Every finding on record at Westwood Post Acute

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests and rodents when cockroaches were seen by three of three sampled residents (Residents 1, 2 and 3) and also a dead cockroach was found behind Resident 1's bedside chest drawer in the facility. This failure affected the residents' quality of life to live in a healthy and sanitary environment. A review of a complaint intake information dated 8/19/26 indicated a cockroach infestation at the facility. Review of the facility's minutes of Resident Council Meeting, dated 6/3/26 indicated, Resident 1 had seen bugs coming from the wall, bathroom, smells molds over painted wall. A resident in room B had seen two big cockroaches in the hallway. During a concurrent observation and interview on 8/20/26, at 12:07 p.m., with Resident 1, in room A, a dead cockroach was found behind Resident 1's bedside chest drawer. Resident 1 stated, the dead cockroach was killed by her after falling behind her bedside chest drawer from last night. Resident 1 further stated that she also had seen silverfish (is a small, primitive, wingless insect) and spider in room A. During an interview on 8/20/26, at 12:22 p.m., with Resident 2, Resident 2 stated she had seen cockroaches coming out at night in the restroom and her closet. Resident 2 further stated she also had seen spiders in room C, the last time she had seen cockroaches, was two weeks ago. During a follow -up interview on 8/20/26, at 12:25 p.m., with Resident 3 who was the roommate of Resident 2, she stated she had seen cockroaches once a while in room C. During an interview on 8/20/26, at 1:10 p.m., with the maintenance director/ housekeeping supervisor (MD/HS), MD/HS stated, each month they would provide at least twice pest services, and they had been provided pest control services (6/10/26) in June 2026 and also should have provided deep cleaning to resident's room. However, there was no evidence deep cleaning was provided to room A and C in August 2026. During a review of the facility's policy and procedure (P&P) titled, Pest Control, revised 5/2008, the P&P indicated, The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on interviews and record reviews, the facility failed to provide the care and services needed as ordered by physicians to one of three sampled residents, (Resident 1), when the facility did not arrange transportation for Resident 1 for an outside appointment which resulted in Resident 1 missing her appointment.This failure had the potential to compromise Resident 1's health and well-being. During a review of Resident 1 's face sheet (document that summarizes a person's information such as medical history) indicated Resident 1 was admitted to the facility with diagnoses including migraine, unspecified not intractable, without status migrainosus (a standard headache migraine without warning flashes (aura), the attack has not lasted past 72 hours, and pain responds to normal medical treatments) and low back pain, unspecified. During a review of Resident 1's, Order Summary Report, dated 6/16/26 indicated an order, June 8/26 130PM arrive by 1145AM Botox (botulinum toxin to temporarily relax targeted muscles, commonly smoothing facial wrinkles or treating medical issues like chronic migraines and excessive sweating) injection with Dr. [name] neuro at [clinic address] .[phone#], dated 5/12/26. During a review of Resident 1's Brief Interview for Mental Status (BIMS, a short performance-based cognitive screener for nursing home (NH) residents.), dated 4/15/26 BIMS is 15 (the range of 13-15, suggests that the person is cognitively intact). During a review of Resident 1's nurses progress notes, dated 6/8/26 indicated, .Pt (patient) became upset when she found out that her transportation was never booked. therefore, she was not able to attend her appointment. During a review of Resident 1's social service progress notes, dated 6/8/26 indicated, Resident called the writer stating that she had a scheduled appointment at [NAME] today and inquired whether transportation had been arranged. The writer asked the resident who she had provided the appointment paperwork to. The resident stated that she had given the appointment letter to the front desk staff because they requested her paperwork after the appointment was scheduled. During a phone interview on 6/26/26 at 10:17 a.m., with Resident 1, She stated the facility is aware about her appointment on 6/8/26, but they forgot to set up the transportation that's why she missed the appointment, Resident 1 further stated June 4th is for prosthetic and June 8th was for Botox injection for her migraine. During a concurrent interview and record reviews on 7/29/26 at 11:58 a.m., with Assistant Director of Nursing A (ADON A), she reviewed Resident 1's physician's order and she confirmed there was an order for appointment on June 8/26 130PM arrive by 1145AM Botox injection with Dr. [name] neuro at [clinic address] .[phone#], dated 5/12/26. ADON A stated usually they put in the communication about the appointment and the Social Service set up the transportation. ADON A reviewed Resident 1's Social Service progress notes dated 6/8/26 and Nurse progress notes dated 6/8/26, the ADON confirmed that Resident 1 missed the appointment because the transportation was not booked. ADON was asked if Resident 1's attending physician was notified about missing the Botox appointment, ADON A reviewed Resident 1's documentation. She stated she cannot find any documentation that Resident 1's attending physician was notified, she stated usually they notified the attending physician if the appointment is missed or cancelled and documented. During a review of Social Services Lead Assistant job description titled, Social Services Lead Assistant job description indicated, Duties and Responsibilities; Administrative Functions .Assist in making appointments for the resident/family as requested or appropriate. Assist in arranging transportation, when necessary. During a review of the facility's policy and procedures titled, Transportation, Social Service, Revised 12/2008, indicated, Our Facility shall help arrange transportation for residents as needed.2. Social Service will help the residents as needed to obtain transportation .

