Every finding on record at Visalia Post Acute

Based on interview and record review, the facility failed to ensure its policy and procedure (P&P) was followed when the physician was not notified when a urine culture and sensitivity (C&S-culture and sensitivity-used to identify the specific germ causing an infection and to determine which specific medicine or antibiotic will work best to kill it) result indicated one of three sampled residents (Resident 1) was being treated with an ineffective antibiotic. This failure had the potential to result in Resident 1 experiencing a prolonged and unresolved infection. Findings:During a review of Resident 1's Lab Report (LR) dated 7/29/26, the LR indicated, Urine Culture.susceptibility results. Stenotrophomonas maltophilia (bacteria infection).Antibiotic.levofloxacin (best to kill bacteria infection).During a review of Resident 1's Order Summary Report (OSR) dated 7/1/26-8/31/26, the OSR indicated, Cephalexin (antibiotic) tablet 500 mg (milligrams) give 1 capsule by mouth every 12 hours for UTI (Urinary Tract Infection) for 10 days.start date 8/3/26.During a review of Resident 1's PN dated 8/9/26 at 2:23 p.m., the PN indicated, Resident is currently on ABT (antibiotic-cephalexin) r/t (related to) UTI (urinary tract infection), no s/s (signs and symptoms) of a/r (adverse reaction) or sensitivity to ABT, resident stated that the medication does not seem to be working and she is having pain in her bladder, abdmennon [sic] distended.During an interview on 8/10/26 at 2:06 p.m. with IP, IP stated when the 7/29/26 C&S came back with the results, Resident 1 was not susceptible to the Cephalexin antibiotic that was ordered by the physician. IP stated the physician was not notified of the discrepancy and per policy he should have been. During an interview on 8/10/26 at 3 p.m. with Director of Nursing (DON), DON stated the physician should have been notified when Resident 1 was not susceptible to the Cephalexin antibiotic prescribed.During a review of the facility's policy and procedure titled, Antibiotic Stewardship dated December 2016, the P&P indicated, When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.

Based on interview and record review, the facility failed to implement one of three sampled residents (Resident 1) care plan when Resident 1's physician was not notified of Resident 1's episodes of aggression (behavior intended to cause harm can be physical actions or verbal attacks). This failure resulted in a delay of physician notification placing Resident 1 and other residents at risk for continued aggressive behavior.Findings:During a review of Resident 1's Care Plan Report (CPR), dated [DATE], the CPR indicated, Psychosocial-Behavior: Exhibits or is at risk for behavioral symptoms. verbally aggressive towards staff and peers. physical aggression towards staff and peers.GOAL.Will have needs met. Will not harm self-and/or others secondary to socially inappropriate and/or disruptive combative behavior. INTERVENTIONS . Document and record behavioral episodes.Notify physician. of episodes of aggression & abusive behaviors.During a concurrent interview and record review on [DATE] at 1:51 p.m. with Director of Nursing (DON), Resident 1's Psychosocial-Behavior care plan dated [DATE] was reviewed. The DON stated, if a care plan indicates physician notification, then nursing staff needs to notify the physician because it's our intervention.During a review of Resident 1's Psychotropic MAR [Medication Administration Record] (BEHAVIOR AND SE MONITORS ONLY)(PMAR), dated [DATE] through [DATE], the PMAR indicated, Monitor episodes of verbal aggression manifested by cussing or yelling at other residents q [every] shift. The PMAR indicated Resident 1 had verbal episodes on the following dates: 2 verbal episodes on [DATE] verbal episode on [DATE] verbal episodes on [DATE] verbal episodes on [DATE] verbal episodes on [DATE] verbal episodes on [DATE] verbal episode on [DATE] verbal episode on [DATE] verbal episode on [DATE] verbal episodes on [DATE] verbal episodes on [DATE] verbal episodes on [DATE] During a review of Resident 1's Progress Notes (PN) dated [DATE] through [DATE], the PN indicated there was no documentation of physician notification when Resident 1 had episodes of verbal aggression on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. During a concurrent interview and record review on [DATE] at 10:03 a.m. with DON, DON reviewed Resident 1's PN dated [DATE] through [DATE]. DON confirmed there was no documented evidence of a physician notification when Resident 1 had verbal episodes on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. DON stated, there should be documented evidence. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated [DATE], the P&P indicated, Policy Interpretation and Implementation.4. Each resident's comprehensive person-centered care plan is consistent with the resident's right to participate in the development and implementation of his or her plan of care, including the right to.g. receive the services and/or items included in the plan of care.7. The comprehensive, person-centered care plan.b. describes 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, Change in a Resident's Condition or Status, dated February 2021, the P&P indicated, Policy Interpretation and Implementation 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an).i. specific instruction to notify the physician of changes in the resident's condition.

Based on observation, interview, and record review the facility failed to implement one of three sampled residents (Resident 1) comprehensive care plan when no documentation was completed for Resident 1 with a known behavior of manipulating and pulling dialysis catheter (a tube placed into a large vein to access the bloodstream to filter toxins from the blood). This failure had the potential for inconsistent care and severe infection to Resident 1's dialysis site. Findings:During an observation on [DATE] at 12:42 p.m. in Resident 1's room, Resident 1 was sitting in a wheelchair grabbing at dialysis catheter. During an interview on [DATE] at 12:42 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1 scratches at her dialysis catheter and kind of tugs on it too.During an interview on [DATE] at 1:15 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated She [Resident 1] pulls at her [dialysis] catheter. She scratches at them [dialysis catheter].During an interview on [DATE] at 2:08 p.m. with Director of Nursing (DON), DON stated, She [Resident 1] has a tendency to fiddle and scratch at it [ dialysis catheter]. DON stated, There should be documentation of it [when Resident 1 pulls at catheter].During a concurrent interview and record review on [DATE] at 1:44 p.m. with DON, Resident 1's Order Summary Report (OSR), dated [DATE] was reviewed. DON stated that the OSR indicated there were no orders to monitor Resident 1's behavior of pulling at the catheter. DON stated, There are no monitor orders for [Resident 1's] behaviors [pulling at catheter] and staff did not document. DON stated Resident 1's behaviors of rubbing and pulling dialysis catheter should be monitored and documented. During a review of Resident 1's Brief Interview for Mental Status (BIMS) [an assessment tool used by facilities to screen and identify memory, orientation and judgment status of the resident] dated [DATE], the BIMS indicated Resident 1 had a BIMS score of 11 (8-12 moderate impairment [mild to moderate memory issues]).During a review of Resident 1's CPR dated [DATE], the CPR indicated, Psychosocial- Behavior .Rubs and pulls at dialysis access sites . GOALS Will have needs met. Interventions/Task Document and record behavioral episodes.During a review of the facility policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated [DATE], the P&P indicated, Policy Interpretation and Implementation .4. Each resident's comprehensive person-centered care plan is consistent with the resident's right to participate in the development and implementation of his or her plan of care, including the right to. g. receive the service and/or items included in the plan of care . 7. The comprehensive, person-centered care plan. b. describes 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 ensure the care plan was implemented after a resident to resident altercation for two of three sampled residents (Resident 1, Resident 2). This failure had the potential for the staff to be unaware of an ongoing infection and the potential for further incidents.Findings:During a review of Resident 1's Progress Notes (PN) dated 6/22/26, the PN indicated, IDT (Interdisciplinary Team-coordinated group of medical and support professionals who collaborate to evaluate, plan, and deliver patient care.this writer observed (Resident 2) attempting to maneuver his wheelchair around (Resident 1) wheelchair. (Resident 2) then began ramming his wheelchair in (Resident 1) with his wheelchair. This writer immediately called out to direct (Resident 1) to stop. Despite repeated verbal redirection, (Resident 1) made physical contact with (Resident 2) striking him on the right shoulder.Interventions.order Labs/UA (urine analysis).During a review of Resident 1's Care Plan (CP) dated 6/15/26, the CP indicated, Resident was in a resident to resident altercation with no injury.Interventions.Order Labs/UA for resident.Date initiated.6/15/26.During a review of Resident 2's PN dated 6/22/26, the PN indicated, (Resident 2) had displayed verbal aggression with female patients'.in the activity room. Per CNA on duty, this resident went up to patient while stating to them Do not touch female patient., if I see you touch her, I will hit you b******.Interventions.Order Labs/UA for resident.During a review of Resident 2's CP dated 6/20/26, the CP indicated, Resident was the aggressor in a verbal resident-to-resident altercation.Date initiated: 6/20/26.Interventions.Order Labs/UA for resident.Date Initiated.6/22/26.During a concurrent interview and record review on 6/26/26 at 12:59 p.m. with the Assistant Director of Nurses (ADON), ADON reviewed Resident 1 and Resident 2's clinical record. ADON was unable to provide evidence that the care plan was implemented when the UA's were not done for Resident 1 and Resident 2. ADON stated the urine analysis was not done for Resident 1 and Resident 2 and it should have been completed.During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered dated 3/22, the P&P indicated, the comprehensive, person-centered care plan.describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-bind.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.The interdisciplinary team reviews and updates the care plan.when there has been a significant change in the resident's condition.

Based on interview and record review, the facility failed to ensure physician orders were implemented for one of three sampled residents (Resident 1) when wound care was not initiated upon return from the hospital. This failure resulted in a delay of care to Resident 1's cellulitis (serious bacterial infection affecting the deep layers of the skin and the underlying tissues).Findings:During an interview on 6/9/26 at 11:56 a.m. with Resident 1, Resident 1 stated she was hospitalized with a foot infection and when she returned from the hospital on 5/30/26, she was not receiving wound care.During a review of Resident 1's Long Term Documentation (LTD-discharge orders from the hospital) dated 5/30/26 at 4:38 p.m., the LTC indicated, Diagnoses.Cellulitis of toe of left foot.Assessment/Plan.left toe cellulitis.Wound care.During a review of Resident 1's Admission/readmission Evaluation/Assessment (AREA-completed by the admitting nurse at the facility) dated 5/30/26 at 9:09 p.m., the AREA indicated Skin Evaluation.left toes 2nd and 3rd toes black color. Resident has wounds or skin concerns present on admission.yes.left toes black discoloration.Summary Note.left foot 2nd and 3rd toes black, no surgical intervention was made and no treatment ordered.During a concurrent interview and record review on 6/9/26 at 2:10 p.m. with Assistant Director of Nursing (ADON), Resident 1's clinical record was reviewed. There were no wound treatments provided to Resident 1's left toes until 6/4/26 (4 days after returning from the hospital). ADON stated upon Resident 1 return from the hospital on 5/30/26 the physician should have been contacted and treatment orders obtained.During a review of the facility's policy and procedure (P&P) titled admission Assessment and Follow Up: Role of the Nurse dated 9/12, the P&P indicated, Conduct a physical assessment, including the following systems.skin.contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings.

Based on observation, interview, and record review, the facility failed to follow its own policy and procedure (P&P) titled, Safety and Supervision of Residents for one of two sampled residents (Resident 1) when Resident 1 was outside the patio area without supervision. This failure resulted in Resident 1 having unwitnessed fall, sustaining a fracture (broken bone) to the right humerus (long bone of the upper arm).FindingsDuring a review of Resident 1's admission Record (AR), dated [DATE], the AR indicated, Resident 1 is [AGE] years old, was admitted on [DATE] with diagnoses of muscle weakness, Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), unsteadiness on feet, difficulty in walking, dizziness, and history of falling.During a review of Resident 1's quarterly Minimum Data Set (MDS-a federally mandated resident assessment tool), dated [DATE], the MDS indicated Resident 1 had a BIMS (Brief Interview for Metal Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 3 (0-7 severely impaired [decline in one or more mental abilities that affects a person's daily functioning]). During a review of Resident 1's Fall Risk Observation/Assessment (FROA-an assessment tool used to identify the likelihood of falling) dated [DATE], the FROA indicated, Score 18 [score of 16-42 means high risk for falls].During a review of Resident 1's Care Plan Report (CPR), dated [DATE], the CPR indicated, Resident 1 was at risk for falls.During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated [DATE], the SBAR indicated, resident (Resident 1) found laying [sic] face down on pavement, responsive, noted to scattered abrasion underneath chin with controlled bleeding, c/o (complaint of) loss of sensation to RUE (right upper extremity) note to arm in free hanging motion unable to lift extremity.During a review of Resident 1's hospital right shoulder x-ray (medical imaging technique that uses radiation to create a picture of the inside of the body) report dated [DATE], the x-ray result indicated Resident 1 had a comminuted (bone is broken or shattered into three or more pieces) displaced (moved out of its normal alignment) proximal (close to) humeral (long bone in the upper arm) fracture (broken bone).During a review of the facility Follow Up Report dated [DATE], the report indicated, Resident 1 had an unwitnessed fall on the outside patio area.later received from (hospital name) who reported imaging (x-ray) of the right upper extremity showed. fracture to the upper humerus.During an observation on [DATE] at 10:13 a.m. in Resident 1's room, Resident 1 was sitting on the side of the bed. Resident 1's right arm was swollen and purple, wrapped in a sling (medical device to protect and keep arm from moving). During an interview on [DATE] at 10:22 a.m. with Patio Aide (PA) 1, PA 1 stated, it was his responsibility to keep an eye and supervise all residents while outside in the patio area. PA 1 stated, on [DATE] his shift ended at 7 p.m. and left the patio area at 6:48 p.m. PA 1 stated he was not aware Resident 1 was still outside the patio area unsupervised. During an interview on [DATE] at 10:36 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated all residents require supervision when outside the patio area. LVN 1 stated no residents, including Resident 1, were allowed to go outside the patio area when there was no patio aide present. During an interview on [DATE] at 10:55 a.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 1 was not ok to be outside the patio area without supervision. During an interview on [DATE] at 1:24 p.m. with Director of Nursing (DON), DON stated Resident 1 had an unwitnessed fall outside the patio area on [DATE]. DON stated there were no staff present outside the patio area when Resident 1 fell on [DATE] at 6:48 p.m. During an interview on [DATE] at 1:47 p.m. with Administrator, Administrator stated, patio aide's shift was over at 7:00 p.m. and should remain in the patio area until end of shift. Administrator stated residents, including Resident 1, should not be outside the patio area unsupervised. During an interview on [DATE] at 2:01 p.m. with Activities Director (AD), AD stated, PA's responsibilities are to keep residents safe and prevent falls. AD stated, patio area is open until 7:00 p.m. and PA's end of shift is 7:00 p.m. AD stated, I know they (PA) leave early sometimes and they're not supposed to. During a review of the facility's patio aide job description titled, Patio Aide- Memory Lane (PAML) undated, the PAML indicated, Monitor/Assist residents in patio area.During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents dated 7/2017, the P&P indicated, Individualized, Resident-Centered Approach to Safety 3. The care team shall target interventions to reduce individual risk related to hazards in the environment, including adequate supervision. Systems Approach to Safety 2. Resident supervision is a core component of the systems approach to safety.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a physician's order for the use of side rails (a safety device or structural support installed on beds, to prevent fall, assist with repositioning, and provide stability when getting in and out of bed). This failure had the potential for inappropriate use of side rails and potential for injury.Findings:During an observation on 5/4/26 at 9:58 a.m. in Resident 1's room, Resident 1 was lying in bed with side rails positioned up on both sides at the head of the bed.During a concurrent interview and record review on 5/4/26 at 11:57 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Order Summary Report (OSR), dated 5/4/26 was reviewed. LVN 1 was not able to find a physician order for Resident 1's side rails. LVN 1 stated Resident 1's side rails should have a physician's order. During an interview on 5/4/26 at 12:05 p.m. with Director of Nursing (DON), DON stated side rails need a physician's order.During a review with of the facility's policy and procedure (P&P) titled, Bed Safety and bed Rails dated August 20, 2022, the P&P indicated, 5. If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of be rails. The interdisciplinary evaluation includes d. consultation with the attending physician.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) needs were met when the bed was not long enough. This failure resulted in Resident 2 being uncomfortable due to not being able to extend his legs while in bed. Findings:During a concurrent observation and interview on 5/4/26 at 11:03 a.m. with Resident 2, in Resident 2's room, Resident 2 was lying on the bed. Resident 2's head of bed was elevated, his knees were bent and his feet were flat against the foot board of the bed. Resident 2 stated he slept squished up and with his knees bent because the bed was not long enough and he was uncomfortable. Resident 2 stated he had told several staff that the bed was too short but was told the facility did not have longer beds.During a concurrent observation and interview on 5/4/26 at 1:15 p.m. with Assistant Director of Nursing (ADON), in Resident 2's room, ADON stated she could see where the bed needed to be longer for Resident 2.During an interview on 5/4/26 at 1:38 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated when she cared for Resident 2, when he was first admitted (3/15/26), Resident 2 told her that his feet were always hitting the bottom of the bed. CNA 1 stated when Resident 2 told her that she should have put it in the maintenance log or told the nurse. CNA 1 stated she thought the issue would have been resolved by now.During a concurrent interview and record review, on 5/4/26 at 1:54 p.m. with Maintenance (MT), station 2's maintenance logs dated March and April 2026 were reviewed. There was no documentation of Resident 2's bed being too short on the log. MT stated he was unaware of Resident 1's bed being too short.During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs dated 3/21, the P&P indicated, The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis.In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility.providing a variety of types.sizes (height and depth), and firmness of furniture in rooms and common areas.

