the movements allowing resident to be transferred without injury. The SSD stated the Interdisciplinary Team met after the investigation to review and the team agreed it was unsubstantiated. On August 28, 2024, at 1:15 p.m., an interview with the DON to review and clarify the incident and the outcome of the investigation, the DON stated incident was not sent to CDPH as an investigation was completed in house. The DON stated there was no slapping incident but it was the usual intervention to calm Resident 1, by softly patting or tapping. The DON stated acknowledged the incident should have been reported, even if it was a suspected abuse. The DON also acknowledged even without injury the facility should have reported to CDPH, in accordance with their facility policy, even a suspicion must be reported immediately. A review of the facility ' s policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating. Dated October 2023, indicated, allegations of abuse .are reported to local, state and federal agencies (as required by current regulations) .abuse, neglect .must be immediately reported .state licensing/certification agency .within two hours of any allegation involving abuse .

Based on interview, and record review, the facility failed to review and revise the care plan for one of five residents reviewed (Residents 1) based on the changing needs of the resident who has involuntary twitching and jerking movement related to a disease process. This failure had the potential to result in increased discomfort and possibility of injury to the resident. Findings: On August 28, 2024, at 7:05 a.m., an unannounced visit was conducted at the facility to investigate an abuse allegation. On August 28, 2024, Resident 1 ' s record was reviewed. Resident 1 was admitted to the facility on [DATE], with Huntington ' s Disease (an incurable neurodegenerative disease that is mostly inherited) and muscular weakness. A review of the Minimum Data Set (MDS - an assessment tool) dated July 13, 2024, indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a cognitive screening tool) score of 05 (cognitively severely impaired). The care plan titled, The resident has an alteration in neurological status INVOLUNTARY TWITCHING/JERKING r/t disease process HUNTINGTON ' S CHOREA DZ(diagnosis) . dated 10/03/2022, was reviewed. The care plan goals and interventions were initiated on 10/03/2022. There was no documented evidence the care plan was periodically reviewed and updated to reflect the goals and objectives were met and interventions were effective addressing interventions to assist control resident ' s involuntary movements, related to Huntington ' s Chorea. On August 28, 2024, at 08:00 a.m., during an interview with Registered Nurse (RN) 1, RN 1 stated she was not aware of Resident 1's care plan being revised recently with new goals and interventions for Resident 1 ' s involuntary twitching and jerking related to Huntington ' s Chorea. On August 28, 2024, at 11:05 a.m., during an interview with the Social Services Director (SSD), the SSD stated CNA 1 had been caring for Resident 1 for long time and the method of rhythmic tapping on Resident 1 ' s extremity, seemed to cause movements to lessen. The SSD further stated CNA 2 explained CNA 1 was tapping on the resident ' s leg, in a rhythmic way which would usually calm the movements allowing resident to be transferred without injury. The SSD stated she was unaware if that intervention had been added to Resident 1 ' s care plan. On August 28, 2024, at 1:15 p.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON stated the tapping and gentle patting was not included in Resident 1 ' s care plan as each nurse has different methods. The DON acknowledged the importance of including effective, safe interventions in care plans to allow for person-centered care.