Based on interviews and record review, the facility failed to implement their abuse policy and procedure for one of three sampled residents (Resident 1) when the facility did not report Resident 1's allegation of abuse (someone who changes her diaper sexually assaulted her) to required agencies (California Department of Public Health [CDPH] and Long-Term Care Ombudsman) timely. This failure had the potential to compromise the safety of Resident 1 in the facility. Findings:Review of Resident 1's clinical record titled, Face sheet (document that summarizes a person's information such as medical history) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including anxiety disorder (mental health conditions characterized by excessive, persistent, and uncontrollable worry or fear that is disproportionate to actual situations) and major depressive disorder (serious mood disorder characterized by a persistent feeling of sadness, hopelessness, and a loss of interest in activities), recurrent, severe with psychotic symptoms. Review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 4/6/2026, indicated Resident 1's brief interview for mental status (BIMS, an assessment to test a person's cognitive level) score was 10 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 cognitively intact). A review of Resident 1's progress note dated, 4/21/25 indicated, @ 2000, Police arrived in the facility looking for the resident after receiving report from APS (Adult Protective Services, a government social agency that investigates reports of abuse, neglect, or financial exploitation targeting vulnerable older adults and people with disabilities). Police was escorted to resident's room and spoke with resident. After the interview, Police declined to disclose info and verbalized that APS or a social worker will be reaching out. Small details reported by police that resident reported that someone who changes her diaper sexually assaulted her but was unable to give a timeframe. Police left the facility @ 2040, received SJ POLICE INCIDENT CARD. Case #[ **-***-****], TYPE OF INCIDENT: REPORT OF SEXUAL ABUSE OFFICER/BADGE#[******] #[****] PHONE: [***-***-****]. During an observation and interview on 6/2/26 at 11:49 am., inside Resident 1's room. Resident 1 declined the interview, she stated she doesn't feel good today, just come back next time. During an interview on 6/2/26 at 1:18 p.m., with the Administrator (ADM), the ADM stated the police came to Resident 1 for sexual allegation they did the investigation with the police and nothing happened. The ADM stated it happened 5 to 10 years ago, and Resident 1 did not give further information, the police unsubstantiated the sexual allegation. The ADM stated in this case they don't have to report, and he confirmed it was not reported to CDPH and Ombudsman. During a phone interview on 6/5/26 at 10:01 a.m., with Licensed Nurse A (LN A), LN A confirmed he did the progress notes on 4/21/26 for Resident 1. The progress notes indicated, someone who changes her diaper sexually assaulted her. LN A stated the allegation was on 4/20/26 around 8:00 p.m., but the progress notes were written on the electronic record after midnight and show the date 4/21/26. LN A stated two police officers came to the facility, the police gave little information about Resident 1's sexual allegation; LN A further stated he went to Resident 1's room to ask what happened, Resident 1 refused to talk. LN A stated he notified the Director of Nursing (DON), ADM, MD (Medical Doctor), and ADON (Assistant Director of Nursing); LN A stated he was instructed to monitor Resident 1 for 72 hours. LN A further stated the ADM was not in the facility at that time, because it happened after hours around 8:00 p.m. During a concurrent interview and record review on 6/5/26 at 11:15 a.m., with the Director of Nursing (DON), the DON reviewed Resident 1's IDT ( interdisciplinary team, a group of health care professionals from diverse fields who work toward a common goal for residents) Comprehensive note dated 4/21/26, the DON stated the IDT indicated, section G. other entities notified: Ombudsman and CDPH was marked by mistakes, the DON confirmed it was not reported to CDPH and Ombudsman, the DON further stated the IDT decided not to report it because there is nothing to report. During a review of Resident 1's IDT Comprehensive note dated 4/21/26, the Section C. Investigation indicated, Resident assessed as alert and oriented x4. No visible injuries or acute distress observed. Skin assessment completed with no significant findings noted. Vital signs obtained. Resident remains at baseline with no significant changes in physical condition. Safety precautions maintained. Resident educated/reoriented as needed. Plan to continue close monitoring for changes in cognitive status, behavior, or physical condition. Will notify MD and RR (resident is self-responsible) of any significant changes or concerns. Resident unable to recall accurate timeline of reported occurrence. During assessment, resident provided inconsistent and varying accounts of events, with statements not supported by objective findings or available evidence. No male CNA/staff allowed in resident's room. None were assigned in resident's care. During a review of facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting Reviewed date October 2022, the P&P indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman;2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted.