Based on observation, interview, and record review, the facility failed to ensure their policy and procedure was followed when medications were left at the bedside for one of three sampled residents (Resident 1). This failure had the potential for the staff to be unaware if the medication was taken by Resident 1and put other residents at risk for ingesting the medication and experiencing an adverse reaction.Findings:During a concurrent observation and interview on 5/4/26 at 10:12 a.m. with Resident 1, in Resident 1's room, Resident 1 was sitting at the end of her bed in her wheelchair with the over bed table next to her. There was a medicine cup on the over bed table that contained six pills. Resident 1 stated the nurse left the medications on her table so she could take them after she ate her breakfast. During a concurrent observation and interview on 5/4/26 at 10:36 a.m. with Registered Nurse (RN) 1, in Resident 1's room, RN 1 confirmed she was the nurse for Resident 1. RN 1 stated she left the medications on the table for Resident 1 because Resident 1 wanted to take her medications after she ate her breakfast. RN 1 stated the medicine cup contained atenolol (medications used to treat high blood pressure), cranberry capsule (supplement used to promote urinary health), iron tablet (supplement used to treat low blood count), stool softener (used to make stool easier to pass), Vitamin C (supplement), and magnesium (supplement). RN 1 stated the medications should not have been left on the table.During an interview on 5/4/26 at 12:33 p.m. with Assistant Director of Nursing (ADON), ADON stated Resident 1 did not have an assessment for self-administration of medications and the medications should not have been left on Resident 1's table.During a review of the facility's policy and procedure (P&P) titled, Administering Oral Medications dated 10/10, the P&P indicated, Remain with the resident until all medications have been taken.

Based on interview and record review, the facility failed to ensure an effective grievance process for three of 33 sampled Residents (Residents 122, 66, and 120), when: 1.Resident 122 was not aware of the facility's response to her grievance related to visiting her friend in the facility and expressed she continued to have issues visiting her friend. 2. Resident 66 reported missing clothes to Social Services Assistant (SSA) six months ago and no action was taken.3. Resident 120 requested assistance from SSA regarding scheduling surgery since admission. These failures had the potential to result in violation of resident's right to voice grievances, feel unheard and/or feel unsupported, and the lack of a functional grievance process left residents' concerns unaddressed. Findings: 1.Resident 122 was admitted on [DATE], with diagnoses which included weakness and unsteadiness on feet. During an interview with Resident 122 on 3/5/26 at 8:14 AM, Resident 122 stated she had an issue with staff and filed a grievance. Resident 122 stated she wanted to visit her friend who lived at the facility and a staff member would not allow her to visit her friend's room. Resident 122 was asked if they have heard anything back about her issue and stated, I never heard anything else about it. Resident 122 further stated, They are keeping me from [friend]. I have to visit her when I see her in the dining room. Resident stated she is still not able to visit her friend in her friend's room. During an interview with the Social Services Assistant (SSA) on 3/5/26 at 4 PM, SSA stated Resident 122 reported a staff member would not allow her to enter her friend's room. SSA stated, We spoke with the staff and then informed the resident, she was ok with the outcome. During an interview with Social Services Director (SSD) on 3/5/26 at 4 PM, SSD stated We did not give Resident 122 anything in writing. SSD further stated she was unaware a written response was required. During a record review of grievances log on 3/4/26 at 12 PM, the log indicated Resident 122 reported a grievance on 1/12/26. There was no documentation which indicated Resident 122 received a written response to her grievance including what the grievance was about, the actions taken by the facility, a conclusion, the remedies the facility took to resolve, or the date a written response was sent to resident or responsible party. During a review of the facility policy titled, Grievances/Complaints, Filing revised April 2017, the policy indicated, The resident, or the person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems.A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office. 2. During a review of Resident 66's admission Record (AR) from 5/2/25 shows that Resident66 was first admitted to the facility on [DATE] and then re-admitted on [DATE]. During a review of Resident 66's Quarterly MDS/CAA (Minimum Data Set/Care Area Assessment: a comprehensive and mandatory nursing home assessment process utilized to evaluate a resident's functional, medical, and psychosocial status) dated 1/22/26, indicated that the Brief Interview for Mental Status (BIMS: a standardized 15-point screening tool primarily used to assess cognitive function) for Resident 66 was scored at 15. During an interview on 3/5/26 at 2:58 PM with Resident 66, Resident 66 stated he spoke to Social Services Assistant (SSA) half a dozen times regarding missing clothes for six months. Resident 66 also stated he spoke with SSA last week and asked to get his belonging inventory list, but request was not fulfilled. During an interview on 3/5/26 at 3:04 PM with Housekeeping Director (HD), HD stated when a resident complains of missing clothes, she asks social services or nurses for the copy of the belongings inventory or description of the clothes so she can start looking. HD also stated she recalled Resident 66 reporting multiple times about missing clothes within the last four months. During a review of Resident Grievance/Complaint Log, dated March 2025 to March 2026, the grievance log did not indicate Resident 66's complaint about missing clothes. During an interview on 3/5/26 at 4:09 PM with SSA, SSA stated Resident 66 informed her about six weeks ago regarding missing clothes. SSA stated she provided the belongings inventory to HD and they found the clothes. SSA stated she should have written down the complaints about Resident 66's missing clothes in the Grievance Log even though the clothes were found. SSA also stated residents do not receive a written record of the result of the investigation of the grievances. During an interview on 3/5/26 at 4:01 PM with Social Services Director (SSD), SSD stated staff usually notify Social Services Department if there were any grievance reported to them by the residents. SSD reported receiving only three grievances from March 2025 to March 2026. They log complaints as grievances only when residents label them as such; other complaints are addressed immediately but not recorded in the grievance log. During a review of the facility policy and procedure (P&P) titled, Grievances/Complaints, Filing dated April 2017, the P&P indicated, Residents . have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident. 1. Any resident . may file a grievance or complaint concerning care, treatment . staff members, theft of property, or any other concerns regarding his or her stay at the facility. 2. Residents . have the right to voice or file grievances. 3. All grievances, complaints or recommendations stemming from resident . concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. 7. The administrator has delegated the responsibility of grievance and/or complaint investigation to the grievance officer who is Social Services Department. 8. Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator withing five (5) working days of receiving the grievance and/or complaint. 3. During a review of Resident 120's admission Record, from 10/22/24 shows that Resident 120 was first admitted to the facility on [DATE] and then re-admitted on [DATE] with diagnosis including spinal stenosis (narrowing of the spinal canal) of the neck and upper back area. During a review of Resident 120's Quarterly MDS/CAA: (a comprehensive and mandatory nursing home assessment process utilized to evaluate a resident's functional, medical, and psychosocial status) dated 2/12/26, indicated that the Brief Interview for Mental Status (BIMS: a standardized 15-point screening tool primarily used to assess cognitive function) for Resident 120 was scored at 15. During an interview on 3/5/26 at 3:38 PM with Resident 120, Resident 120 stated she spoke with Social Services Assistant (SSA) about getting assistance with scheduling neck surgery since she was admitted on [DATE]. Resident 120 also stated the surgery was not something she could schedule herself and asked the assistance from Social Services Department multiple times but gave up asking because social services did not follow through.

Based on interview and record review, the facility failed to ensure the Social Services Director and Social Services Assistant met the qualification requirements as stipulated by the regulation. This failure had the potential to result in misidentification or mishandling of residents' cases which can lead to poor interventions and lack of support for all residents.Findings: During an interview on 3/4/26 at 2:37 PM with Social Services Director (SSD), SSD stated she had15 years of social service experience but no degree, just high school diploma. SSD stated she worked full time and oversees the facility's social services department. During a concurrent interview and record review on 3/5/26 at 11:09 AM with the Director of Staff Development (DSD), SSD's Employee File was reviewed. The file indicated SSD has a high school diploma. DSD stated SSD had a performance evaluation completed by the Facility Administrator on 6/2/25. During a concurrent interview and record review on 3/5/26 at 11:03 AM with the Human Resources Director (HRD), SSD's Position History was reviewed. The history indicated SSD started the social services director role on 6/6/11. HRD stated that SSD had not held any other positions since then. During a review of Job Description: Social Services Director, dated February 2024, the job description indicated, Qualification Education and/or Experience Bachelor's Degree in Social Work or in Human Services and 2 years of supervised social work experience . MSW 's (Master's of Social Work) preferred. During an interview on 3/4/26 at 2:39 PM with Social Services Assistant (SSA), SSA stated she had no degree, just a high school diploma. SSA stated she started as full-time SSA around 2023. During a concurrent interview and record review on 3/5/26 at 10:56 AM with the DSD, SSA's Employee File was reviewed. The file indicated SSA had a high school diploma. DSD stated SSA was originally hired at the facility on 3/8/17 for a different position. During a concurrent interview and record review on 3/5/26 at 11:03 AM with the HRD, SSA's Position History was reviewed. The history indicated SSA started the social services assistant role on 10/15/23. During a review of Job Description: Social Services Assistant, dated November 2016, the job description indicated, Qualification Education and/or Experience Bachelor's Degree in Social Work or related major and 1 year of supervised social work experience . During an interview on 3/4/26 at 2:49 PM with the Facility Administrator, the administrator stated she was aware of the requirements of social services to have a minimum of bachelor's degree in social services or related field. The administrator stated that neither the SSD nor the SSA had a bachelor's degree. During a review of Facility Assessment Tool, dated June 2025 through December 2025, the tool indicated, Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies . Social Services Department - Social Services Director and Assistant (Discharge Planning, Grievances, and Psychosocial needs) . Education Required for the position . Social Services Director: The individual must have a bachelor's degree in social work or other related field from an accredited school with experience in SNF's.

Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program (the facility's program for identifying problems and improving resident care) addressed concerns related to social services staffing qualifications, including the lack of a qualified Social Services Director (SSD) and Social Services Assistant (SSA), as part of the facility's ongoing assessment and performance improvement activities. The QAPI program failed to identify and address this concern.This failure had the potential to limit the facility's ability to identify and address systemic issues (problems that affect more than one resident or area of the facility) related to psychosocial services (services that support residents' emotional and social needs), discharge planning, and resident support services, potentially impacting the quality of care and services provided to residents.During an interview on 3/4/26 at 2:39 PM with Social Services Assistant (SSA), SSA stated she had no degree, just a high school diploma. SSA stated she started as full-time SSA around 2023. During a concurrent interview and record review on 3/5/26 at 10:56 AM with the DSD, SSA's Employee File was reviewed. The file indicated SSA had a high school diploma. DSD stated SSA was originally hired at the facility on 3/8/17 for a different position. During a concurrent interview and record review on 3/5/26 at 11:03 AM with the Human Resources Director(HRD), SSA's Position History was reviewed. The history indicated SSA started the social services assistant role on 10/15/23.During an interview on 3/4/26 at 2:49 PM with the Facility Administrator (Adm), the Adm stated she was aware of the requirements of social services to have a minimum of bachelor's degree in social services or related field. During a review of Job Description: Social Services Assistant, dated November 2016, the job description indicated, Qualification Education and/or Experience bachelor's degree in social work or related major and 1 year of supervised social work experience .During a record review of the facility document titled Quality Assurance Performance Improvement Plan the plan indicated, .QAPI is integrated into the responsibilities and accountability of all facility leadership. However, the issue of the SSD and SSA not meeting the regulatory required qualifications had not been identified or addressed through the facility's QAPI program.During an interview on 03/06/26 at 9:15 AM with the Adm, the Adm was asked whether the issue of the Social Services Director and the Social Services Assistant qualifications had been addressed through the facility's QAPI program. The Adm confirmed the issue had not previously been addressed.

Based on interview and record review, the facility failed to implement and maintain an effective Quality Assurance and Performance Improvement (QAPI) program (the facility's program for identifying problems and improving resident care) to ensure resident and family complaints were consistently identified, documented, tracked, and analyzed through the QAPI process.This failure had the potential to prevent the facility from identifying systemic issues (problems that affect more than one resident or area of the facility), implementing corrective actions, and improving the quality of care and services provided to residents.On 03/04/2026 at 12:00 PM during a reviewed Facility Grievance Log there were only three grievances listed since March 2025. The log did not indicate what the grievance was about, the actions taken by the facility to investigate, a conclusion, the remedies the facility took to resolve the grievance, nor the date a written response was sent to the resident or representative. On 03/05/26 at 4:00 PM, during an interview with the Grievance Committee consisting of the Administrator (Adm), Social Service Director (SSD) and the Social Services Assistant (SSA), the SSD stated complaints were not the same as grievances and stated, I don't put all complaints on the grievance log. The SSD stated the facility maintained a theft and loss log to track missing items, but those complaints are not considered grievances. The SSD further stated complaints, theft, or lost property complaints were not processed as grievances. It's always been like that since I've been here.On 03/06/26 at 9:15 AM, during an interview with the Administrator (Adm), the Adm confirmed that not all complaints were documented on the grievance log. The Adm acknowledged that complaints and grievances are the same. The Adm stated, To be quite honest, if they state that they want to file a formal grievance, that's when we actually put it on the grievance log and complete the paperwork for a formal grievance.The Adm further acknowledged that other complaints may or may not be documented. The Administrator stated, When a resident or family member has a complaint, they don't all get documented. Some of it gets documented in the resident's chart in the progress notes, but some of it doesn't.The Adm also indicated there was not a consistent process guiding documentation of complaints. The Adm stated, There's no real guideline as to what gets documented and what doesn't. It kind of depends on how quickly we're able to resolve it.A review of the facility's QAPI Plan dated June 2, 2025, IV. Feedback, Data System and Monitoring section b, indicated, The following data is monitored through QAPI.v. Complaints/Grievances.