Based on observation, interview and record review, the facility failed to ensure, for one of (Resident A) five residents, residents with a multidrug- resistant organism (MDRO-bacteria and other microorganisms that have developed a resistance to one or more classes of antimicrobial drugs) was placed in a single room or cohorted with other residents with the same MDRO infection, according to the facility's policy and procedure. This failure had the potential to exposed Resident A's two susceptible roommates to acquiring an infection. Findings: On August 5, 2024, at 9 a.m., an unannounced visit was conducted at the facility for the investigations of three complaints. On August 5, 2024, at 10 a.m., two Certified Nursing Assistants (CNAs) were observed caring for a resident in bed one, wearing gloves. A sign outside the room, indicated, Contact Isolation (a set of precautions used in healthcare facilities to prevent the spread of germs from patients with illnesses that can be transmitted through direct or indirect contact). A cart was observed outside of the room, next to the doorway, containing personal protective equipments (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses). On August 5, 2024, at 10:05 a.m., an interview was conducted with the CNA. The CNA stated she did not know why the contact isolation sign was on the door. The CNA stated a contact isolation sign means we are to put on gloves, a gown, and sometimes a mask or shield before caring for a patient. The CNA stated the other staff member said she only needed to wear gloves. The CNA stated only bed three (Resident A) required contact isolation, the residents in bed one and two bed were okay. The CNA stated she did not know why bed three was placed on contact isolation. On August 5, 2024, at 10:10 a.m., an interview was conductedwith the Licensed Vocational Nurse (LVN). The LVN stated she was the charge nurse for Resident A, and Resident A had ESBL(extended spectrum beta-lactamase: a bacteria that is difficult to kill, because it is resistant to many antibiotics) in her urine. The LVN stated it was okay if Resident A stays in the room, Resident A did not need a private room, the ESBL was contained, and Resident A had a catheter (flexible tube inserted into the body) for draining her urine. The LVN stated she did not know when Resident A tested positive for ESBL and did not know if it was an active infection. A review of Resident A's record indicated Resident A was admitted to the facility on [DATE], with diagnoses which included a fractured left femur (broken upper leg), and dementia (a group of thinking and social symptoms, such as memory loss and judgement). Resident A's History and Physical, dated July 10, 2024, indicated Resident A did not have the ability to make decisions. Resident A's urinalysis laboratory result, dated July 30, 2024, indicated positive for ESBL. Resident A's Order Summary Report, included a physician's order, dated August 2, 2024, indicated, Contact Isolation related to ESBL in urine, every shift until August 8, 2024. Resident A's Progress Notes, dated August 3, 2024, at 3:32 a.m., indicated, .continues on contact isolation as ordered . On August 5, 2024, at 6:20 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident A was not provided a single room when the lab results for the urine test showed Resident A had ESBL of urine, because she had a foley catheter that was containing her urine. The DON stated Resident A was placed on contact isolation, and Resident A's roommates stayed in the room with her. The DON stated Resident A was not moved to a single private room. The DON stated Resident A should have been placed in a private room after Resident A's urine test showed she had ESBL. A review of the facility's policy titled Multidrug-Resistant Organisms, dated November 2023, indicated, .Appropriate precautions are taken when caring for individuals known or suspected to have infection with a multidrug-resistant organism .Multidrug-resistant organisms (MDROs) are bacteria and other microorganisms that have developed resistance to one or more classes of antimicrobial drugs. Infection means that the organism is present and is causing illness. Colonization means that the organism is present in or on the body but is not causing illness .strategies are adopted from the Centers for Disease Control and Prevention and provide current recommendations for MDRO prevention and control .recommendations are incorporated into the facility infection prevention and control processes as indicated .Make MDRO prevention/control an organizational priority .implement a multi-disciplinary process to monitor and improve staff adherence to recommended practices for standard and contact precautions .follow standard precautions in all situations .resident's clinical situation and facility resources in deciding whether to implement contact precautions .when single-resident rooms are available, assign priority for these rooms to residents with known or suspected MDRO colonization or infection .when single-resident rooms are not available, cohort residents with the same MDRO in the same room or resident-care area .implement contact precautions routinely for all residents colonized or infected with a target MDRO .