Based on interviews and record review, the facility failed to protect a resident's right to be free from sexual abuse when Certified Nursing Assistant (CNA) C witnessed Resident 5 placed his male genital (penis) inside Resident 4's mouth. This failure resulted in nonconsensual sexual act that put Resident 4 at risk for sexually transmitted infection, injury and psychosocial distress.FINDINGS: A review of Resident 4's medical record indicated an admission date of 1/18/2018. Resident 4's son had Power of Attorney (a legal document that allows a resident to appoint someone else to manage financial, legal, or medical affairs) and was the responsible party for Resident 4's finances and care. Resident 4's diagnoses included but were not limited to, contracture of muscle right and left lower leg (the permanent, abnormal shortening or stiffening of muscles, tendons, ligaments, or skin, causing joint stiffness and restricting movement); paroxysmal atrial fibrillation (an irregular, often rapid heart rate that comes and goes, starting and stopping on its own); generalized anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry about everyday things-such as health, finances, or family); unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance ((a mental health condition characterized by a loss of contact with reality, where an individual's thoughts and perceptions are significantly disrupted); mood disturbance (when a person loses touch with reality, making it hard for them to know what is real and what is not), and anxiety (a decline in mental abilities-like memory, reasoning, and communication-severe enough to interfere with daily life); major depressive disorder, recurrent, unspecified (a mental health condition characterized by a persistent feeling of deep sadness, emptiness, or loss of interest in activities); and other frontotemporal neurocognitive disorder (a progressive brain disease that shrinks the areas responsible for personality, behavior, and language). A review of Resident 4's Minimum Data Set (MDS, an assessment tool), dated 3/9/26, indicated a brief interview for mental status score of 12 [BIMS - an assessment to test a person's cognition level, a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 patient is cognitively intact].A review of Resident 4's Physician Orders included but were not limited to, Admit to [Name of Hospice Company] Hospice [a specialized type of care focused on comfort, quality of life, and dignity for patients with terminal illnesses rather than curing them] with DX [diagnosis] terminal diagnosis of: Advanced frontotemporal dementia, sepsis age related physical debility on 3/27/26. In short, Resident 4 was in Hospice Care. Morphine Sulfate (concentrate) Solution 20 mg/ml [milligram/milliliter, a unit of measurement] Give 0.25 ml by mouth every 6 hours as needed for BTP [Breakthrough Pain, transitory, intense flare of pain that occurs on top of otherwise stable, controlled chronic pain]. A review of Resident 5's medical record indicated an admission date of 4/23/25 and a discharge date of 4/7/26. Resident 5's diagnoses included but were not limited to polyneuropathy [a condition where multiple peripheral nerves throughout the body are damaged simultaneously, causing widespread symptoms]; hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease [a condition where long-term high blood pressure damages both the kidneys and the heart simultaneously]; atherosclerotic heart disease of native coronary artery without angina pectoris [hardening of original arteries that supply blood to your heart due to plaque buildup, causing narrowing]; unspecified dementia, unspecified severity, with other behavioral disturbance.A review of Resident 5's Minimum Data Set (MDS, an assessment tool), dated 1/8/26, indicated a brief interview for mental status score of 4 [BIMS, an assessment to test a person's cognition level, a score of 0 to 7 indicates severe cognitive impairment, 8- 12 moderate cognitive impairment, 13-15 patient is cognitively intact]. A review of Resident 5's Order Summary Report indicated, Active orders as of 1/5/2026, 2/01/2026, 3/02/2026 and, 4/01/2026 all these monthly orders indicated, Order Summary1. ATTEMPTED TO REDIRECT. 2. 1:1 INTERVENTION. 3. SPOKEN IN CALM MANNER. 9. ENCOURAGE TO EXPRESS FEELINGS/CONCERNS. 11. TAKEN TO ACTIVITIES . , with Order Date 8/15/2025 and Start Date 8/15/2025. This order indicated Resident 5 was to be on 1:1 intervention. A review of Resident 5's Order Summary Report: Active Orders as of 4/1/2025 indicated, Resident 5'S medication included:Oxcarbazepine Oral tablet 300 mg, give 1 tablet by mouth two times a day for MOOD DISORDER M/B (manifested by) SUDDEN ANGRY OUTBURST, with Order Date 3/10/2026 and Start Date of 3/10/26.PROZAC Oral Capsule 20 mg (Fluoxetine HCL) Give 1 capsule by mouth one time a day for DEPRESSION M/B INTENSE AFFECTION TO OTHERS AND SEEKING OUT COMPANY OBSESSIVELY, with Order Date 3/31/2026 and Start Date 4/01/2026. Further review of Resident 5's Order Summary Reports : Active Orders as of 1/5/2026, 2/012026 and 3/02/2026, all included order forOxcarbazepine Oral tablet 300 mg, give 1 tablet by mouth two times a day for MOOD DISORDER M/B (manifested by) SUDDEN ANGRY OUTBURST, with Order Date of 1/2/2026 and Start Date of 1/3/2026. All Active Orders as of 1/5/2026, 2/01/2026, 3/2/2026 and 4/01/2026 included and indicated, Behavior Monitoring (Oxcarbazepine) Document Number of Episodes per shift or target behavior [Specify] SUDDEN ANGRY OUTBURST every shift. Order date 10/03/2025 and start date of 10/03/2025 A review of Resident 5's Care Plan with Date Initiated 8/15/2025 indicated, Focus: The resident has mood disorder problem(s) r/t (related to) DX. OF DEMENTIA M/B (manifested by) SUDDEN ANGRY DISORDER. 8/15/25: Resident started on Oxcarbazepine for MOOD DISORDER. 