Based on observation, interview and record review, the facility failed to ensure that allegations of abuse and injuries of unknown origin were reported to the State Agency for three of 33 sampled residents (Resident 49, 22, and 153).This failure resulted in delay in initiation of an external investigation and ensure residents' safety and resident-to-resident abuse to go uninvestigated and leave vulnerable residents unprotected from further abuse. Findings: 1. During an observation on 3/2/26 at 4:20 PM in the Memory Care Unit, Resident 49 was observed with red and purple bruising on her right upper and lower eyelids and bridge of nose. When resident was asked how she obtained the injury to her face, the resident appeared confused and unable to respond to the question. During an interview on 3/2/26 at 4:25 PM with Licensed Vocational Nurse (LVN) 6. LVN 6 stated that she did not know how Resident 49's injury happened. She stated the injury was first noted on 2/27/26. During an interview on 3/3/26 at 10:50 AM with the Administrator, the Administrator stated she was aware of Resident 49's bruising in her face. She stated it was an unwitnessed injury. The Administrator stated she was not sure if the injury was reported to the state agency district office. During a review of Resident 49's Progress Notes dated 2/27/26, the Progress Notes indicated, At approx. (approximately) 0730 CNA reported that resident has a new skin issue. Writer came inside her room, and found resident resting in her bed, writer observed discoloration to the right eye. When asked what happened, resident is unable to recall. During a review of Resident 49's Progress Notes dated 3/2/26, the Progress Notes indicated, Discoloration is now above her upper eyelid and below lower eyelid, color red/purple. During an interview on 3/4/26 at 10:05 AM with LVN 7, LVN 7 stated she was the nurse that conducted the assessment for Resident 49 on 2/27/26. LVN 7 stated during her assessment, she noted the discoloration on resident's right lower eyelid. She stated the resident could not recall how the injury to her face occurred. During an interview on 3/4/26 at 10:46 AM with the Administrator, the Administrator confirmed the injury of unknown origin to Resident 49's face was not reported to the state agency district office. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, with a revision date of September 2022, the P&P indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations). 2. Review of the admission Record indicated Resident 153 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's Disease (a brain disorder that slowly destroys a person's memory and thinking skills). During an interview with Certified Nursing Assistant (CNA) 4 on 3/2/2026 at 3:20PM, CNA stated that Resident 153 reached out and yanked Resident 22's hair around lunch time. During an interview with Licensed Vocational Nurse (LVN) 10 on 3/2/2026 at 3:22PM, LVN 10 stated around lunch time, Resident 153 walked into the dining area, reached out and yanked Resident 22's hair. During an interview with Administrator and Assistant Director of Nursing (ADON) 2 on 3/4/2026 at 4:00PM, Administrator stated that she was the Abuse Coordinator. The Administrator stated resident to resident physical abuse was reported immediately to Ombudsman and the Law Enforcement, but not to the California Department of Public Health (CDPH). Administrator was unaware of the requirement to report all resident-to-resident abuse to CDPH and confirmed CDPH was not notified of the incident between Resident 153 and Resident 22. During a record review of Incident: Physical Aggression report, dated 3/2/2026, with Assistant Director or Nursing (ADON) 2, on 3/5/2026 at 9:56AM, the report indicated that Resident 153 had an altercation with another resident. Resident 153 tugged at Resident 22's hair. The report did not indicate that CDPH was notified of the incident. During a record review of the facility's policy and procedures titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating revised September 2022, the policy indicated, All reports of resident abuse (including injuries if unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program for 6 of 33 residents when:1.Certified Nursing Assistant (CNA) 2 obtained vital signs (pulse rate, temperature, respiration rate, and blood pressure) without disinfecting the equipment between use for Resident 100 and 93.2. CNA 1 did not wear a gown while providing toileting assistance to Resident 11 who was on Enhanced Barrier Precautions (EBP-gown and glove use to reduce spread of infection).3. Oxygen concentrator filters for Residents 6, 69 and 83 were observed covered with lint.These failures had the potential to increase the risk of cross-contamination and the spread of infection within the facility.1.During an observation on 3/2/26 at 2:33 PM in Resident 100's room, CNA 2 was observed obtaining Resident 100's vital signs. After completion, CNA 2 did not disinfect the blood pressure cuff or pulse oximeter and proceeded to obtain vital sign for Resident 93 using the same equipment. During an interview on 3/2/26 at 2:38 PM with CNA 2, CNA 2 acknowledged she did not disinfect the equipment between residents use. CNA 2 stated the equipment should have been disinfected to prevent cross-contamination. CNA 2 further stated she usually obtains disinfectant wipes from the room counter; however, none were available at that time. During a concurrent interview and record review on 3/4/26 at 2:55 PM with the Infection Preventionist (IP), the facility policy and procedure titled Cleaning and Disinfecting Non-Critical Resident-Care Items dated 06/2011 was reviewed. The policy indicated durable medical equipment are cleaned and disinfected or sterilized between residents. The IP stated vital sign equipment must be disinfected between residents to prevent the transmission of bacteria or infections. 2. During a review of Resident 11's physician orders dated 2/25/26 indicated Resident 11 required EBP during high contact activities due to chronic wound.During an observation on 3/2/26 at 3:19 PM in Resident 11's room, CNA 1 was observed assisting Resident 11 with toileting without wearing a gown. During a concurrent observation and interview on 3/2/26 at 3:32 PM with CNA 1, in front of Resident 11's room, a sign posted outside Resident 11's room indicated staff must wear a gown and gloves when changing briefs or assisting with toileting. CNA 1 acknowledged she should have worn a gown while providing toileting assistance to prevent cross-contamination. During a concurrent interview and record review on 3/4/26 at 2:55 PM with the IP, the facility policy and procedure titled Enhanced Barrier Precautions dated 2/2025 was reviewed. The policy indicated high-contact resident care activities requiring the use of gowns and gloves for EBPs include changing briefs or assisting with toileting. The IP stated, to prevent cross contamination gown and gloves should be worn when assisting with toileting. 3. During a review of Resident 83's admission Record (AR) undated, the AR indicated Resident 83 was admitted to the facility on [DATE] with a diagnosis of shortness of breath.During a concurrent observation and interview on 3/4/26 at 9:59 AM with LVN 3 in Resident 83's room, Resident 83 was receiving oxygen via a nasal canula (flexible plastic tube). LVN 3 removed the oxygen concentrator filter and stated the filter was covered with lint. LVN 3 stated the filter should be clean to allow proper functioning of the machine. During a review of Resident 69's AR undated, the AR indicated Resident 69 was admitted to the facility on [DATE] with Chronic Obstructive Pulmonary Disease (COPD-lung disease).During a concurrent observation and interview on 3/4/26 at 10:05 a.m. with LVN 3 in Resident 69's room, LVN 3 removed the oxygen concentrator filter and stated the filter was covered with lint. During a review of Resident 6's AR undated, the AR indicated Resident 6 was admitted to the facility on [DATE] with a diagnosis of COPD.During a concurrent observation and interview on 3/4/26 at 10:07 AM with LVN 3 in Resident 6's room, LVN 3 removed the oxygen filter and stated the filter was covered with lint.During a concurrent interview and records review on 3/4/26 at 2:55 PM with the IP, the facility policy and procedure titled Oxygen Concentrator and Oxygen Storage dated 12/1/23 was reviewed. The policy indicated, to administer oxygen in a safe manner using oxygen concentrator. Wash filters weekly and as needed, document in medical record. The IP stated oxygen concentrator filters should be kept clean as part of infection control practices. The IP further stated housekeeping is responsible for cleaning the filters and licensed nurses are responsible for verifying that the filters have been cleaned.

Based on observation, interview, and record review, the facility failed to safely store, and label drugs and supplies in accordance with acceptable standards of practice when: One of two treatment carts was left unlocked and unattended on station 3.Personal food items were stored in one vaccine refrigerator. This failure had the potential to allow unauthorized access to treatment supplies by residents, staff, or visitors and maintain a controlled and sanitary environment for the storage of vaccines. 1.During an observation on 3/3/26 at 8:35 AM, Station 3's treatment cart was observed across the nurses' station. The treatment cart was unlocked and unattended. During a concurrent observation and interview on 3/3/26 at 8:46 AM, with Licensed Vocational Nurse (LVN) 2, the treatment cart remained located across from the nurses' station against the wall and was still unlocked and unattended. LVN 2 acknowledged the treatment cart had been left unlocked and stated the cart should be locked when unattended to prevent unauthorized access. During a concurrent interview and record review on 3/4/26 at 3:42 PM with the Assistant Director of Nurses (ADON), the facility policy and procedure titled Storage of Medications dated 11/2020 was reviewed. The policy indicated, the facility stores all drugs and biologicals in a safe, secure, and orderly manner and that compartments, including drawers and carts containing biologicals, must be locked when not in use. The ADON stated the treatment cart should be locked when unattended to prevent unauthorized access to treatment supplies. 2. During an observation on 3/2/26 at 5:50 PM of the infection prevention vaccine refrigerator, there was one personal food container, one box of soft cheese, and one container of dip stored directly alongside boxes of vaccines. During an interview with Infection Preventionist (IP) on 3/4/26 at 3:12 PM, IP stated Food should not be stored with vaccines, due to cross contamination. During a review of the facility policy titled, Medication Storage dated 2019, the policy indicated, Other foods such as employee lunches and activity department refreshments are not stored in this refrigerator. During a review of the facility policy titled, Storage of Medications revised November 2020, the policy indicated, Medications are stored separately from food and are labeled accordingly.

Based on observation, interview, and record review, the facility failed to ensure food safety standards were met when: 1.A linear black substance was found inside the ice machine in the kitchen.2. Two open bags of pasta and one open cornstarch were found in the kitchen unlabeled and undated and were not stored in an airtight container.3. One unlabeled and undated partially consumed bottled drink was found inside the resident's nutrition refrigerator at Station 2.4. One unlabeled and undated partially consumed frozen yogurt was not found inside the resident's nutrition freezer at Station 2.5. [NAME] 1 covered his mustache while preparing food in the kitchen.These failures had the potential to result in foodborne illnesses to all residents.Findings: During a review of the facility's policy and procedure (P&P) titled, Preventing Foodborne Illness - Food Handling, dated July 2014, the P&P indicated, Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized . 1. This facility recognizes that the critical factors implicated in foodborne illness are: a. poor personal hygiene of food service employees . 1.During a concurrent observation and interview on 3/2/26 at 2:52 PM with the Certified Dietary Manager (CDM) in the main kitchen, a black linear substance was found inside the ice machine when the cover was lifted and easily came off when wiped with a paper towel. CDM stated the black linear substance should not be there. During a review of undated facility document titled, YR Series Icemaker End-User Manual, the manual indicated, Cleaning/Sanitizing Procedure: This procedure must be performed a minimum of once every three months . Removes mineral deposits from areas or surfaces that are in direct contact with water . Clean the area around the ice machine as often as necessary to maintain cleanliness and efficient operation. During a review of the facility's policy and procedure (P&P) titled, Ice Machines and Ice Storage Chests, dated January 2012, the P&P indicated, Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. 2. During a concurrent observation and interview on 3/2/26 at 2:30 PM with the Certified Dietary Manager (CDM) in the main kitchen's dry goods storage area, two open bags of pasta noodles without an open date were found not tightly sealed. CDM stated once the item was opened, it should be dated and placed in a sealed bag. During a concurrent observation and interview on 3/2/26 at 2:26 PM with the Certified Dietary Manager (CDM) in the main kitchen's dry goods storage area, an open box of cornstarch without an open date was found not tightly sealed. CDM stated the cornstarch should have been labeled with an open date and tightly sealed. During a review of the facility's policy and procedure (P&P) titled, Storage of Food and Supplies, dated 2023, the P&P indicated, Food and supplies will be stored properly and in a safe manner . Dry food items which have been opened . will be tightly closed, labeled, and dated . 3. During a concurrent observation and interview on 3/4/26 at 10:05 AM with Registered Nurse (RN) 1 at Station 2 medication room, one (1) opened partially consumed bottled drink was found stored in the residents' nutrition refrigerator unlabeled and undated. RN 1 stated the unlabeled and undated partially consumed bottled drink was not supposed to be stored in the residents' nutrition refrigerator. During a review of the facility's policy and procedure (P&P) titled, Refrigerator, Storage of Food from Outside Sources, dated May 2024, the P&P indicated, The facility will ensure that food brought into the facility . is safely stored, handled, and monitored in facility-designated refrigerators . to reduce the risk of foodborne illness . All outside food must be identified with discard date . Any unlabeled or undated food will be discarded. 4. During a concurrent observation and interview on 3/4/26 at 10:08 AM with Registered Nurse (RN) 1 at Station 2 medication room, a bowl of partially consumed frozen yogurt without label and date was found stored in the residents' nutrition freezer. RN 1 stated the yogurt bowl was not supposed to be stored in the residents' nutrition freezer unlabeled and undated. During a review of the facility's policy and procedure (P&P) titled, Refrigerator, Storage of Food from Outside Sources, dated May 2024, the P&P indicated, The facility will ensure that food brought into the facility . is safely stored, handled, and monitored in facility-designated refrigerators . to reduce the risk of foodborne illness . All outside food must be identified with discard date . Any unlabeled or undated food will be discarded. 5. During a concurrent observation and interview on 3/5/26 at 2:14 PM with [NAME] 1 in the main kitchen, [NAME] 1 was observed preparing food with the beard net but not covering his mustache. [NAME] 1 stated he was preparing gravy. During an interview on 3/5/26 at 2:22 PM with the Certified Dietary Manager (CDM), CDM stated [NAME] 1 should have worn the beard net all the way to cover the mustache not just the beard while preparing food. During a review of the facility's policy and procedure (P&P) titled, Dress Code, dated 2023, the P&P indicated, Personal hygiene and appropriate dress are a very important part of the total appearance of the Food & Nutrition Services Department . Proper Dress . beards and mustaches (any facial hair) must wear beard restraint.