Based on record reviews, interviews, and facility document and policy review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for 1 (Residents #37) of 5 sampled residents reviewed for unnecessary medications and 1 (Resident #17) of 4 sampled residents reviewed for accidents. Specifically, the facility failed to ensure Resident #37's use of psychotropic medications and Resident #17's fall event was accurately coded on their MDS assessments. Findings included: A review of a facility policy titled Resident Assessments, revised in September 2023, revealed, 8. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 9. All resident assessments completed within the previous 15 months are maintained in the resident's active clinical record. The results of the assessments are used to develop, review, and revise the resident's comprehensive care plan. 1. A review of Resident #37's Admission Record indicated the facility admitted the resident on 10/20/2023 with diagnoses that included alcoholic cirrhosis of the liver with ascites (abnormal fluid buildup in the abdominal cavity), mood disorder due to known physiological condition and anxiety disorder. A review of Resident #37's quarterly MDS, with an Assessment Reference Date (ARD) of 01/26/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed active diagnoses that included anxiety disorder, mood disorder due to known physiological condition, and alcoholic cirrhosis of the liver with ascites. Further review revealed the MDS was inaccurately coded to indicate the resident had taken an antipsychotic medication during the seven-day assessment period. The MDS did not include Resident #37's use of antianxiety or hypnotic medication. A review of Resident #37's care plan revealed a Focus area, initiated on 10/20/2023, that indicated the resident used antianxiety medications related to the diagnosis of anxiety disorder. The care plan revealed interventions included staff instructions to administer medication, lorazepam (an antianxiety medication), as ordered. Further review of Resident #37's care plan revealed a Focus area, initiated on 12/20/2023, that indicated the resident had a sleep pattern disturbance. The care plan revealed interventions included staff instructions to administer the medication Ambien (a hypnotic medication used for sleep) to promote sleep. A review of Resident #37's Order Summary Report for active orders as of 04/12/2024 revealed an order dated 12/20/2023 for Ambien 10 milligrams (mg) with instructions to give one tablet by mouth at bedtime and an order dated 12/18/2023 for lorazepam 2 mg with instructions to give one tablet by mouth at bedtime. The Order Summary Report revealed it did not include an order for an antipsychotic medication. A review of the January 2024 Medication Administration Record [MAR] for the timeframe from 01/01/2024 through 01/31/2024 revealed staff documented Resident #37 received Ambien 10 mg every night at 8:00 PM and received lorazepam 2 mg every night at 9:00 PM. The MAR revealed the medications were documented as administered during the quarterly MDS assessment period. The MAR revealed it did not include a transcription of an order for an antipsychotic medication. During an interview on 04/12/2024 at 10:17 AM, the MDS Coordinator stated she got the information for the MDS through interviews, record reviews of the MARs, and treatment administration records (TARs). She stated if the resident was taking the medication during the assessment period, then it should be captured on the MDS and if they were not taking the medication, then it should not be coded. During a follow-up interview on 04/12/2024 at 10:32 AM, the MDS Coordinator confirmed that Resident #37's MDS was coded incorrectly. During an interview on 04/12/2024 at 1:09 PM, the Director of Nursing (DON) stated Resident #37 was on an antipsychotic medication when the resident was admitted , but it had been discontinued. 31524 2. A review of Resident #17's Admission Record revealed the facility originally admitted the resident on 05/06/2019 and readmitted the resident on 10/03/2022. The Admission Record revealed the resident had diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or partial paralysis of one side of the body) following non-traumatic intracerebral hemorrhage (blood pooling in the tissue of the brain) affecting the right dominant side, Huntington's disease, and cognitive communication deficit. A review of Resident #17's quarterly MDS, with an Assessment Reference Date (ARD) of 01/13/2024, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. Per the MDS, Resident #17 had no falls since admission. A review of Resident #17's IDT [Interdisciplinary Team] - Incident Review, dated 11/04/2023, indicated staff found Resident #17 on the floor next to the door of their room, and their bed was in the lowest position at the time. The document indicated that staff assessed the resident and discovered no injuries, assisted the resident back to bed, and applied a bed alarm and bilateral landing pads. During an interview on 04/12/2024 at 10:17 AM, the MDS Coordinator stated she reviewed the resident's medical record over the previous quarter when completing the MDS. The MDS Coordinator further stated that Resident #17's fall in November 2023 should have been captured on the 01/13/2024 assessment, but it was not.