10/13/25: Resident with behavior of taking/getting staff personal property such as cell phone, other resident's clothing. >>> GETTING CLOSE and PROTECTIVE TO OTHER RESIDENT. A review of Resident 5's Care Plan with Date initiated 3/31/26 indicated, Focus: Resident has DEPRESSION M/B [manifested by] intense affection to others and seeking out company obsessively. A review of Resident 5's Care Plan with Date Initiated 4/3/26 indicated Focus: [name of Resident 5] was observed standing with inappropriate exposure and contact involving the other resident. This is the care plan initiated for the abuse which occurred on 4/3/26. A review of Resident 5's Care Plan with Date Initiated 4/7/26 indicated, Focus: ALTERCATION [Name of Resident 5] Room no. to CNA 1 on 1 sitter With intervention INCLUDING Fax SOC 341 (Reports of Suspected Dependent Adult/Elder Abuse) to CDPH, Ombudsman & Law Enforcement. This Intervention has a Date Initiated 4/8/26 However, a review of the SOC 341 received at the State Agency only indicated it was faxed to the State Agency and cross- reported to Ombudsman but it did not indicate the abuse incident was reported to Law Enforcement during the date of occurrence and it did not indicate it was also faxed to the Ombudsman. During an interview on 4/9/26 at 3:18 p.m. with the Administrator (ADM) and the Director of Nursing (DON), the ADM stated that CNA C reported Resident 5 was seen on 4/3/26 in Resident 4's room with his pants down by Resident 4's bedside. The ADM also stated the staff reported Resident 5's genitals touched Resident 4's head. The DON stated CNA C witnessed and reported the sexual abuse. During a phone interview on 4/13/26 at 2:09 p.m. with CNA C, CNA C stated that on 4/3/26 at around lunch time, she noted Resident 5 was not in his room or dining area. CNA C then stated she noticed Resident 4's room was closed and she walked inside the room with CNA D without making any noise and saw Resident 5 standing by Resident 4's top left bedside. CNA C also stated Resident 4 was asleep with eyes closed and Resident 5's male genital (penis) was inside Resident 4's mouth. CNA C stated Resident 5 was asked to get outside of Resident 4's room. CNA C also stated staff were aware of Resident 5's behaviors such as entering other residents' rooms and grabbing clothes and staff were supposed to supervise him. CNA C stated Resident 5 can walk without assistance, can eat by himself and was able to get to the bathroom unassisted. CNA C stated she did not mention the sexual abuse to anyone and waited for the supervisor to report the incident. CNA C also stated she was not aware who was their Abuse Coordinator. During a phone interview on 5/4/26 at 3:15 p.m. with the DON, the DON stated CNA D was with CNA C when the sexual abuse was witnessed on 4/3/26 in Resident 4's room. The DON also stated CNA C reported the incident to the Unit Manager (UM) and the UM reported it to the ADM on 4/7/26. The DON stated it should have been reported earlier. During a phone interview on 5/6/26 at 10:57 a.m. with the UM, the UM stated CNA C reported the sexual abuse incident to her on 4/3/26 at 12:15 p.m. The UM also stated Resident 4's responsible party was not informed of the sexual abuse on 4/3/26. The UM stated she reported the sexual abuse incident to their Abuse Coordinator, the ADM on 4/7/26. The UM stated their Abuse Reporting Protocol indicated it should have been reported within two hours to the Ombudsman, California Department of Public Health, and the police. A review of facility's 5 Day Investigation Report submitted on 4/10/26 to California Department of Public Health indicated, .Event Description: On 4/7/2026 at approximately 12:25 pm, a report was received from staff regarding an alleged inappropriate physical interaction involving resident and a female resident. Per report, the resident was observed standing with exposed genitalia and physical contact occurred with the female resident in the head area. The alleged event was reported to have occurred in room [ number/letter] on 4/3/2026 at around 12:00 pm . A review of facility's policies and procedures (P&P) entitled Resident Rights revised December 2016, the P&P indicated, .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .c. be free from abuse, neglect, misappropriation of property, and exploitation; . A review of facility's policies and procedures (P&P) entitled Abuse and Neglect- Clinical Protocol revised March 2018, the P&P indicated, Definitions.3. 'Sexual abuse' is defined.as 'non-consensual sexual contact of any type with a resident.A review of facility's policies and procedures (P&P) entitled Abuse Investigation and Reporting dated October 2022, the P&P indicated, .Reporting:.2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; orTwenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.Verbal/written notices to agencies may be submitted via special carrier, fax, e-mail, or by telephone.

Based on interview and record review, the facility failed to ensure an alleged violation involving sexual abuse was reported immediately when the Unit Manager (UM) failed to immediately report a witnessed sexual abuse on Resident 4 by Resident 5 on 4/3/26. The UM failed to call the Police, notify the State Agency (CDPH - California Department of Public Health) and the Ombudsman on 4/3/26 when the sexual abuse occurred and within the timeframe defined by regulations. This failure resulted in delayed investigation of the abuse allegation and put residents at risk of possible violations such as abuse, neglect, exploitation or mistreatment with or without injuries.FINDINGS: A review of Resident 4's medical record indicated an admission date of 1/18/2018. Resident 4's son had Power of Attorney (a legal document that allows a resident to appoint someone else to manage financial, legal, or medical affairs) and was the responsible party for Resident 4's finances and care. Resident 4's diagnoses included but were not limited to, contracture of muscle right and left lower leg (the permanent, abnormal shortening or stiffening of muscles, tendons, ligaments, or skin, causing joint stiffness and restricting movement); paroxysmal atrial fibrillation (an irregular, often rapid heart rate that comes and goes, starting and stopping on its own); generalized anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry about everyday things-such as health, finances, or family); unspecified dementia (a decline in mental ability-including memory, language, and reasoning-severe enough to interfere with daily life), unspecified severity, without behavioral disturbance, psychotic disturbance (a mental health condition characterized by a loss of contact with reality, where an individual's thoughts and perceptions are significantly disrupted); mood disturbance (when a person loses touch with reality, making it hard for them to know what is real and what is not), and anxiety (body's natural response to stress characterized by feelings of fear, dread, and uneasiness); major depressive disorder, recurrent, unspecified (a mental health condition characterized by a persistent feeling of deep sadness, emptiness, or loss of interest in activities); and other frontotemporal neurocognitive disorder (a progressive brain disease that shrinks the areas responsible for personality, behavior, and language). A review of Resident 4's Minimum Data Set (MDS, an assessment tool), dated 3/9/26, indicated a brief interview for mental status score of 12 [BIMS, an assessment to test a person's cognition level, a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. A review of Resident 4's Physician Orders included but were not limited to, Admit to [Name of Hospice Agency] Hospice [a specialized type of care focused on comfort, quality of life, and dignity for patients with terminal illnesses rather than curing them] with DX [diagnosis] terminal diagnosis of: Advanced frontotemporal dementia, sepsis age related physical debility on 3/27/26. In short, Resident 4 was in Hospice Care. Morphine Sulfate (concentrate) Solution 20 mg/ml [milligram/milliliter, a unit of measurement] Give 0.25 ml by mouth every 6 hours as needed for BTP [Breakthrough Pain, transitory, intense flare of pain that occurs on top of otherwise stable, controlled chronic pain]. A review of Resident 5's medical record indicated an admission date of 4/23/25 and a discharge date of 4/7/26. Resident 5's diagnoses included but were not limited to polyneuropathy [a condition where multiple peripheral nerves throughout the body are damaged simultaneously, causing widespread symptoms]; hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease [a condition where long-term high blood pressure damages both the kidneys and the heart simultaneously]; atherosclerotic heart disease of native coronary artery without angina pectoris [hardening of original arteries that supply blood to your heart due to plaque buildup, causing narrowing]; unspecified dementia, unspecified severity, with other behavioral disturbance. A review of Resident 5's Minimum Data Set (MDS, an assessment tool), dated 1/8/26, indicated a brief interview for mental status score of 4 [BIMS, a assessment to test a person's cognition level, a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. A review of Resident 5's Order Summary Report indicated, Active orders as of 1/5/2026, 2/01/2026, 3/02/2026 and, 4/01/2026 all these monthly orders indicated, Order Summary1. ATTEMPTED TO REDIRECT. 2. 1:1 INTERVENTION. 3. SPOKEN IN CALM MANNER. 9. ENCOURAGE TO EXPRESS FEELINGS/CONCERNS. 11. TAKEN TO ACTIVITIES . , with Order Date 8/15/2025 and Start Date 8/15/2025. This order indicated Resident 5 was to be on 1:1 intervention. A review of Resident 5's Order Summary Report: Active Orders as of 4/1/2025 indicated, Resident 5'S medication included:Oxcarbazepine Oral tablet 300 mg, give 1 tablet by mouth two times a day for MOOD DISORDER M/B (manifested by) SUDDEN ANGRY OUTBURST, with Order Date 3/10/2026 and Start Date of 3/10/26.PROZAC Oral Capsule 20 mg (Fluoxetine HCL) Give 1 capsule by mouth one time a day for DEPRESSION M/B INTENSE AFFECTION TO OTHERS AND SEEKING OUT COMPANY OBSESSIVELY, with Order Date 3/31/2026 and Start Date 4/01/2026. Further review of Resident 5's Order Summary Reports : Active Orders as of 1/5/2026, 2/012026 and 3/02/2026, all included order forOxcarbazepine Oral tablet 300 mg, give 1 tablet by mouth two times a day for MOOD DISORDER M/B (manifested by) SUDDEN ANGRY OUTBURST, with Order Date of 1/2/2026 and Start Date of 1/3/2026. All Active Orders as of 1/5/2026, 2/01/2026, 3/2/2026 and 4/01/2026 included and indicated, Behavior Monitoring (Oxcarbazepine) Document Number of Episodes per shift or target behavior [Specify] SUDDEN ANGRY OUTBURST every shift. Order date 10/03/2025 and start date of 10/03/2025 A review of Resident 5's Care Plan with Date Initiated 8/15/2025 indicated, Focus: The resident has mood disorder problem(s) r/t (related to) DX. OF DEMENTIA M/B (manifested by) SUDDEN ANGRY DISORDER. 8/15/25: Resident started on Oxcarbazepine for MOOD DISORDER. 10/13/25: Resident with behavior of taking/getting staff personal property such as cell phone, other resident's clothing. >>> GETTING CLOSE and PROTECTIVE TO OTHER RESIDENT. A review of Resident 5's Care Plan with Date initiated 3/31/26 indicated, Focus: Resident has DEPRESSION M/B [manifested by] intense affection to others and seeking out company obsessively. A review of Resident 5's Care Plan with Date Initiated 4/3/26 indicated Focus: [name of Resident 5] was observed standing with inappropriate exposure and contact involving the other resident. This is the care plan initiated for the abuse which occurred on 4/3/26. A review of Resident 5's Care Plan with Date Initiated 4/7/26 indicated, Focus: ALTERCATION [Name of Resident 5] Room no. to CNA 1 on 1 sitter With intervention INCLUDING Fax SOC 341 (Reports of Suspected Dependent Adult/Elder Abuse) to CDPH, Ombudsman & Law Enforcement. This Intervention has a Date Initiated 4/8/26 However, a review of the SOC 341 received at the State Agency only indicated it was faxed to the State Agency and cross- reported to Ombudsman but it did not indicate the abuse incident was reported to Law Enforcement during the date of occurrence and it did not indicate it was also faxed to the Ombudsman. During an interview on 4/9/26 at 3:18 p.m. with the Administrator (ADM) and the Director of Nursing (DON), the ADM stated that CNA C reported Resident 5 was seen on 4/3/26 in Resident 4's room with his pants down by Resident 4's bedside. The ADM also stated the staff reported Resident 5's genitals touched Resident 4's head. The DON stated CNA C witnessed and reported the sexual abuse to the Supervisor (UM) on 4/3/26. The ADM further stated that the UM reported this sexual abuse to him (ADM - who is the Abuse Coordinator) on 4/7/26. During a phone interview on 4/13/26 at 2:09 p.m. with CNA C, CNA C stated that on 4/3/26 at around lunch time, she noted Resident 5 was not in his room or dining area. CNA C then stated she noticed Resident 4's room was closed and she walked inside