Based on an interview, and record review, the facility failed to coordinate discharge planning with the receiving facility and communicate with the resident and resident's responsible party (RP) for one of 33 sampled residents (Resident 122). In addition, the facility failed to ensure the discharge care plan reflected the residents' goals and resident specific interventions. This failure resulted in facility staff, Resident 122, and the resident's responsible party not being aware of the resident's discharge plan. Findings: Resident 122 was admitted on [DATE], with diagnoses which included weakness and unsteadiness on feet. During an interview with Resident 122, on 3/5/26 at 8:37 AM, Resident 122 stated she was doing much better and wanted to move to an assisted living facility (ALF- residential housing for seniors or individuals with disabilities who need help with daily care). Resident 122 stated she has been waiting for a very long time and has no idea what was going on with her move. During an interview with Resident 122's family member (RP), on 3/5/26 at 9 AM, RP stated she has been trying to get Resident 122 into an ALF and a bed was available, but the resident could not transfer. RP stated she understood there was an insurance issue, but she was unsure what else needed to be done. RP stated she had no idea why it was taking so long to get resident moved as the ALF has been holding a bed for months for Resident 122. RP further stated she had not received any help from the facility's social services department and had not received any updates from them as to the discharge plan and when Resident 122 could move to ALF. During an interview with Social Services Director (SSD) on 3/5/26 at 10:24 AM, SSD stated the facility was currently waiting for [transition services management organization] to approve Resident 122's placement for ALF. SSD stated We have never worked with them [Transition Service Management Company] before. [RP] is getting her placed at ALF. SSD stated RP would let facility know when Resident 122 can move to the ALF. SSD stated, I have not spoken to [RP] in a while. SSD stated, in September 2025, SSD spoke with the ALF and has not followed up with the ALF or [transition services management company] since. SSD confirmed Resident 122 has been ready to move to a lower level of care since October 2025. During an interview with Licensed Vocational Nuse (LVN) 1, on 3/5/26 at 9:30 AM, LVN 1 stated she was unaware of Resident 122's discharge plan. During an interview with Registered Nurse Supervisor (RNS) on 3/5/26 at 2:04 PM, RNS stated she was not aware of any discharge plan for Resident 122. During a concurrent interview and review of Resident 122's Discharge Care Plan dated 9/9/25, with Minimum Data Set (assessment tool) Nurse (MDS) the Care Plan indicated, Resident preference to discharge to Assisted Living. The Care Plan further indicated a goal of Current level of care is appropriate considering current physical/social/emotional status. Interventions included: Review plan of care initial/quarterly or as needed, social services to document changes to goal, and social services to schedule IDT care plan meetings upon admission, quarterly, and as needed. MDS confirmed the care plan did not include a resident specific goal with measurable outcomes and did not include interventions which should be implemented to assist the resident in achieving those goals. MDS stated she was unaware of Resident 122's discharge plan. During a review of the Social [NAME] Progress Note dated 9/18/25, the note indicated SSD met with RP and [representative from ALF] on 9/18/25 to discuss possible placement when Resident 122 was ready for discharge. During a review of the Social History Review notes dated 12/4/25, the notes indicated Discharge Plan: Goal is for resident to go to [ALF] when there is a spot for resident, per RP. During a review of the Social History Review notes dated 2/27/26, Discharge Plan: Goal is for resident to go to [ALF] when there is a spot for resident, per RP. There was no documentation in the Social Service notes that the ALF or [transition management services organization] had been contacted to coordinate Resident 122's discharge since 9/23/25. During a review of the facility policy titled, Discharge Summary and Plan revised March 2025, the policy indicated, Every resident has an individualized discharge plan, which begins at admission and is part of the comprehensive care plan.develop interventions to meet the resident's discharge goals and needs that must be addressed before the resident can be safely discharged .

Based on observation, interview, and record review, the facility failed to administer insulin (medication used to lower blood sugar) within professional standards, when Lispro Insulin (fast acting insulin) was administered to one of 33 sampled residents (Resident 111) one hour prior to a meal. This failure had the potential to cause adverse outcome from hypoglycemia (a condition in which blood glucose concentration is below 70 mg/dl (unit of measurement) or harm to the residentFindings: Review of the admission Record indicated Resident 111 was admitted to the facility on [DATE], with diagnoses which includes Type 2 Diabetes Mellitus with Ketoacidosis (a serious health condition when the body can't make enough insulin). During an interview with Licensed Vocational Nurse (LVN) 1 on 3/4/2026 at 12 PM, LVN 1 was asked if she would be checking Resident 111's blood sugar prior to lunch. LVN 1 stated that she had already checked Resident 111's blood sugar at 11:00AM and administered Lispro Insulin to the resident. During a concurrent observation and interview with the Speech Therapist (ST) in Unit 3 dining room on 3/4/26 at 12:10 PM, Resident 111 was observed beginning to eat his lunch meal with staff assistance. ST stated Resident 111 received his lunch tray and began eating his lunch at 12:05 PM. During an interview with LVN 1 on 3/4/2026 at 4:30 PM., LVN 1 stated Resident 111's blood sugar was checked at 11 AM and she administered Lispro Insulin at that time. LVN 1 stated the resident's meal tray was served at 12:05 PM LVN 1 stated Lispro Insulin was fast acting, probably 30 minutes after given, and it lowers the blood sugar. LVN 1 stated that she should have waited a little longer to check Resident 111's blood sugar and administer insulin. During a concurrent interview and record review on 3/5/2026 at 9:37 AM with Assistant Director of Nursing (ADON) 2, Medication Administration Record (MAR) for Insulin Lispro Injection solution was reviewed. Resident's 111 blood sugar was checked on 3/4/2026 at 11:00 AM by LVN 1, 4 units of insulin Lispro was administered. ADON 2 stated that Insulin Lispro was fast acting, and Resident 111's blood sugar could drop to low levels after administration. ADON 2 stated that nurse expectations are to give medications in the appropriate time. ADON 2 stated that if meal tray comes late, the doctor should be notified. During a record review of the Provider Order Summary, dated 12/4/2025, the order summary indicated, Insulin Lispro Injection Solution, inject subcutaneously [under the skin] before meals . During a review of the Insulin Lispro Manufacturer's Instructions, revised 9/23, the instructions indicated, Administer within 15 minutes before a meal or immediately after a meal. During a review of the facility's policy and procedure titled, Administering Medications revised date April 2019, indicated medications were administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview and record review, the facility failed to ensure effective pain management was implemented for Resident 151 when:1.The as needed pain medication (Tylenol) for Resident 151 was not administered according to the physician's order.2. Resident 151's pain level was not assessed timely post-administration of the as needed pain medication.These failures had the potential to result in Resident 151's suffering and decreased mobility due to unresolved pain.Findings: 1.During a review of Resident 151's admission Record, from 1/15/26 showed that Resident 151 was first admitted to the facility on [DATE] and then re-admitted on [DATE] with diagnoses including right knee pain. During a review of Resident 151's Quarterly MDS/CAA (Minimum Data Set/Care Area Assessment: a comprehensive and mandatory nursing home assessment process utilized to evaluate a resident's functional, medical, and psychosocial status) dated 12/4/24, indicated that the Brief Interview for Mental Status (BIMS: a standardized 15-point screening tool primarily used to assess cognitive function) for Resident 151 was scored at 12. During a review of Resident 151's Physician Progress Note, dated 2/23/26, the progress note indicated Resident 151 had osteoarthritis (breakdown of joint tissues) contributing to joint pain, stiffness, and reduced functional mobility. During a concurrent observation and interview on 3/4/26 at 6:07 PM with Resident 151, Resident 151 was observed sitting at the edge of her bed with a walker next to her. Resident 151 stated she told a female staff about her right knee pain in the morning and did not receive the as needed pain medication until five (5 PM) in the afternoon. During a review of Resident 151 Physician Order (PO), dated 1/15/26, the PO indicated, Tylenol Tablet 325 mg (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for pain mild (1-3) . During a concurrent interview and record review on 3/4/26 at 6:16 PM with Licensed Vocational Nurse (LVN) 5, Resident 151's Medication Administration Record (MAR), dated February 2026 was reviewed. The MAR indicated Resident 151 received the as needed pain medication on six (6) occasions. Two (2) of which, dated 2/9/26 and 2/25/26, Resident 151 reported a pain level of five (5) out of 10. LVN 5 stated he should have called the physician for a stronger pain medication appropriate for the reported pain level because the as needed pain medication that was administered to Resident 151 on 2/9/26 and 2/25/26 was for mild pain only (for pain level 1-3). During a review of the facility's undated policy and procedure (P&P) titled, Physician Orders, Accepting, Transcribing and Implementing (Noting), the P&P indicated, Licensed nursing personnel will ensure that telephone and verbal orders will be recorded and implemented . 2a. Licensed nursing shall verify each order for completeness, clarity and appropriateness of doses . b. Institute monitoring criteria for the medications . 2. During a review of Resident 151's admission Record, from 1/15/26 showed Resident 151 was first admitted to the facility on [DATE] and then re-admitted on [DATE] with diagnoses including right knee pain. During a review of Resident 151's Quarterly MDS/CAA (Minimum Data Set/Care Area Assessment: a comprehensive and mandatory nursing home assessment process utilized to evaluate a resident's functional, medical, and psychosocial status) dated 12/4/24, indicated that the Brief Interview for Mental Status (BIMS: a standardized 15-point screening tool primarily used to assess cognitive function) for Resident 151 was scored at 12. During a review of Resident 151's Physician Progress Note, dated 2/23/26, the progress note indicated Resident 151 had osteoarthritis (breakdown of joint tissues) contributing to joint pain, stiffness, and reduced functional mobility. During a concurrent observation and interview on 3/4/26 at 6:07 PM with Resident 151, Resident 151 was observed sitting at the edge of her bed with a walker next to her. Resident 151 stated she told a female staff about her right knee pain in the morning and did not receive the as needed pain medication until five (5 PM) in the afternoon. During a review of Resident 151's Medication Administration Record (MAR), dated February 2026, the MAR indicated Resident 151 received the as needed pain medication on 2/9/26 at 9:26 PM and on 2/25/26 at 7:04 PM, for Resident 151's reported pain level of five (5) out of 10. During a concurrent interview and record review on 3/4/26 at 6:03 PM with Licensed Vocational Nurse (LVN) 4, Resident 151's Weights and Vitals Summary, dated 2/9/26 and 2/25/26 were reviewed. The vitals summary indicated Resident 151 reported a pain level of five (5) out of 10 on 2/9/26 at 9:26 PM, also the time Resident 151 received the pain medication. Resident 151's pain level was not re-assessed until 2/10/26 at 12:42 AM (more than two (2) hours has passed since pharmacological intervention was provided). In addition, on 2/25/26 Resident 151 reported a pain level of five (5) out of 10 at 7:04 PM, also the time Resident 151 received the pain medication. Resident 151's pain level was not re-assessed until 9:25 PM (more than two (2) hours had passed since pharmacological intervention was provided). LVN 4 stated the pain level should have been re-assessed after 30 minutes to one (1) hour of administration of pain medication to assess for effectiveness. During a review of facility's policy and procedure (P&P) titled, Pain Assessment and Management, dated October 2022, the P&P indicated, Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after onset and reassessed as indicated until relief is obtained.

Based on observation, interview, and record review, the facility failed to ensure IDT (Interdisciplinary Team-group of dedicated healthcare professionals who work together to provide you with the care you need, when you need it) and therapy recommendation for bed bolster (a long thick pillow that is placed under other pillows for positioning, to prevent resident from rolling off the bed) were implemented for one of three sampled residents (Resident 1). This failure resulted in Resident 1 falling and sustaining a second metacarpal neck fracture (fracture of the bones within the palm of the hand). Findings: During a review of Resident 1's Safety Events--Falls/Found on Floor (SEFFOF) note, dated 12/17/21, at 3:30 PM, the SEFFOF indicated, Found on the floor. Activity during or just prior to fall?. Rolling/sliding out of bed. Was Fall Witnessed? . No, found resident after fall. IDT notes. IDT feels [Resident 1] would benefit from a therapy screen for bolsters to bilateral sides of bed for positioning. During a review of Resident 1's Rehab Status Post Fall Screen (RSPFS) note, dated 12/20/21, at 11:20 AM, the RSPFS indicated, Date of Event 12/17/21. residents room. unwitnessed fall. Rehab Evaluation indicated. Not indicated (why) - no functional decline noted per staff. However recommended bed bolster to prevent patient from rolling off the bed. During a review of Resident 1's Safety Events-Falls/Found on Floor (SEFFOF), dated 2/23/22, at 9:10 AM, the SEFFOF indicated, Found on the floor. Resident Room. Activity during or just prior to fall?. laying in bed awake. Was Fall Witnessed?. No, Found resident after fall. Body assessment. bruising. Site of injury. brusing to left hand. IDT notes. On 2/23/22 at approximately 9:10 AM [Resident 1] was found in her room on the landing mat with her alarm sounding (anti-fall system that is activated when pressure is applied on the mat to alert the caregiver immediately) on each side of the bed. Resident 1 was not interviewable. [Resident 1] was noted to have discoloration to her left hand and discomfort. X-ray results showed [Resident 1] had. a metacarpal neck fracture. During a review of Resident 1's Radiology Report (RR), dated 2/24/22, the RR indicated, Acute second metacarpal neck fracture (fracture of the bones within the palm of the hand). During a review of Resident 1's Care Plan (CP), dated 3/24/21, the CP indicated, **Fall Care Plan**At risk for falls r/t [related to]: unsteady gait, altered balance while standing and/or walking, decrease muscular coordination, hx (history) of falls. Approach Start Date: 12/20/2021. Therapy to screen for bolsters to bilateral sides of bed for positioning. During an observation on 3/23/22, at 11:28 AM, in Resident 1's room, Resident 1 was laying in bed with a helmet on her head, 1/4 side rails (a quarter barrier attached to the side of a bed) and landing mats on each side of the bed, no bolsters in bed. Resident 1 was not interviewable. During an inteterview on 3/23/22, at 11:34 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 1 did very litte for herself (needs physical support/assistance from staff), and she was an extreme fall risk. I witnessed Resident 1 attempted to transfer herself without staff assistance. During an interview on 3/23/22, at 11:42 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1 has a history of falls and gets up when she feels like it, and she requires help walking because she is unsteady and could barely make it from the bed to the door of her room. LVN 1 stated, after a fall IDT suggest interventions to put in place to assist with preventing resident from falling. During a concurrent observation and interview on 3/23/22, at 1:58 PM, with Infection Preventionist (IP), there were no bolster on Resident 1's bed. IP confirmed the finding. During a concurrent observation and interview on 3/23/22, at 2 PM, with LVN 1, in Resident 1's room, there were no bolsters on Resident 1's bed. LVN 1 confirmed the finding and stated Resident 1 had never been provided bolsters. During a concurrent interview and record review, on 3/23/22, at 2:04 PM, with Director of Rehabilitation (DOR), reviewed Resident 1's Rehab Status Post Fall Screen (RSPFS), dated 12/20/21 and DOR stated, the bolsters were recommended for Resident 1 to prevent him from rolling out of bed. DOR stated, nursing was responsible to provide the bolsters to Resident 1, but DOR did not remember if nursing was informed that Resident 1 needed bolsters. During an interview on 5/17/22, at 3:33 PM, with Director of Nursing (DON), DON stated, at the time of the fall (5/17/22 at 2:41 PM), Resident 1 did not have bolsters on the bed. During a review of the facility's policy and procedure (P&P) titled, Falls-Clinical Protocol dated 9/12, the P&P indicated, The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. a. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented.