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure pressure injury interventions ordered by the physician were implemented for 1 (Resident #12) of 1 sampled resident reviewed for pressure injury prevention. Findings included: A review of a facility policy titled, Prevention of Pressure Injuries, revised in September 2023, revealed, Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. A review of an Admission Record reveled the facility most recently admitted the resident on 06/19/2023 with diagnoses that included type two diabetes mellitus and hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness affecting one side of the body) following cerebral infarction (stroke). A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/23/2024, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. According to the MDS, the resident had no pressure ulcers or injuries at the time of the assessment but was at risk for the development of pressure ulcers or injuries, and treatment included a pressure-reducing device for their bed. A review of Resident #12's Care Plan revealed a Focus area, initiated on 06/19/2023, that indicated the resident was at risk for the development of skin breaks/pressure injury related to decreased mobility, poor safety awareness, and incontinence. A review of Resident #12's Order Summary Report, listing active orders as of 04/11/2024, revealed an order dated 06/19/2023 that directed staff to float the resident's heels off the bed with pillows every shift. An observation on 04/10/2024 at 10:43 AM revealed Resident #12 was in bed with the resident's heels lying against the mattress. An observation on 04/10/2024 at 2:17 PM revealed Resident #12 was in bed asleep. The resident's heels were not floated off the bed with pillows. A concurrent interview and observation with the Treatment Nurse on 04/11/2024 at 3:47 PM in Resident #12's room revealed the resident's heels were not being floated with a pillow as ordered. During a search of Resident #12's room, the Treatment Nurse located a pillow behind the resident's bed. Observation of the resident's heels with the Treatment Nurse revealed no skin breakdown. The Treatment Nurse stated she did not know how long the pillow had not been underneath the resident's heels. During an interview on 04/11/2024 at 4:04 PM, Licensed Vocational Nurse (LVN) #7 stated she had seen Resident #12 earlier in the shift; however, she did not know if the pillow was in place as ordered. During an interview on 04/12/2024 at 7:56 AM, Certified Nurse Aide (CNA) #9 stated a pillow should be placed under Resident #12's feet throughout the day. CNA #9 confirmed she had not seen the pillow underneath the heels of Resident #12. During an interview on 04/12/2024 at 1:39 PM, the Director of Nursing (DON) stated Resident #12 should have their heels offloaded, using a pillow and that the nurses should have been checking to ensure the pillow remained in place. During an interview on 04/12/2024 at 2:06 PM, the Administrator stated facility staff should follow the physician's orders.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure the medication error rate was less than 5 percent (%). The facility had 2 medication errors out of 36 opportunities, affecting 1 (Resident #19) of 9 residents reviewed during the medication administration task, resulting in a medication error rate of 5.56%. Findings included: A review of a facility policy titled, Administering Medications, revised in April 2023, revealed, 4. Medications are administered in accordance with prescriber orders, including any required time frame. The policy further indicated, 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. A review of an Admission Record revealed the facility admitted Resident #19 on 03/13/2020 with diagnoses that included hypertension (high blood pressure). A review of Resident #19's Order Summary Report, listing active orders as of 04/12/2024, revealed an order dated 11/29/2022 for amlodipine 5 milligrams (mg) with instructions to administer one tablet by mouth two times a day and to hold the medication if the resident's systolic blood pressure (maximum blood pressure during contraction of heart ventricles, the top number on a blood pressure reading) was less than 110 or their heart rate was less than 60 beats per minute. The Order Summary Report also reflected an order dated 10/30/2023 for MiraLAX powder (laxative) with instructions to give 17 grams by mouth two times a day mixed with 120 milliliters (mL) of water. Observations on 04/11/2024 at 4:21 PM revealed Licensed Vocational Nurse (LVN) #3 entered Resident #19's room and obtained their blood pressure and heart rate. The resident's heart rate was 57 beats per minute. LVN #3 then administered the resident's amlodipine, despite having a physician's order that specified to hold the medication if the resident's heart rate was