the room with CNA D without making any noise and saw Resident 5 standing by Resident 4's top left bedside. CNA C also stated Resident 4 was asleep with eyes closed and Resident 5's male genital was inside Resident 4's mouth. CNA C stated Resident 5 was asked to get outside of Resident 4's room. CNA C also stated staff were aware of Resident 5's behaviors such as entering other residents' rooms and grabbing clothes and staff were supposed to supervise Resident 5. CNA C stated Resident 5 can walk without assistance, can eat by himself and was able to get to the bathroom unassisted. CNA C stated she did not mention the sexual abuse to anyone and waited for the supervisor to report the incident. CNA C also stated she was not aware who was their Abuse Coordinator. During a phone interview on 5/4/26 at 3:15 p.m. with the DON, the DON stated CNA D was with CNA C when the sexual abuse was witnessed on 4/3/26 in Resident 4's room. The DON also stated CNA C reported the incident to the Unit Manager (UM) and the UM reported it to the ADM on 4/7/26. The DON stated it should have been reported earlier. During a phone interview on 5/6/26 at 10:57 a.m. with the UM, the UM stated CNA C reported the abuse to her on 4/3/26 at 12:15 p.m. The UM also stated Resident 4's responsible party was not informed of the incident on 4/3/26. The UM stated she reported the incident to their Abuse Coordinator, the ADM on 4/7/26. The UM stated their Abuse Reporting Protocol indicated it should have been reported within two hours to the Ombudsman, California Department of Public Health, and the police. A review of facility's 5 Day Investigation Report submitted on 4/10/26 to California Department of Public Health indicated, .Event Description: On 4/7/2026 at approximately 12:25 pm, a report was received from staff regarding an alleged inappropriate physical interaction involving resident and a female resident. Per report, the resident was observed standing with exposed genitalia and physical contact occurred with the female resident in the head area. The alleged event was reported to have occurred in room [Room no.] on 4/3/2026 at around 12:00 pm. A review of facility's policies and procedures (P&P) entitled Resident Rights revised December 2016, the P&P indicated, .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . c. be free from abuse, neglect, misappropriation of property, and exploitation; . A review of facility's policies and procedures (P&P) entitled Abuse and Neglect- Clinical Protocol revised March 2018, the P&P indicated, Definitions.3. 'Sexual abuse' is defined.as 'non-consensual sexual contact of any type with a resident.A review of facility's policies and procedures (P&P) entitled Abuse Investigation and Reporting dated October 2022, the P&P indicated, .Reporting:.2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; orTwenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.Verbal/written notices to agencies may be submitted via special carrier, fax, e-mail, or by telephone.

Based on interview and record review, the facility failed to facilitate a person-centered care planning meetings for one of one resident (Resident 1) when the interdisciplinary team (IDT - a group of health care professionals from diverse fields who work toward a common goal for residents) missed to hold Resident 1's quarterly care conferences (a regular, formal meeting [usually quarterly] where the resident, their family, and the nursing home staff meet to review the resident's health, discuss goals, and adjust their care plan). This failure had the potential for unmet goals, choices and preferences for Resident 1.Findings:Review of Resident 1's clinical record titled, admission Record, indicated Resident 1 was admitted to the facility with diagnoses including type1 diabetes mellitus (a condition which affects the way the body processes blood sugar) with diabetic autonomic neuropathy (nerve damage caused by diabetes), acquired absence of right and left upper limbs below elbows, and acquired absence of right and left above knees.Review of Resident 1's quarterly minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 1's brief interview for mental status (BIMS -an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 15 (patient is cognitively intact). Review of Resident 1's list of IDT care conferences held with Resident 1 indicated the last care conference was in 8/4/2025. Further review indicated there was no other care conference held after 8/4/2025.During a concurrent interview with social services A (SS A) and record review of Resident 1's list of IDT care conferences, and SS progress notes on 4/30/2026 at 11:01 a.m., SS A confirmed Resident 1's last care conference was held on 8/4/2025 and she stated the care conference should have been held every three months. SS A further stated she could not find any documentation why there were no other care conferences held after 8/4/2025.During a concurrent interview with social services B (SS B) and record review of Resident 1's list of IDT care conferences, SS progress notes and care conference calendar on 4/30/2026 at 11:52 a.m., SS B confirmed Resident 1's last care conference was held on 8/4/2025 and there was no other documented care conference held in 10/2025, 1/2026 and 4/2026. SS B stated she was the one who tracked the care conference schedule and she did not know why they were missed.During a concurrent interview with minimum data set nurse C (MDSN C) and minimum data set nurse D (MDSN D) on 4/30/2026 at 2:24 p.m., they both stated the IDT care conference should have been done quarterly for residents to know the plan of care and if residents' needs were met.During a review of the facility's policy and procedure titled, Resident Participation - Assessment/Care Plans, dated 2/2021, indicated, The resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan.Facility staff supports and encourages resident/representative participation in the care planning process by:.b. holding care planning meetings at times of day when the resident, representative and family members can attend and are functioning at their best; c. providing sufficient notice in advance of the meeting.The social services director or designee is responsible for notifying the resident/representative and for maintaining records of such notices.