Based on observation, interview, and record review, the facility failed to provide supervision for one of two sampled residents (Resident 1), with dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), while outside at station 4's patio. This failure resulted in Resident 1 falling from his wheelchair, acquiring a closed head injury (head injury without breaking the skull) and facial trauma (injury). Findings: During an interview on 9/1/21, at 10 AM, with Assistant Director of Nurses (ADON), ADON stated, on 8/31/21, around 8:10 AM, staff told her Resident 1 was found outside at station 4's patio, his wheelchair had tipped over and Resident 1 was on the ground. During a concurrent observation and interview on 9/1/21, at 10:35 AM, with ADON, in Resident 1's room, Resident 1 was lying in bed with his eyes closed. Resident 1 had bluish-dark color under both eyes. The right side of Resident 1's face had black and red colored areas extending down to his cheekbone area. The left side of Resident 1's face had scattered black and red colored areas below his eye and cheekbone. ADON stated, Resident 1's facial bruising resulted from his fall on 8/31/21. During an interview on 9/1/21, at 10:47 AM, with Patio Aide, Patio Aide stated, after getting report from staff on 8/31/21 at approximately 8:05 AM, he went outside to station 4's patio to set up activities when he saw Resident 1 on the ground by himself. Patio Aide stated, I turned the corner and saw [Resident 1] on the ground, his wheelchair was tilted, his feet dangling in the air. Patio Aide stated, Resident 1 had a diagnosis of dementia and was not allowed to be outside the patio without supervision. During a concurrent interview and record review on 9/1/21, at 11:50 AM, with ADON, Resident 1's current Face Sheet was reviewed. ADON confirmed Resident 1 had a diagnosis of dementia and stated, he had a history of falls. ADON stated, residents in station 4 were allowed to be outside on the patio when Patio Aide was out there to supervise. ADON stated, on 8/31/21, Resident 1 was not supervised when he fell outside on station 4's patio. During an interview on 9/1/21, at 12:12 PM, with Administrator, Administrator stated, it was Patio Aide's job duty to be outside on station 4's patio to keep them [residents] safe. Administrator stated, on 8/31/21, Patio Aide was not outside on station 4's patio when Resident 1 fell . During an interview on 9/17/21, at 8:07 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1 was not allowed to go outside unless the Patio Aide was outside providing supervision. During an interview on 9/17/21, at 8:24 AM, with LVN 2, LVN 2 stated, on 8/31/21, Resident had propelled himself outside to station 4's patio right after he had taken his ordered morning medications. LVN 2 stated, she assumed Patio Aide was outside at the patio and allowed Resident 1 to go outside. LVN 2 stated, I thought he [Patio Aide] was out there. During an interview on 9/17/21, at 8:33 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, on the morning of 8/31/21, she observed Resident 1 up in his wheelchair, going in and out (the door) leading to station 4's patio. At approximately 8 AM, she left to pass breakfast trays. CNA 1 stated, Resident 1 was allowed to go outside as long as we [staff] have eyes on them. CNA 1 stated, she assumed Patio Aide was outside on station 4 patio. During an interview on 9/17/21, at 8:45 AM, with CNA 2, CNA 2 stated, He [Resident 1] was lying down on the grassy area, face up in his wheelchair, blood on his nose, his face looked like he got kicked. CNA 2 stated, the incident could have been prevented if he [Resident 1] was outside with supervision. During a review of Resident 1's hospital Discharge Instructions, dated 8/31/21, the Discharge Instructions indicated, Resident 1 was diagnosed with closed head injury, facial trauma, fall at home. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 1/2011, the P&P indicated, 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on interview and record review, the facility failed to ensure four of four licensed nurses (Registered Nurse (RN) 1, Licensed Vocational Nurse (LVN) 1, LVN 2 and LVN 3) initiated cardio-pulmonary resuscitation (CPR) for one of 64 sampled residents (Resident 1). This failure resulted in Resident 1 not receiving timely CPR, transfer to an acute care hospital, subsequent death and the potential to result in 63 additional residents with full code status to experience a delay in receiving CPR. This resulted in an immediate jeopardy situation. Findings: During a review of Resident 1's Physician order [REDACTED]. During a review of Resident 1's Progress Notes, dated [DATE], at 10:18 AM, Progress Notes indicated, RN 1 Checked on resident (Resident 1) .no oxygen in place. No pulse (heart beat), no respirations (breathing), with cold hands and pale in color .EMTs (Emergency Medical Technicians) provided CPR. During a review of Resident 1's Progress Notes, dated [DATE], at 12:58 PM, Progress Notes indicated, LVN 1 called to residents (sic) (Resident 1's) room by RN supervisor (RN 1) at roughly 9:20 AM, resident (Resident 1) was noted to be pulseless, not breathing and pale . instructed RN supervisor to grab the crash cart and bring it back into the room and begin CPR, writer called 911 and paged for licensed staff overhead. FIRE arrived and initiated CPR with compression machine. During an interview on [DATE], at 11:21 AM, with LVN 1, LVN 1 stated, he did not recall anyone from the facility doing CPR on Resident 1. During an interview on [DATE], at 11:41 AM, with RN 1, RN 1 stated, I could tell right away that he was gone. I went out to the cart to get my stethoscope. RN 1 stated, Resident 1 looked very peaceful. RN 1 stated, Resident 1 did not have a pulse, was not breathing and did not have oxygen on. RN 1 stated, If he would have been alive, I would have put it (oxygen) on him. I told (LVN 1) (Resident 1) was gone. She stated, she did not recall anyone doing CPR while waiting for emergency medical services (EMS). During an interview on [DATE], at 12:01 PM, with Certified Nurse Assistant (CNA) 1, CNA 1 stated, he saw EMS pull Resident 1 off the bed and start CPR. During an interview on [DATE], at 1:15 PM, with LVN 1, LVN 1 stated, the process for residents found unresponsive was to check for a pulse, breathing, determine code (type of emergent treatment a person would or would not receive if their heart or breathing were to stop), and start CPR. During an interview on [DATE], at 2:37 PM, with the Director of Nursing (DON), the DON stated, when an unresponsive resident was found by facility staff, he expected staff to follow the resident's code status. During an interview on [DATE], at 3:10 PM, LVN 1 stated, he told RN 1 to start CPR. LVN 1 stated, he called EMS and the code blue (medical emergency situation). LVN 1 stated, RN 1 did not start CPR. During an interview on [DATE], at 3:54 PM, with RN 1, RN 1 stated, CPR should be started when there is no sign of life. CPR should have been started, (Resident 1) was a full code. RN 1 stated, she knew Resident 1 was a full code before EMS arrived. RN 1 stated, she did not start CPR. During an interview on [DATE], at 4:41 PM, with LVN 2, LVN 2 stated, he walked into Resident 1's room and heard RN 1 saying He's dead, he's dead, he's cold, there is no sign of life. I'm calling his death. LVN 2 stated, he told RN 1 Resident 1 was full code status. LVN 2 stated, CPR should have been started immediately. LVN 2 stated, no facility staff initiated CPR on Resident 1. During an interview on [DATE], at 5:02 PM, with LVN 3, LVN 3 stated, from the doorway of Resident 1's room, she saw RN 1 listen for (Resident 1's) lung sounds with her stethoscope. LVN 3 stated, staff should initiate CPR on all full code residents immediately when found unresponsive. LVN 3 stated, facility staff did not initiate CPR for Resident 1. During a review of Incident Report from the local Fire Department, dated [DATE], the Incident Report indicated, EMS was called at 9:34 AM on [DATE], and arrived on scene at 9:40 AM. The Incident Report indicated, Upon arrival, (EMS) found an unresponsive male lying in bed and initiated care. During a review of Resident 1's Emergency Department (ED) Report, dated [DATE], indicated Resident 1 arrived from the facility after having CPR. Upon arrival to the ED, on [DATE], Resident 1 did not have a pulse, and CPR was initiated. Resident 1 was placed on a ventilator (A machine that supplies oxygen or a mixture of oxygen and air, used in artificial respiration to control or assist breathing). Resident 1 had a [DIAGNOSES REDACTED]. After speaking with the family, it was decided to withdraw care . Resident 1 was removed from the ventilator and quickly expired (died ). Resident 1's time of death was 12:54 PM. During a review of the facility's Advance Directives and Code Status Report (summary of Residents' preferences for life prolonging treatments and CPR), dated [DATE], the Report indicated 63 residents were designated as Full Code. During a review of RN 1's CPR card, dated [DATE], the CPR card indicated, RN 1 was certified in CPR/BLS. During a review of LVN 1's CPR card, dated [DATE], the CPR card indicated, LVN 1 was certified in CPR/BLS. During a review of LVN 2's CPR card, dated [DATE], the CPR card indicated, LVN 2 was certified in CPR. During a review of LVN 3's CPR card, dated [DATE], the CPR card indicated, LVN 3 was certified in CPR. During a review of the American Heart Association webpage titled, What is CPR, the webpage (https://cpr.heart.org/en/resources/what-is-cpr) indicated, Immediate CPR can double or triple chances of survival after [MEDICAL CONDITION] .Keeping the blood flow active - even partially - extends the opportunity for a successful resuscitation once trained medical staff arrive on site. CPR is a critical step in the AHA's Chain of Survival . The 6 links in the adult out-of-hospital Chain of Survival are: Recognition of [MEDICAL CONDITION] and activation of the emergency response system (calling [DATE] in the US); Early CPR with an emphasis on chest compressions .A strong Chain of Survival can improve chances of survival and recovery for victims of [MEDICAL CONDITION]. During a review of facility policy and procedure (P&P) Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS), dated [DATE], the P&P indicated, If an individual (resident, visitor, or staff) is found unresponsive and without a pulse, a licensed staff person who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis).

Based on observation, interview, and record review, the facility failed to implement one of nine sample resident's (Resident 1) smoking care plan when the resident had access to his cigarettes, lighter and matches and was left unsupervised in the smoking area. This resulted in Resident 1 smoking unsupervised with his oxygen tank on, which resulted in a partial thickness burn (also known as a second degree burn (burn which involves the top two layers of the skin)) to the facial area. Resident 1 was oxygen dependent. He received oxygen through a nasal cannula that was connected to an oxygen cylinder in the back of his wheelchair. Findings: During an observation and interview with Resident 2, Resident 3, Resident 8 and Resident 9, on 11/21/18, at 8:59 AM, in the Patio 2 smoking area, Resident 2, Resident 3, Resident 8, and Resident 9, were observed sitting in their wheelchairs, around a table, smoking cigarettes. Resident 2 stated he was outside in the Patio 2 smoking area on 11/19/18 at approximately 7:40 PM, when Resident 1 wheeled himself out to the patio. Resident 2 stated, I saw him (Resident 1) light a cigarette so I told him to take the (oxygen) tank out because it could get caught on fire and blow us up. But he never listens. I saw his face caught (sic) on fire. Resident 3 stated on 11/19/18, There was no one but the three of us (Resident 1, Resident 2, Resident 3). Resident 3 stated on 11/19/18, He (Resident 1) was smoking. He had his oxygen tank and he had the smoke too close to his nose where the oxygen nosepiece (was), and I heard a pop and his whole face caught on fire. It started to spread on his face and a blue fire spread inside the oxygen tubing. Nobody came out. He went back in the building. During an interview with Resident 4, on 11/21/18, at 9:27 AM, in the Patio 2 smoking area, he stated I've seen him (Resident 1) come out several times with his oxygen tank. I'm pretty sure it's sometimes on because his nosepiece is still on his nose. If there are staff around, they take it off for him but that's not always the case. Staff is not always out here. During an interview with Resident 5, on 11/21/18, at 9:47 AM in the Patio 2 smoking area, she stated He (Resident 1) came out quite a bit with the oxygen tank. I'm not sure if it's on or off but they (staff) usually take the tank off the wheelchair before they light his cigarette, but sometimes he comes out with his cigarette and lighter and starts smoking with it (referring to the oxygen tank) on. During an interview with Resident 6, on 11/21/18, at 9:50 AM, in the Patio 2 smoking area, she stated, He (Resident 1) would always sneak out and smoke. They (staff) know he was always doing that, but they never took his cigarettes or lighters away from him. Especially since he came out with his oxygen tank on. During an interview with Resident 7, on 11/21/18, at 9:27 AM in the Patio 2 smoking area, he stated, He (Resident 1) was always smoking with his (oxygen) tank on. During an interview with the Patio Aide (PA) on 11/21/18, at 9:57 AM in the Patio 2 smoking area, he stated for all the residents' safety, it was the facility practice to remove the oxygen tank from the residents' wheelchair and place them in a designated area prior to lighting the residents' cigarettes. During an interview with Director of Nursing (DON) and Assistant Director of Nursing (ADON), on 11/21/18, at 10:29 AM, Resident 1's Minimum Data Set (MDS - a comprehensive assessment tool) dated 10/17/18 was reviewed and both confirmed Resident 1 had a BIMS (Brief Interview for Mental Status) score of 8 (moderately impaired cognition). The ADON reviewed the nurses notes and confirmed the following: a. On 9/28/18, (no time), Made aware by therapy that resident was outside smoking with oxygen on . b. On 11/2/18 at 9:58 AM, Resident was out smoking this AM and continues to wear oxygen via NC (nasal cannula is lightweight tube which on one end splits into two prongs which are placed in the nostrils to deliver supplemental oxygen) at 3 Liters. c. On 11/4/18 at 7:59 PM, Went to patio to administer medication to resident, he is smoking with oxygen at 3 Liters. Writer turned off his tank and walked away. d. On 11/5/18 at 11:38 AM, resident had a lighter. The ADON stated, He has been found several times smoking with his oxygen on. We don't know where he gets his cigarettes or lighters. The ADON stated on 11/19/18 at approximately 7:30 PM Resident 1 was taken outside to the Patio 2 smoking area by Certified Nursing Assistant 1 (CNA 1) and was later heard by CNA 2 screaming for help outside the door. The ADON stated there was no supervision during the incident because it occurred outside the smoking schedule. The ADON stated residents were only supervised during the hours of 9 AM to 11:50 AM, 1:45 PM to 4 PM, and 8 PM to 8:15 PM. During an interview with the DON, on 11/21/18, at 11:50 AM, she stated there was no supervision when Resident 1 went out to the smoking area outside the smoking hours. The DON stated, They (residents) all know the rules and for the most part they all follow and agree with the rules except for (Resident 1). During an interview with CNA 2, on 11/26/18, at 11:26 AM, she stated on 11/19/18, at approximately 7:30 PM, she was in the hallway when she heard someone outside the Patio 2 exit/entrance door screaming loud. I opened the door and I saw his (Resident 1) face was all black. He kept saying I burn, I burn. CNA 2 stated, If somebody took him out, they should have turned off his oxygen. If he wants to go outside it usually means he wants to smoke. I don't think he's safe to smoke. He's got his oxygen on. He's been caught several times smoking with it on. During an interview with Licensed Vocational Nurse 1 (LVN 1), on 11/28/18, at 8:57 AM, she stated on 11/19/18 at around 7:20 PM to 7:30 PM, CNA 1 took Resident 1 outside to the Patio 2 smoking area and left him there with no supervision. LVN 1 stated, His (Resident 1's) face was purple/black. He (Resident 1) said his face went on fire after lighting his cigarette. During an interview with CNA 1, on 11/28/18, at 9:30 AM, she stated she took Resident 1 outside to the Patio 2 smoking area on 11/19/18. CNA 1 stated she left Resident 1 unsupervised, I had to do my rounds with two other residents. CNA 1 stated she did not turn off and/or remove Resident 1's oxygen tank before leaving. CNA stated, . it wasn't time for him to smoke. I didn't think he was going to smoke. During a review of the clinical record for Resident 1, the comprehensive care plan was reviewed. The SMOKING CARE PLAN, dated 10/22/18, indicated Resident 1 has a history of long term smoking and is non-compliant, will smoke while wearing oxygen. The long term goal for this problem included: will smoke in designated areas, will practice safe smoking, will participate with smoking schedule, will participate in the care plan process, and will be free from smoking related injuries daily. The approaches included: keeping the cigarettes, matches, and lighters in a secure area; periodic checks to ensure that all cigarettes and lighter are with staff to take outside during smoking hours, and staff supervision while smoking. During a review of Hospital 1's Emergency Department (ED) report dated 11/19/18, the report indicates Resident 1's chief complaint was Patient BIBA (brought in by ambulance) from (named skilled nursing facility) for burn to face. Patient was smoking with oxygen . 74yoM (year old male) BIBA for evaluation of burn to the face. Patient is on 3 L(iters) oxygen . was smoking tobacco . when his NC (nasal cannula) caught on fire and burned his face . Patient put out the fire with his hands . Final Diagnosis 1. Partial thickness burn to face . Acute, Severe . During a review of Hospital 2's Emergency Department Physician Note dated 11/20/18, the note indicated Resident 1 was transferred from Hospital 1 to a higher level of care secondary to facial burns. The Physical exam indicated he had partial [MEDICAL CONDITION] to (sic) nose and upper lip extending to mid left cheek with singed mustache and nasal hair, burn to right temporal area. admitted [MEDICAL CONDITION] for further airway and burn management. During a review of the facility policy and procedure titled Safe Smoking Policy undated, indicated . 3. A smoking assessment will be initiated to help the Interdisciplinary Team identify: 1) smokers who do not require supervision and 2) smokers who require supervision . a. Social Services will determine the Resident's cognitive abilities. The Resident must meet the following criteria. 1. A clear understanding of the policy . consequences of non-compliance, and responsibilities of the Resident . c. Resident must . Understand that the result of non-compliance is a violation of the Smoking Policy and the termination of unsupervised smoking privileges . 4. Social Services will notify the Resident/Resident's Representative if the Resident does not qualify to smoke unsupervised. There must be total supervision until the cigarette is safely extinguished . 8. All cigarettes and lighters will be secured by nursing in a central location for smokers requiring supervision. All lighters will be secured by nursing in a central location for all smokers . During a review of the facility policy and procedure titled Smoking Policy - Residents dated (YEAR), the policy indicated, 3. Oxygen use is prohibited in smoking areas . 9. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safety with the available levels of support and supervision. This facility shall establish and maintain safe resident smoking practices . 10. 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 . 12. Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision .

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (2 and 3) were free from sexual abuse from one resident (1), who had a known history of inappropriate sexual behaviors. This resulted in Resident 1 sexually assaulting Resident 2, then sexually assaulting Resident 3 eight hours later. This placed the female population of the facility (as many as 35 female residents) in the dementia unit (a locked unit within this long term care facility that segregated residents with a [DIAGNOSES REDACTED]. Findings: During a review of the document titled Report of Suspected Dependent Adult/Elder Abuse (S(NAME) 341), dated 11/14/17, it indicated Witnessed (Resident 1) sucking on (Resident 2's) breast. Witnessed (Resident 1) sucking on breasts of (Resident 3) and dry rubbing with his crotch on top of (Resident 3). During a review of an undated, untitled document from the facility, addressed To whom it may concern, it indicated On 11/14/17, at approximately 3 PM, the CNA (Certified Nursing Assistant) witnessed (Resident 1) in bed with (Resident 3) inappropriately touching her breast and placing his mouth on her breast over her shirt. (Resident 1) was witnessed on top of (Resident 3) thrusting himself against her body. The CNA called for another CNA and separated both residents. The CNA reported to the charge nurse immediately and ensured the safety of (Resident 3). (Resident 1) was admitted to (the facility) on 2/21/17 with the [DIAGNOSES REDACTED]. The CNA reported another incident involving (Resident 1) earlier that day with (Resident 2) at approximately 6:30 AM during breakfast. The CNA stated that she witnessed (Resident 1) inappropriately touching (Resident 2's) breast with his mouth to her areola (area around nipple) under her blouse. The CNA stated that she separated both residents at that time and resumed with the breakfast routine for the other residents. On 11/16/17, (Resident 1) was put on one to one supervision (where one staff person supervises one resident continuously). 1. During a review of the clinical record for Resident 2, the Minimum Data Set, dated dated [DATE], indicated she was 65-years-old, and had a Brief Interview for Mental Status (BIMS) score of 0, indicating severe mental impairments. The Physician order [REDACTED]. During a concurrent interview and clinical record review with LVN 3, on 11/16/17, at 2:32 PM, for Resident 2, the Progress Note dated 11/14/17, at 4:54 PM, indicated Made aware that resident (2) experienced inappropriate sexual contact from another male resident (1). CNA (1) stated she witnessed resident (2) sitting in a chair at the end of 4 B hallway around (6:30 AM) when she saw the male resident (1) sucking on breast with shirt pulled up. When CNA stopped male resident (1) he stood up and patted resident (2) on her head and said thank you. When CNA shocked said Thank you?! The male resident (1) laughed. Resident (2) redirected away from male resident (1) hall, back to 4 A. Resident ambulatory in unit as per norm. Will continue to monitor. No nursing assessments or monitoring of Resident 2 regarding the physical assault was documented. Licensed Vocational Nurse (LVN) 3 confirmed the findings. During an observation of Resident 2, on 11/16/17, at 2:42 PM, she was noted pacing around in the locked dementia unit hallways. Resident 2 would walk in and out of other resident's rooms independently with no re-direction from staff. An interview was attempted and she was unable to answer questions due to her dementia diagnosis. She mumbled her responses and walked away. During an interview with CNA 1, on 11/16/17, at 6:33 PM, she stated Resident 2 did not have the ability to make decisions and the staff must anticipate all of Resident 2's needs because of her inability to make choices. CNA 1 stated Resident 2 was unable to give consent for anything. CNA 1 stated Resident 2 can't even talk, she just mumbles. CNA 1 stated that on 11/14/17, at 6:30 AM, she was coming out of a resident room when she heard a loud sucking noise. She turned to look and saw Resident 2 sitting on a chair out in the hallway next to the dining room and Resident 1 bending over, holding Resident 2's blouse up while he was sucking on her breast. CNA 1 stated she loudly said Hey, and Resident 1 stopped, stood up and patted Resident 2 on the top of her head and said Thank you. CNA 1 stated she looked at him and loudly questioned Thank you? She stated Resident 1 looked at her and laughed so hard, spit started dripping from his mouth. He then walked back to his room. CNA 1 stated she immediately reported this assault to LVN 1. CNA 1 stated LVN 1 just looked at her and gave no further direction. CNA 1 stated at around 7 AM, on the same day, she was in the dining room with the residents and overheard LVN 1 make the statement to another person out in the hallway, You'll never believe what (Resident 1) did this morning and chuckled. CNA 1 stated the facility did not implement protection precautions to prevent another assault from Resident 1. During an interview with CNA 2, on 11/16/17, at 7 PM, she stated on 11/14/17, at 6:30 AM, she was walking down the dementia unit hall towards the dining room when she saw Resident 2 sitting in a chair located out in the hallway next to the dining room. CNA 2 stated she observed Resident 1 holding Resident 2's shirt pulled up and he was bent over sucking on her breast. CNA 2 stated CNA 1 yelled something at Resident 1 and he stopped, stood up, pulled Resident 2 shirt down, patted her on the head and said Thank you. CNA 2 stated Resident 1 then walked back to his room. CNA 2 stated, I did not report it because (CNA 1) told me that she had reported it to (LVN 1). So I didn't report it. CNA 2 stated Resident 1 did not have a one-on-one monitoring with him after that incident with Resident 2. CNA 2 stated, I was at lunch when he did it again to Resident 3. She stated the ADON (Assistant Director of Nursing) asked her to write a statement of what she saw. She stated the ADON did not ask her questions about the incident. CNA 2 stated Nothing else was done. 2. During a review of the clinical record for Resident 3, the Minimum Data Set, indicated she was [AGE] years old, and her BIMS assessment indicated her cognitive skills were severely impaired. The Physician order [REDACTED]. During a concurrent interview and clinical record review with LVN 3, on 11/16/17, at 2:32 PM, for Resident 3, the Progress Note dated 11/14/17, at 3:45 PM indicated Reported by CNA, Resident was the receiver of inappropriate touching from another resident (1). Resident was separated immediately, ADON (Assistant Director of Nursing) notified immediately. No nursing assessments or monitoring of Resident 3 regarding the physical assault was documented. LVN 3 the confirmed findings. During an observation of Resident 3, on 11/16/17, at 2:50 PM, she was noted pacing up and down the locked dementia unit hallways, holding her head downward looking at the floor and wandering into other resident rooms with no re-direction from staff. An interview was attempted and Resident 3 was unable to answer questions due to her dementia diagnosis. Resident 3 mumbled her responses while looking down at the floor and walked away. During an interview with CNA 1, on 11/16/17, at 6:33 PM, she stated Resident 3 did not have the ability to make decisions and the staff must anticipate all of Resident 3's needs because of her inability to make choices. CNA 1 stated Resident 3 was unable to give consent for anything. CNA 1 stated Resident 3 can't even talk, she just mumbles. CNA 1 stated At 3 PM (eight and a half hours after the incident with Resident 2), it happened again. CNA 1 stated she was in another room when a male resident approached her and said He is humping someone in my bed. She went into the room and saw Resident 1 on top of Resident 3 dry humping her and sucking on (Resident 3's) breast over her shirt. CNA 1 stated I yelled out 'come help me' and (CNA 3) responded. CNA 1 stated Resident 1 looked at them both and smiled. CNA 1 stated she escorted Resident 1 back to his room. CNA 1 stated she and CNA 3 then took Resident 3 to LVN 1 and LVN 2. CNA 1 stated she reported this second sexual assault to them and made the statement, This has to stop. She stated (Resident 1) knows what he is doing and the female residents do not know. CNA 1 stated LVN 1 made the comment that she was aware of the 6:30 AM incident and LVN 2 turned and looked at LVN 1 and stated, You have to open an event and report it. CNA 1 stated both LVNs looked at Resident 3's shirt, which had large saliva wet spots over both breasts, and instructed her to Take her, wipe her down and change her shirt. CNA 1 stated she saw no assessments performed to Resident 2 and Resident 3. She stated that later that day, the ADON asked her to write what she saw and gave no additional direction or asked questions regarding either assault. CNA 1 stated, I was surprised, no one asked or did anything. During an interview with LVN 2, on 11/16/17, at 5:51 PM, she stated CNA 1 and CNA 3 escorted Resident 3 to the nurses' station and reported Resident 1 was found on top of her, Dry humping and sucking on her breast over her blouse. LVN 2 stated Resident 3 had large wet areas on both of her breasts over the shirt. LVN 2 stated an assessment was not completed and stated, My bad. LVN 2 stated she directed LVN 1 to Open an event (document the incidents) and LVN 2 reported the abuse to the ADON and completed an S(NAME) 341 (a state form that documents episodes of suspected abuse) and gave that document to the Social Services Department. She stated Resident 1 was not placed on one-on-one protection to ensure abuse did not reoccur. LVN 2 stated the ADON asked her to write a statement. During an interview with CNA 3, on 11/18/17, at 4:11 PM, she stated on 11/14/17, at 3 PM, she heard CNA 1 yell out for help. As she responded, she saw Resident 1 on a bed on top of Resident 3 Dry humping her and sucking on her breast over her blouse. She stated CNA 1 escorted Resident 1 to his room and she (CNA 3) took Resident 3 with her. CNA 3 stated Resident 3 had large Oreo-cookie sized saliva wet stains on her shirt on top of both breasts. She stated Resident 3 was escorted to the nurses' station to report the incident to both LVN 1 and LVN 2. She stated That's when I found out he did the same thing to another resident at 6:30 AM. CNA 3 stated CNA 1 stated she had reported the 6:30 AM incident to LVN 1 in the morning. She stated both LVN 1 and LVN 2 looked at Resident 3's wet saliva stains and instructed her and CNA 1 to Get (Resident 3) wiped down and change her shirt. CNA 3 stated The nurses just looked at the saliva stains, that's all, and did not perform an assessment. CNA 3 stated Resident 3 was then cleaned and clothes changed. She stated Resident 1 was not placed on one-on-one supervision and he could continue walking around the unit. CNA 3 stated No one has asked me anything, I was surprised. 3. During a concurrent interview with LVN 3 and review of the clinical record for Resident 1, on 11/16/17, at 2:32 PM, the Physician order [REDACTED]. Nursing staff note resident is sexually forward with female peer(s). The same document indicated on 6/20/17, Resident 1 continued with Inappropriate sexual behavior. Nursing staff report resident still attempts to touch female peers inappropriately. If not already started, consider behavior monitoring for inappropriate touching of female residents. There were no care plans or behavior monitoring in the clinical record that addressed this documented history of inappropriate sexual behavior towards female peers or female residents. LVN 3 confirmed the findings. The Progress Note by LVN 2, dated 11/14/17, at 3:02 PM, indicated Was reported to charge nurse (LVN 2) by CNA, resident (1) was sucking on (Resident 3) and (Resident 2) breast. Resident was able to be redirected. Was reported to ADON. The Progress Note by Social Service Designee dated 11/14/17, at 3:57 PM, indicated Resident in pleasant spirits and very friendly. Per resident, he is doing well and has had a good day. The document titled Event Report: Behavior and Mood Change of Condition, dated 11/15/17, at 11:33 AM, indicated Resident 1 demonstrated physical behaviors symptoms directed toward others, including abusing others sexually, and that these behavior symptoms interfere with resident care, disrupt care or living environment, put others at risk for injury, and significantly intrude on the privacy or activity of others. The document indicated that the only immediate measures taken by the facility following the incidents was to separate the residents. LVN 3 confirmed the findings. During an interview with LVN 1, on 11/16/17, at 1:50 PM, she stated CNA 1 had informed her of both sexual assault incidents with Resident 2 and Resident 3. She stated the first sexual assault occurred to Resident 2 at 6:30 AM and the sexual assault occurred to Resident 3 at 3 PM that same day (11/14/17), approximately eight hours from the first assault. LVN 1 stated she did not implement safety precautions to prevent a reoccurrence of the assault after the first incident at 6:30 AM. She stated she was unsure on how to handle the situation and waited to get direction from another LVN (LVN 2) who was working with her. She stated once LVN 2 gave her direction (after the 3 PM sexual assault that occurred to Resident 3), she reported both sexual abuses to the ADON after 3 PM, on 11/14/17. She stated Resident 1 was not placed on one-on-one monitoring after the 6:30 AM or the 3 PM sexual assaults. LVN 1 stated the report of both assaults was submitted after 3 PM to the ADON. LVN 1 stated she did not perform an assessment of Resident 2 and Resident 3. LVN 1 stated I looked at (Resident 3's) wet areas on both of her breasts over her shirt. She stated the facility did not conduct an investigation after she reported the event. She stated the ADON asked her to write a statement. LVN 1 stated, Nothing else was said. During an observation of Resident 1 on 11/16/17, at 2 PM, he was noted to be an elderly male, lying on his bed in the locked dementia unit with his eyes closed and covered with a blanket. Resident 1 removed the blanket, stood up and walked to his bathroom independently without an assistive device. Resident 1 walked to his doorway, looked around and headed down the hallway to the dining room. He looked into the dining area at residents and staff, then walked back to his room. Resident 1 did not have a one-to-one staff person with him during the observation. The untitled documents containing the staff one-on-one monitoring entries for Resident 1, indicated the first such observation occurred on 11/16/17, at 4:15 PM, or 58 hours after the sexual assault on Resident 2. During an interview with CNA 4, on 11/16/17, at 2:10 PM, she stated Resident 1 had sexually inappropriate touching behaviors. She stated he will go up to the (female residents) and start by holding their hands, then look around to see if we are looking. We will redirect him away from the ladies because we know he is up to something when we see him doing that. He is able to understand. His behavior have been the same from the first day he came here. CNA 4 stated Resident 1 was not on one-on-one behavior monitoring. CNA 4 stated Resident 1 was not on any special type of monitoring. During an interview with Resident 1, on 11/16/17, at 2:23 PM, he stated he was admitted to the facility in February of 2017. He stated My daughter brought me here. He stated he had no recollection of the witnessed assaults on Resident 2 or Resident 3. During an interview with CNA 5, on 11/16/17, at 3:10 PM, she stated Resident 1 had behaviors of attempting to inappropriately touch female residents in the locked dementia unit from the beginning of his admission. She stated he would park his wheelchair in front of female resident rooms, look around for staff and would attempt to enter. She stated He has that predator look in his eyes. She stated He is not your usual dementia resident. He knows what he is doing. CNA 5 stated Resident 1 was not on one-on-one monitoring. During an interview with the ADON, on 11/16/17, at 5:30 PM, she stated LVN 1 and LVN 2 both reported the sexual assault incidents that occurred at 6:30 AM and 3 PM, on 11/14/17. The ADON stated she received the sexual assault report after 3 PM on 11/14/17, and she asked CNA 1, CNA 2, and LVN 1 to write a statement of what they saw. The ADON stated she did not give direction to initiate protection from further assaults. She stated an investigation was not initiated to ensure staff was aware of the mandated reporting abuse laws. The ADON stated, It didn't occur to me to ask why they didn't report the assault at 6:30 AM. I didn't think about it. The ADON stated Resident 1 was not placed on one-on-one precautions to prevent re-occurrence of assaults. The ADON stated she did not ensure physical assessments were performed on Resident 2 and Resident 3 at the time of the assault. The ADON stated, I didn't think to check. The facility policy and procedure titled Abuse Prevention dated 2/9/17, indicated Abuse, neglect, abandonment, isolation, financial abuse. will not be tolerated in this facility at any time. It is the policy of this facility to take proactive measures to prevent the occurrence of abuse to any resident. Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. Residents must not be subject to abuse by anyone, including, but not limited to. other residents. Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility's identification of residents whose personal histories render them at risk for abusing other residents, and development of interventions strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. Purpose: to ensure that resident's rights are protected by providing a method for the prevention of resident abuse/neglect. Scope: This policy applies to all facility residents, staff. Responsibility: This policy is to be implemented by the Administrator and advocated by all staff members at all times. Prevention: The facility will identify, correct and intervene in situations in which abuse/neglect. are more likely to occur (i.e., physical environment that may make abuse/neglect. are more likely to occur , use of staff in sufficient numbers to meet the needs of the residents, supervision of staff to identify inappropriate behaviors, and assessment, care and planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect). Protection: The following efforts will be made in a resident incident where the health, welfare or safety of the resident is involved: Provide a safe environment for residents as indicted by the situation: (a) If a suspected perpetrator is another resident: Separate the resident so they do not interact with each other until circumstances of the reported incident can be determined.