less than 60 beats per minute. At 4:38 PM, LVN #3 administered the resident's MiraLAX powder with 120 mL of cranberry juice. The MiraLAX powder was not completely dissolved, and after the resident drank the juice, medication remained in the bottom of the cup. During an interview on 04/11/2024 at 4:56 PM, LVN #3 stated she should have held the amlodipine due to the resident's heart rate. LVN #3 stated Resident #19's heart rate was frequently in the 50s, so she thought it would be okay. LVN #3 also stated she should have ensured the MiraLAX powder was completely dissolved before administering it to the resident. LVN #3 said she noticed halfway through the resident drinking the MiraLAX, that it was not all mixed, and she did not know what to do at that point She stated by not mixing it thoroughly, the resident did not get the full dose of the medication. During an interview on 04/12/2024 at 1:09 PM, the Director of Nursing (DON) stated if a resident's vital signs were outside of parameters in which an order specified to hold a medication, then the nurse should hold the medication. During an interview on 04/12/2024 at 1:29 PM, the Administrator stated he expected medications to be given according to physician's orders and professional standards.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure no significant medication errors occurred for 1 (Resident #19) of 9 residents reviewed during the medication administration task. Specifically, staff failed to hold Resident #19's amlodipine when the resident's heart rate was outside the parameters specified by the physician's order. Findings included: A review of a facility policy titled, Administering Medications, revised in April 2023, revealed, 4. Medications are administered in accordance with prescriber order, including any required time frame. The policy further indicated, 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. A review of an Admission Record revealed the facility admitted Resident #19 on 03/13/2020 with diagnoses that included hypertension (high blood pressure). A review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/10/2024, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated Resident #19 had active diagnoses that included hypertension. A review of Resident #19's Care Plan revealed a Focus area, initiated on 03/13/2020, that indicated the resident was at risk for decreased cardiac output secondary to hypertension. Interventions directed staff to monitor the resident's blood pressure as ordered and notify the physician if out of designated parameters. A review of Resident #19's Order Summary Report, listing active orders as of 04/12/2024, revealed an order dated 11/29/2022 for amlodipine 5 milligrams (mg) with instructions to administer one tablet by mouth two times a day and to hold the medication if the resident's systolic blood pressure (maximum blood pressure during contraction of heart ventricles, the top number on a blood pressure reading) was less than 110 or their heart rate was less than 60 beats per minute. Observation on 04/11/2024 at 4:21 PM revealed Licensed Vocational Nurse (LVN) #3 entered Resident #19's room and obtained the resident's blood pressure and heart rate. The resident's heart rate was 57 beats per minute. LVN #3 then administered the resident's amlodipine, despite having a physician's order that specified to hold the medication if the resident's heart rate was less than 60 beats per minute. During an interview on 04/11/2024 at 4:56 PM, LVN #3 stated she should have held the amlodipine due to the resident's heart rate. LVN #3 stated Resident #19's heart rate was frequently in the 50s, so she thought it would be okay. A review of Resident #19's February 2024 Medication Administration Record (MAR) revealed documentation that indicated LVN #3 also administered amlodipine to the resident on 02/06/2024 at 5:00 PM with a documented heart rate of 56, on 02/26/2024 at 5:00 PM with a documented heart rate of 56, and on 02/27/2024 at 5:00 PM with a documented heart rate of 56. A review of Resident #19's April 2024 MAR revealed documentation that indicated LVN #3 also administered amlodipine to the resident on 04/03/2024 at 5:00 PM with a documented heart rate of 58. During an interview on 04/12/2024 at 3:48 PM, the Physician Assistant stated if amlodipine were given when the heart rate was less than 60 it could cause the heart rate to drop into the 40s and could be detrimental to the resident. He stated amlodipine was a cardiac medication, not just a blood pressure medication. He stated he had not been notified of the resident's heart rate being low and he stated the medication should not have been given if the heart rate was less than 60. During an interview on 04/12/2024 at 1:09 PM the Director of Nursing (DON) stated if a resident's vital signs were outside of parameters in which an order specified to hold a medication, then the nurse should hold the medication. During an interview on 04/12/2024 at 1:29 PM, the Administrator stated he expected medications to be given according to physician's orders and professional standards.