Based on interview and record review, the facility failed to provide services according to professional standards for one of one resident (Resident 1) when licensed nurses had no documentation of Resident 1's use and care of sequential compression device (SCD - a pair of inflatable leg wraps connected to a machine that acts as a massager for the legs to prevent blood clots while inactive, a compression therapy) and there was no care plan (a summary of a person's health conditions, goals, specific care needs, and current treatments) developed for the SCD's use.These failures resulted in multiple fluid filled blisters (a small, raised bubble on the skin filled with clear, water liquid, blood, or pus) and pain on Resident 1's bilateral (affecting two sides) lower extremities (legs).Findings:Review of Resident 1's clinical record titled, admission Record, indicated Resident 1's original admission date was 6/3/2025 and was readmitted to the facility on [DATE] with diagnoses including malignant neoplasm of overlapping sites of urinary organs refers to cancer that has started in or spread across multiple nearby parts of the urinary system such as the bladder, kidneys, or ureters), myelodysplastic syndrome (MDS - a group of disorders caused by blood cells that are poorly formed or does not work properly), and type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar).Review of Resident 1's August 2025 order summary report indicated an order dated 8/9/2025, for Resident 1 to use SCD to both lower legs every shift for deep venous thrombosis (DVT - a serious condition where a blood clot forms in a deep vein, usually in the leg or thigh) prevention.During a concurrent interview with the Director of Sub-Acute (DSA) and record review of Resident 1's 8/2025 order summary report, assessments, and progress notes on 2/27/2026 at 10:30 a.m., the DSA confirmed Resident 1 had SCD in 8/2025 for her legs, and stated they had two different SCD sleeves (used to wrap the legs): a cloth material and the other one was made of plastic which the DSA described was rough. The DSA stated Resident 1 had the plastic type of SCD sleeves. The DSA further stated Resident 1 developed blisters to her legs on 8/18/2025 and Resident 1's family member (FM) was present at bedside. She stated the FM was adamant to transfer Resident 1 to the hospital to further evaluate Resident 1's legs. The DSA further stated Resident 1's doctor saw Resident 1 on 8/18/2025 and noticed discoloration and blisters to left lower leg. The DSA stated licensed nurses should have monitored Resident 1's skin every two hours while in use of SCD. The DSA confirmed there was no monitoring of Resident 1's bilateral lower leg's skin condition since they started Resident 1's SCD use in 8/2025.During an interview with licensed vocational nurse A (LVN A) on 2/27/2026 at 1:10 p.m., LVN A stated licensed nurses should check the skin wrapped with the SCD sleeves for any redness every time they entered the resident's room and should have documentation of their assessment. LVN A further stated certified nursing assistants (CNAs) should also notify licensed nurses if they found any skin issues.During a review of Resident 1's nurses notes dated 8/18/2025, indicated Resident 1 had a change in condition of poor circulation and intact (whole or undamaged) fluid filled blister on left lower leg. Further review indicated that Resident 1 was transferred out to the emergency room (ER) for further evaluation on 8/18/2025, and it was licensed nurse B (LN B) who assessed Resident 1.During a phone call to LN B on 2/27/2026 at 2:08 p.m. and 4/30/2026 at 12:23 p.m., LN B did not answer both calls and never called back.During a concurrent interview with the director of nursing (DON) and record review of Resident 1's 8/2025 order summary report, nurses' notes and list of care plans on 4/30/2026 at 1:00 p.m., the DON confirmed the following: a. Resident 1 had SCD order, dated 8/9/2025; b. Licensed nurses had no documentation of SCD care like checking of Resident 1's bilateral lower leg's skin condition, and circulation; and c. Care plan for SCD use was not developed. The DON stated a care plan should have been developed for SCD use and there should have been documentation on Resident 1's SCD use and care.Review of Resident 1's attending physician's Discharge summary dated [DATE], indicated, She developed blisters on legs and had to be transferred.Review of Resident 1's hospital records titled, HPI [History of Present Illness]-General Illness, dated 8/18/2026 at 4:20 p.m., indicated, Chief complaint: Blisters to bilateral lower extremities.Of note, patient had been on compression therapy.Bilateral lower extremities with well demarcated lines [a clearly visible boundary that separates infected, or dead tissue from surrounding healthy tissue] at the ankles bilaterally, cyanotic [a bluish or purplish discoloration of the skin, lips, or fingernails caused by low oxygen levels in the blood].Multiple fluid-filled blisters to the lower extremities in linear [skin condition arranged in a straight line] fashion.Review of Resident 1's attending physician's H&P [History and Physical], dated 8/23/2025, indicated, I had seen her the Sunday [8/17/2025] the day before she came to the hospital and she had SCDs on and boots to protect her heels. I noticed that her lower legs and feet were swollen.They had a [NAME] texture to them.She was grimacing and I asked her .are you in pain? she nodded yes. I said where, she did not attempt to say where, but when I asked if it was her legs, she nodded yes, and when I asked her if she wanted something for pain, she nodded yes.Biggest problems right now are.skin damage and superficial vein damage (a condition where a blood clot forms in a vein just below the skin's surface, causing inflammation, pain, and redness) supposedly from SCDs bilateral lower legs.Review of Resident 1's hospital records titled, Wound/Pressure Ulcer [damage to the skin caused by prolonged pressure] Assessment, dated 8/19/2025 at 2:00 a.m., indicated the following: 1. Skin discoloration on bilateral feet; 2. Blisters on bilateral front view of her legs; 3. Skin tear upper front view of right leg; 4. Bilateral heels redness; 5. Skin tear to the back view of the left leg.During a review of the facility's policy and procedure titled, Applying a Pneumatic Compression Device (PCD - also known as SCD - a medical device that uses air-filled sleeves or boots connected to a pump to apply rhythmic, squeezing pressure to the legs), date revised 10/2010, indicated, Verify that there is a physician's order for PCD application and removal. If there is no order for the procedure, contact the attending Physician to obtain orders.Review the resident's care plan to assess for any special needs of the resident.Every 8 hours after the application: a. assess the position of the sleeves and tubing. Check connection to the air pump [an electric device that automatically forces air into the leg sleeves to compress the legs to keep blood moving and prevent blood clots]. c. Remove device and assess conditions of the legs and skin. D. Assess resident's level of comfort.Documentation The following information should be recorded in the resident's medical record: 1. The date and time of application. 2. Type of sleeves used.4. Assessment data gathered before and after the procedure. 5. The resident's response to the procedure. 6. The schedule of removal and reapplication.