Based on interview, observation, and record review, the facility failed to provide supervision to one of three sampled residents (1) when Resident 1 was left unattended while on the toilet, which resulted in a fall, head injury, and subsequent death. Findings: During an interview on [DATE] at 8:05 AM, Family Member (FM) 1 stated Resident 1 was paralyzed on the left foot, arm, and leg. FM 1 stated that on [DATE], staff had left Resident 1 on a commode chair (a plastic chair on wheels which goes over the toilet) and she must have fallen to the left and sustained an injury to the left eye. Resident 1 was taken to the emergency room (ER) and a CT scan (Computerized Tomography, a computer assisted x-ray) was performed and stitches (also known as sutures) placed on her left forehead. FM 1 stated when she called on Thursday morning ([DATE]) the nurse said She's doing great. FM 1 stated My sister went in at 8 AM and found her not waking up and soaked in sweat and called me. I called the nurse and she went to the bedside. The nurse said 'she's probably tired from the fall.' My sister called me and said we need to get her back to hospital. The ER doctor told me the fall had caused her brain to shift (move) . now her brain is bleeding. The doctor said we might not see damage for the first few hours and this was the case. They (the facility) shouldn't have left her. They knew she couldn't sit up on her own. She would lean to her left. FM 1 stated Resident 1 had since died on [DATE], and that makeup for the funeral didn't cover up the bruise on her face. During an interview with Licensed Vocational Nurse (LVN) 1 on [DATE], at 10:20 AM, she stated, I wasn't there (when Resident 1 fell ). I saw CNAs (Certified Nursing Assistants) looking for a nurse. (Resident 1) was on the floor bleeding on the left side. (Resident 1) didn't remember what happened. She has left side paralysis. She was sitting on the commode chair above the toilet. The CNA was there and had turned around to pick up clothes. During a concurrent interview and observation with CNA 1 on [DATE], at 10:45 AM, she stated Resident 1 could not move her left side and that day me and another CNA (CNA 2) grabbed her pants and put her on the toilet. CNA 1 stated CNA 2 left after Resident 1 was transferred to the toilet and was not present when the fall happened. CNA 1 stated she was going to get Resident 1's shirt out of her closet and I didn't see what happened. It was so quick. CNA 1 demonstrated going to the closet to get the shirt and when the closet was opened the resident was out of sight and out of reach of CNA 1. During an interview on [DATE] at 11:15 AM, CNA 2 stated she had helped transfer Resident 1 and did not see the fall. During a review of the clinical record for Resident 1, the Resident Face Sheet indicated she was [AGE] years old with [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set (MDS, a standardized, comprehensive assessment tool) dated [DATE] indicated a BIMS (Brief Interview for Mental Status which evaluates cognition, the ability to remember and think clearly) score of 9, which indicated moderately impaired cognition. The MDS indicated Resident 1 showed difficulty in short-term recall. The MDS also indicated Resident 1 required the extensive physical assistance of two persons for toilet use. The MDS indicated Resident 1 was involved in the activity, but two staff persons staff did provide weight-bearing support for the act of toileting, which is defined in the MDS as how the resident uses the toilet room. transfers on/off toilet. The instructions for the MDS toileting section indicated Code for the least steady episode of moving on and off a toilet or portable commode, using an assistive device if applicable. The MDS also indicated Resident 1 was Not steady, only able to stabilize with staff assistance regarding Moving on and off toilet. The MDS indicated Resident 1 had a Functional Limitation in Range of Motion, with Impairment on one side of her Upper extremity (shoulder, elbow, wrist, hand) and her Lower extremity (hip, knee, ankle, foot). Resident 1's Progress Note dated [DATE], at 10:44 AM, written by LVN 1 indicated, Resident was taken to bathroom by CNA on duty. Sat on shower chair which was placed above the toilet. While CNA turn around to grab resident's clothes from the closet which is right next to the bathroom, she heard a loud noise. T he CNA turn around to check on the resident and resident was found on the floor bleeding from the left side of her eye. The CNA did not actually saw resident falling. Resident did not remember that she fell when asked. Resident 1's Progress Note dated [DATE] at 7 PM, written by LVN 1 indicated, Resident return from (hospital) this evening with 8 stitches to skin tear to left side of eye due to (status [REDACTED]. Resident 1's Progress Note dated [DATE], at 11:30 AM, by LVN 2 indicated, RP (Responsible Party) requesting resident be sent to ER because she feels resident is alerted from her baseline. The Progress Note dated [DATE] at 5:59 PM written by LVN 2, indicated, Resident is being admitted . for acute left subdural bleed (a life-threatening injury that occurs when blood vessels rupture between the brain and its membranes and the blood presses on the brain tissue). During a review of the hospital's clinical record for Resident 1, the documentation titled Physician Documentation, dated [DATE], at 9:49 AM indicated, [AGE] year-old female on Eliquis (a medication that slows the blood's ability to clot) brought in by ambulance after a fall in which she hit her head on tile flooring and sustained a head laceration (cut). The fall was unwitnessed and patient is unsure if she lost consciousness or not. But a thump was heard by staff at (the facility). They ran in to help her and she was conscious. The physical examination indicated an 8 centimeter (3.14 inch) laceration to left upper forehead with active bleeding. The Physician Documentation dated [DATE], at 12:19 PM indicated, The patient is a [AGE] year-old female who present to the facility with a complaint of AMS (altered mental status). The symptoms began this morning. Family states that patient was not acting herself this morning. Had CT done on [DATE] which came back normal. History of left sided deficits from previous stroke. The CT of the head report dated [DATE], at 12:28 PM indicated, Compared to prior exam, there is interval development of left holohemispheric subdural hematoma (brain bleeding), measuring up to 1.2 centimeters in size. The Physician Documentation on [DATE], at 12:58 PM indicated, There was an acute impairment of an organ system with high probability of imminent or life threatening deterioration in the patient's condition. Nursing Notes on [DATE], at 1 PM indicated the family did not want to transfer Resident 1 to another hospital and requested comfort care measures. Resident 1 died on [DATE]. The hospital document titled Death Summary, dated [DATE], indicated This is an [AGE] year-old female, who was living at (facility) over the last 6 months. Apparently, she was on the bathroom commode and she fell and hit her head, and she was discharged back to (the facility). Apparently, the CT at that time showed no acute findings; however, the patient became more and more lethargic (tired or sluggish) and was unable to hold on a conversation, so she was sent back to the emergency room , at which point, there was an interval development of a left-sided subdural hematoma measuring 1.2 centimeters (about ,[DATE] inch) with a mass effect (a life threatening condition where the hematoma presses against the brain) . comfort care measures were initiated given patient's very grave prognosis. Unfortunately, the patient's condition continued to decline and the patient died [DATE]. The State of California, County of Tulare, Office of Vital Records, document titled Certificate of Death, dated [DATE], indicated Patient 1's Immediate Cause of Death was Respiratory Failure. The UNDERLYING CAUSE (diseases or injury that initiated events resulting in death) were Acute Subdural Hematoma, Acute Closed Head Trauma. During an observation on [DATE] at 10:20 AM, the commode chair was observed in a shower room. On the bottom of the chair was a sticker which indicated Patient must never be left unattended or unsupervised.

Based on observation, interview, and record review, the facility failed to initiate one-to-one supervision (one staff member supervising one resident) for one of two sampled residents (2) who was admitted with known assaulting behaviors and maintain one-to-one supervision after he had assaulted another resident (1). This failure had the potential to place all residents in the Dementia Unit at risk of being assaulted by Resident 2. Findings: A Dementia Unit is a separate and distinct unit within a long term care facility that segregates and provides a special program for residents with a [DIAGNOSES REDACTED]. The clinical record for Resident 2 was reviewed. The hospital History and Physical record for Resident 2 dated 1/10/17, indicated Neurological disorder. Dementia: Lewy Body (a type of dementia that manifest itself with hallucinations and violent behaviors), chronic, progressive, associated with behavioral issues, confusion--currently symptomatic with progressive decline in function and cognition, intermittent aggressive behavior, confusion .family unable to provide adequate care. The admission record dated 2/8/17, for Resident 2 indicated Resident 2 had a [DIAGNOSES REDACTED]. (The term behavioral disturbance refers to a pattern associated with subjective distress, functional disability, or impaired interactions with others or the environment.) During a review of the transfer documents from the previous Skilled Nursing Facility for Resident 2 sent to the facility on [DATE], the hospital Progress report dated 1/18/17, at 10:30 PM, indicated Pt (Patient) had recent admission after he was found to be threatening to kill wife, others, and himself. He was placed 5150 (involuntarily confine a person suspected to have a mental disorder that makes them a danger to themselves, and/or a danger to others). The Facility Activity Report for Resident 2 dated 2/15/17, at 11:17 PM, indicated Resident 2 was involved in an incident in the Dementia Unit were he was the aggressor of an alleged resident to resident altercation. The clinical record for Resident 1 was reviewed. The Nursing Progress Note for Resident 1 dated 2/15/17, at 9:40 PM, indicated At (approximately 9:37 PM) writer (Licensed Nurse-LN 4) was at the nurses' station charting when alarm on station 4 door started sounding. CNA ((Certified Nursing Assistant) 4) turned alarm off and assessed area. CNA (4) noticed resident (Resident 1) laying (sic) tipped over on w/c (wheel chair) on back, still buckled in safety belt. CNA (4) then called for nurse and assistance. Upon assessment, (Resident 1) had discoloration to bilat (both) eyes, bleeding from nose and mouth with swollen lips. Resident (Resident 1) responsive to name, complaining of body pain. Immediately called RN (Registered Nurse) sup (supervisor) to further assess, placed call to 911. During this event, staff members rushed down hall to assist, Resident (Resident 2) making references to (CNA 4) that he hit someone, he shot someone, someone call the police. This Resident (Resident 2) also noted with blood on left sleeve of shirt. Resident 1 was transferred to an acute care hospital Emergency Department for evaluation immediately after the incident. She was admitted to inpatient for treatment for [REDACTED]. During a review of the hospital History and Physical dated 2/16/17, indicated Resident 1 sustained facial trauma with nasal bridge lacerations (cuts), diffuse (spread) facial and periorbital (around eyes) swelling and chest ecchymosis (bruising), acute manubrium (upper part of chest bone) fracture, acute upper sternal (chest bone) fractures, acute R (right) 2-6 (2, 3, 4, 5, and 6th) rib fractures, acute L (left) 2-7 (2, 3, 4, 5, 6, and 7th) rib fractures, acute nasal bridge lacerations (cuts), acute facial contusions (bruising) .Due to the extent of her injuries possible assault could not be ruled out. Police Department contacted by ER (emergency room ) staff and currently pending investigation. The Nursing Progress Note for Resident 2 dated 2/16/17, at 8:04 AM, indicated Events 02/15/2017 Aggressive/Combative .Staff noticed (Resident 2) walking in from station 4 patio with alarm sounding, staff checked outside to make sure all other residents were no longer outside. Staff noticed a resident (Resident 1) was on the floor, staff notified writer (LN 6) to help station 4 nurses assess resident (Resident 1). During assessment of resident (Resident 1) found on the floor, staff went back in building to get vital machine (a machine that assesses resident's blood pressure and pulse), and (Resident 2) stated to staff member (CNA 4) that he pushed (someone) outside down and have blood on sleeve of shirt .writer (LN 6) asked resident what happened. (Resident 2) was visibly distraught, stating that kids were making fun of him with a gun, and that he took the gun away and shot the kids. (Resident 2) then told other staff members that he took the gun away and hit the guy with it. During a concurrent observation and interview in the hallways of the Dementia Unit on 2/24/17, at 10:27 AM, Resident 1 was observed in her wheelchair with a seat belt around her waist. Resident 1 had bluish, yellow discoloration around eyes, nose, checks, mouth, and right hand. Resident 1 was observed with a closed laceration on the ridge of her nose and discoloration to her mid chest area as she gently moved her blouse and softly rubbing her upper chest area. Resident 1 stated in Spanish, It hurts so bad. She stated in Spanish, I don't know what happened to me, I'm not sure how I was bruised. I hurt so much. During an observation of Resident 2 on 2/24/17, at 11:46 AM, Resident 2 was walking outside in the social patio area for the Dementia Unit when other residents were present without staff in the area to supervise him. Resident 2 entered the Dementia Unit and walked the hallways independently without one-on-one supervision. During this observation, CNA 2 stated Resident 2 was not on one-to-one supervision but every 15 minute location checks. During an interview with CNA 4, on 2/24/17, at 12:56 PM, CNA 4 stated as she responded to station door alarm she saw Resident 2 enter from the patio area. CNA 4 stated she opened the exit patio door to check the area and saw Resident 1 in her wheelchair tipped backwards with her legs up in the air. The back of her head was on the concrete. CNA 4 stated She (Resident 1) had blood on her face dripping on the concrete. Her coffee cup was on the concrete and bloody. She was still strapped in her wheelchair with her seatbelt, and (Resident 1) couldn't tip her wheelchair over. She had blood all over. Her eyes were purple, her nose looked broken, swollen, bleeding bad. Her lips were purple, swollen. She looked horrible, I screamed for the nurse to come .I ran to get towels to stop the bleeding, all the nurse responded . during all this (Resident 2) kept saying call the police, I killed someone, call her family too, call the police, I just killed someone because they had a gun. During an interview with LN 4, on 2/24/17, at 1:33 PM, LN 4 stated when she arrived to the patio area she saw Resident 1 in her wheelchair on her back, with both of her eyes and lips swollen and bruised. LN 4 stated Resident 1 had blood all over her face, and dripping from her nose and mouth. LN 4 stated Resident 1's coffee cup was found on the ground and it had blood all over it, like if she was hit with it. LN 4 stated after the incident she noticed Resident 2 had blood on his shirt sleeve. During an observation of Resident 2 on 2/24/17, at 2:17 PM, Resident 2 was in the rehabilitation room performing exercises on an elliptical machine with a group of residents. Resident 2 was not observed with one-on-one staff supervision. During an interview with CNA 4, on 2/24/17, at 5:23 PM, she stated He (Resident 2) becomes aggressive with some residents, he starts walking towards them saying something about killing, he's been like that since he came here (2/8/17). During an interview with CNA 5, on 2/24/17, at 5:29 PM, he stated (Resident 2) becomes very anxious when residents are in his way. His eyes become wide and bulging and he yells out you better get out of my way. During an interview with Family Member (FM) 1, on 2/28/17, at 11:26 AM, she stated Resident 2 was hospitalized in a mental ward in January (2017) because he was trying to attack her with a hammer. She stated, I was afraid. I called the police and they took him .they kept him on a 72 hour hold. FM 1 stated the hospital worked to stabilize his medications and then transferred him to a (Skilled Nursing Facility) in Fresno and he had behavior issues in that facility. FM 1 stated the Fresno facility transferred Resident 2 to the Visalia facility. She stated Resident 2's behaviors have been escalating for the past two years. He would become easily upset if he was told No. FM 1 stated, I was afraid for him, or if he hurt someone. FM 1 stated the current facility had knowledge of Resident 2's mental disorder history and dangerous behaviors towards others. FM 1 stated she took the discharge paper work from the other skilled nursing facility indicating Resident 2's behaviors to the current facility. She stated They had all the paperwork. During an interview with Trauma Medical Doctor (TMD) 1, on 2/28/17, at 2:30 PM, TMD 1 stated Resident 1 had severe facial injuries and multiple rib and sternal fractures that did not coincide with a ground fall from a wheelchair. TMD 1 stated the injuries, based on her years of trauma experience, appeared to be related to an assault. The care plan for Resident 2 titled Behavioral Symptoms dated 2/17/17, two days after the incident, indicated one-on-one supervision to ensure resident safety (one-on-one-when residents have a history of behaviors that might hurt themselves or others, the facility will have a staff member stay with the resident to decrease the chances of injury). The Psychologist Consultation for Resident 2 dated 2/22/17, indicated Staff reports resident shows agitation .is very difficult to re-direct is psychotic and aggressive towards others. During a concurrent interview with the Director of Nursing (DON) and review of Resident 1's and Resident 2's clinical record, on 2/24/17, at 2:30 PM, the DON verified the above clinical record review findings for Resident 1 and Resident 2. The DON stated Resident 2 was not on a one-on-one supervision as indicated by Resident 2's behavioral care plan. The DON stated Resident 2 does not have a care plan for a resident to resident altercation because no one actually saw the altercation between Resident 1 and Resident 2. The DON stated she was aware that Resident 2 had a history of [REDACTED]. On 2/24/17, at 2:58 PM, it was determined that an immediate jeopardy (IJ) existed because Resident 2 was not on one-to-one supervision as indicated in his plan of care placing other residents in the Dementia Unit in danger. The Administrator and DON were informed of the situation of immediate jeopardy at this time. The Administrator and DON immediately placed Resident 2 on one-to-one supervision. On 3/6/17 at 12:48 PM, in the presences of the Administrator and DON, the IJ was removed after it was determined the facility placed Resident 2 on permanent one-to-one supervision and had in-serviced the Dementia Unit staff on abuse prevention, protection, and reporting. The facility policy and procedure titled Abuse Prevention updated 2/9/17, indicated Abuse .will not be tolerated in this facility at any time. It is the policy of this facility to take proactive measures to prevent the occurrence of abuse to any resident .Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to .other residents . This includes the facility's identification of residents whose personal histories render them at risk for abusing other residents, and development of interventions strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior .Protection:(a) If a suspected perpetrator is another resident: Separate the residents so they do not interact with each other .

Based on observation, interview, and record review, the facility failed to provide pain relief for one of two sample residents (1) when Resident 1 was experiencing severe pain from spinal, rib, shoulder and chest bone fractures from an alleged resident-to-resident assault, which resulted in Resident 1 sustaining excruciating pain since she was discharged from an acute care hospital. Findings: The clinical record for Resident 1 at the skilled nursing facility was reviewed. Resident 1, a [AGE] year-old lady was a victim of an alleged resident to resident assault that occurred on 2/15/17. The Resident Progress Notes for Resident 1 dated 2/15/17, at 10:27 PM, indicated At approx. (approximately) 21:37 (9:37 PM) writer (a Licensed Nurse-LN 4) was at the nurses station charting when alarm on station 4 door started sounding. CNA ((Certified Nursing Assistant)4) turned alarm off and assessed area. CNA (4) noticed resident (Resident 1) laying (sic) tipped over on w/c (wheel chair) on back, still buckled in safety belt. CNA (4) then called for nurse and assistance. Upon assessment, (Resident 1) had discoloration to bilat (both) eyes, bleeding from nose and mouth with swollen lips. Resident (Resident 1) responsive to name, complaining of body pain .During this event, staff members rushing down hall to assist, resident (2) making references that he hit someone, he shot someone, someone call the police' .Resident 1 left facility .at 21:51 . Resident 1 was treated at an acute care hospital's emergency department on 2/15/17. She was then admitted to the hospital and returned to the skilled nursing facility on 2/23/17. The History and Physical dated 2/16/17, from the acute care hospital, indicated Resident 1sustained facial trauma with nasal bridge lacerations (cuts), diffuse (spread) facial and periorbital (around eyes) swelling and chest ecchymosis (bruising), acute manubrium (upper part of chest bone) fracture, acute upper sternal (chest bone) fractures, acute R (right) 2-6 (2, 3, 4, 5, and 6th) rib fractures, acute L (left) 2-7 (2, 3, 4, 5, 6, and 7th) rib fractures, acute nasal bridge lacerations (cuts), acute facial contusions (bruising). Resident 1 sustained multiple facial lacerations, fracture of sternum, five rib fractures to her right chest, and six to her left chest. Resident 1 was in severe pain and was managed by using two pain medications during her hospital stay: [MEDICATION NAME] and [MEDICATION NAME]. [MEDICATION NAME], a pain medication contains opioids. Resident 1 was prescribed to have [MEDICATION NAME] one tablet twice a day routinely and one tablet every six hours as needed. [MEDICATION NAME] Patch is a local numbing medication. It works by blocking nerve signals in your body to reduce pain or discomfort caused by skin irritations such as sunburn, insect bites, poison ivy, poison oak, poison [MEDICATION NAME], and minor cuts, scratches, hemorrhoids, and burns. During a concurrent observation, and interview with Resident 1, on 2/24/17, at 10:20 AM, Resident 1 was observed sitting in her wheelchair while parked against the wall facing the nurses' station. Resident 1's face was observed with bluish, yellow skin discoloration around eyes, nose, checks, mouth, right hand and a closed laceration (cut) on the ridge of her nose. She was observed grimacing, moaning, clenching her chest while softly rubbing her upper chest area with her hands stating in Spanish, It hurts so bad while two nurses sat talking with each other approximately five feet away. Resident 1 stated in Spanish, I have a lot of pain on my chest. I'm really hurting. Facility staff members were passing by as Resident 1 verbally expressed pain and was loudly moaning and grimacing. None of the staff stopped and addressed Resident 1's verbal and physical expressions of pain. CNA 1 stopped and stated I'll take her to her room and you can talk to her there. CNA 1 wheeled Resident 1 to her room, parked her next to the bed, and walked away without addressing Resident 1's verbal and physical expressions of pain. During an observation, in Resident 1's room, on 2/24/17, at 10:40 AM, CNA 2 and CNA 3 entered her room and asked Resident 1 if she needed something. Resident 1 stated in Spanish, I'm in a lot of pain (points to her chest area and moans). I can't stand it, it hurts so much, so much, and I can't stand it. CNA 2 stated I'll call for a nurse. During an observation on 2/24/17, at 10:45 AM, Licensed Nurse (LN) 1 entered Resident 1's room while Resident 1 was loudly moaning and grimacing stating in Spanish It hurts so much, I can't stand it. LN 1 stated I'm going to get you a pain pill. During an observation on 2/24/17, at 10:47 AM, LN 1 returned to the room and asked CNA 2 to translate in Spanish, Tell her (Resident 1) that she already received a pain pill at 10 AM. She is not due for another pain pill yet. Resident 1 was moaning and grimacing as the nurse stood in front of her. CNA 2 translated in Spanish The nurse said you already received your pain pill at 10 AM, and it's not time for another. They can't give you anything else. If they give you another pain pill, it's bad for you. So if your pain gets worst tell me. Resident 1 responded in Spanish, It's really bad now, I can't stand it. Resident 1 was moaning stating repeatedly I can't stand it, it hurts so much. CNA 2 translated Resident 1's response to LN 1, She (Resident 1) said she's in pain. During a concurrent observation of Resident 1 and interview with LN 1, on 2/24/17, at 10:52 AM, LN 1 stated Resident 1 had routine [MEDICATION NAME] (pain medication) twice a day and Resident 1 had received a [MEDICATION NAME] pill at 10 AM. LN 1 stated, (Resident 1) has PRN (as needed) [MEDICATION NAME] every six hours but I can't give her anything. Resident 1 was moaning and grimacing in front of the nurse. LN 1 was asked if she understood CNA 2's translation of Resident 1's complaint of pain from the above observation at 10:47 AM. LN 1 stated yes and walked out of Resident 1's room without offering Resident 1 pain intervention options. At this time, CNA 2 and CNA 3 proceeded to provide help Resident 1 use the restroom. Resident 1 yelled out in pain as the two CNA's helped her stand and sat her on the toilet. Resident 1 began to moan loudly while on the toilet with CNA 2 and CNA 3 remained present in the restroom. During a review of the clinical record for Resident 1, the Medication Administration Record [REDACTED]. Resident 1 was admitted on [DATE] at 4 PM. She received [MEDICATION NAME] at 9:39 PM the day of her admission and then another [MEDICATION NAME] at 10 AM on 2/24/17. Resident 1 did not receive any [MEDICATION NAME] as needed in between routine doses. During further review of Resident 1's pain assessment on re-admission on 2/23/17, there was no admission pain assessment found. During a concurrent observation and interview with the Director of Nurses (DON), on 2/24/17, at 10:54 AM, the DON entered Resident 1's room and stated, We are going to review her pain medication because in the hospital she was receiving [MEDICATION NAME] (strong pain medication). Resident 1 was moaning loudly while in the restroom. The DON walked out of the room without assessing Resident 1's pain or offering pain relief. During an observation on 2/24/17, at 10:58 AM, Resident 1 asked CNA 2 and CNA 3 to help her to bed. Resident 1 stated, Let me lie down maybe it will help the pain. CNA 2 and CNA 3 attempted to lie her down and Resident 1 yelled out No, no, I can't stand it, it hurts. CNA 2 and CNA 3 stopped and helped Resident 1 back into her wheelchair. Resident 1 was moaning and grimacing. CNA 2 and CNA 3 left the room without offering pain relief. Resident 1 stated she was unable to do anything to alleviate the pain. She stated, I just have to sit here and suffer, what else can I do? She closed her eyes, became tearful and put her head back, moaning and grimacing. During a subsequent observation on 2/24/17, at 11:25 AM, LN 2 entered Resident 1's room and asked CNA 2 to translate in Spanish. LN 2 handed CNA 2 a white paper with a line of faces with expressions and numbers at the bottom of each face. LN 2 asked CNA 2, Ask her (Resident 1) to point to a face indicating her pain. CNA 2 held the white paper with faces in Resident 1's face and asked her to point to a face with her pain. Resident 1 stated, All of them .what can I do .I can't stand it, it hurts. LN 2 instructed CNA 2 to tell Resident 1 in Spanish I can't give her anything, she has to wait. LN 2 was asked about Resident 1's pain rating, LN 2 stated She's moaning and grimacing so she's in a lot of pain. But I can't say how much pain because she can't tell me. Resident 1 continued grimacing and moaning as LN 2 walked out of the room without offering pain relief alternatives. During an interview with the DON, on 2/24/17, at 11:40 AM, she stated, She's in a lot of pain. I'm going to have the nurse call the doctor right now. During an interview with the DON and LN 2 on 2/24/17, at 11:49 AM, LN 2 stated she had not called the physician. The DON instructed her, Call the doctor and tell him of her pain and that we need something in a liquid form (liquid pain medication) right now. She's in severe pain. During a subsequent interview and record review with the DON on 2/24/17, at 3:11 PM, the DON reviewed Resident 1's plan of care for 2/23/17 to 2/24/17 and provided a copy of it to the surveyor. The goal for Will have s/sx (signs and symptoms) of pain managed with (in) 45 Minutes- 1 Hours after intervention rendered was discontinued on 2/23/17. The Approach indicated DC (discontinue) ON: 02/23/17-Discontinued Pain Assessment/Observation As Indicated. There was no further documentation found in the record to justify the decision to discontinue the pain assessment. The facility policy and procedure titled Pain Assessment and Management dated 3/2009, indicated Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals .a. assessing the potential for pain; .c. Identifying the characteristics of pain; d. addressing the underlying causes of the pain; developing and implementing approaches to pain management .g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary .Recognizing Pain: a Verbal expressions such as groaning, crying, screaming; b. Facial expressions such as grimacing, frowning, clenching .e. Limitations in his or her level of activity due to the presence of pain .4. The physician and staff will establish a treatment regimen based on consideration of the following: a. The resident's medical condition .c. Nature, severity and cause of the pain.