Based on interview and record review, the facility failed to ensure the availability of medication for one out of 3 sampled residents (Resident 1) when Resident 1 missed four doses of Fidaxomicin Oral Tablet (treats diarrhea caused by bacteria) from 1/29/26 to 1/30/26 when the facility staff did not send the Prior Authorization for High Cost Medication to the Pharmacy on time.The failure had the potential for untreated or worsening of medical conditions for Resident 1.Findings: Resident 1's clinical record was reviewed. Resident 1 was admitted to the facility with diagnoses includes Parkinson's disease (a movement disorder of the nervous system that worsens over time) without dyskinesia (involuntary, erratic, and uncontrollable muscle movements, such as writhing, fidgeting, or jerking) and cardiogenic shock (life-threatening medical emergency where the heart suddenly cannot pump enough blood to meet the body's oxygen needs, often resulting from a severe heart attack). A review of Resident 1's January 2026's Medication Administration Record (MAR, a record of medications given), indicated an order for fidaxomicin Oral Tablet 200 MG Give 1 tablet by mouth two times a day for CDAD (Clostridioides difficile-Associated Diarrhea, a severe, antibiotic-associated intestinal infection caused by the Clostridioides difficile [bacterium that causes severe diarrhea and colon inflammation]), start date 1/29/26 at 0900 and D/c date 2/7/26.A review of Resident 1's January 2026's MAR, indicated Resident missed the following dose:-1/29/26 at 0900 Licensed Nurse A documented 2 = drug refused.-1/29/26 at 1700 Licensed Nurse B documented 13 = drug not available.-1/30/26 at 0900 unsigned MAR, no documentation.-1/30/26 at 1700 LN B documented 2 = drug refused. During a review of Resident 1's progress notes dated 1/29/26 indicated LN B documented fidaxomicin oral tablet 200 mg give 1 tablet by mouth two times a day for CDAD. ABT (antibiotic) not available called pharmacy to f/up (follow up) an order. Per pharmacy will be delivered 1/30 at 1pm. During a phone interview and record review on 5/11/26 at 2:30 p.m., with Licensed Nurse A, she reviewed Resident 1's 1/2026 MAR, she stated she documented refused on 1/29/26 at 0900 for fidaxomicin, she further stated she don't really remember if the fidaxomicin is available, she thinks it was there and all medications was refused, she confirmed fidaxomicin documented on 1/29/26 in the MAR as drug refusal. During a phone interview and record review on 5/13/26 at 3:48 p.m., with LN B she reviewed Resident'1 progress notes dated 1/29/26 and 1/2026 MAR, she stated on 1/29/26 she documented fidaxomicin is not available she stated the pharmacy will deliver on 1/30/26 at 1pm., she stated on 1/30/26 she documented in the MAR as drug refused, she stated she can't remember if the medication is available, she further stated fidaxomicin was not in the e-kit (Emergency Kit, a prepared, accessible supply of essential medications). During a phone interview on 5/14/26 at 8:28 a.m., with the Consultant Pharmacist (CP), the CP was asked if the fidaxomicin is available in the e-kit, the CP checked and stated the fidaxomicin is not available in the e-kit. During a follow up phone interview on 5/14/26 at 1:02 p.m., with the CP, she stated on 1/28/26 at 10:16 p.m., the pharmacy received the fidaxomicin order from facility, she stated the medication is a high-cost medication exceeding $500, requiring authorization from the facility. On 1/29/26 the pharmacy sent an authorization to the facility (Prior Authorization for High Cost Medication), on 1/31/26 at 12:06 a.m., the pharmacy received the signed authorization and dispensed the medication for delivery on 1/31/25. During a review of pharmacy delivery receipt indicated, Resident 1's fidaxomicin oral tablet 200 mg tablet 20 each was delivered on 1/31/26 at 5:00 a.m. During a review of Resident 1's Nurse Practitioner progress notes dated 1/30/26 indicated, Patient was noted to have significant hematochezia (passing fresh, bright red blood from the anus, usually in or with stool.) with mucoid (substances that are like or resemble mucus, typically sticky, gelatinous, or slimy) stool today, representing an acute change in condition. The patient was recently discharged from the hospital following septic shock C/B Clostridioides difficile infection. Since discharge, the patient has been non compliant with prescribed medications, and Dificid (fidaxomicin) is currently unavailable per pharmacy, limiting appropriate treatment options at the facility. Given the significant amount of hematochezia, recent severe infection, and overall medical fragility, there is high concern for ongoing or worsening C. difficile colitis and potential complications. Hospital transfer was strongly recommended, and the patient's current medical status, risks, benefits, and need for further evaluation and treatment were discussed in detail. Risks of delaying transfer, including worsening bleeding, hemodynamic (how blood flows through the cardiovascular system.) instability, sepsis (life-threatening response to an infection), and death, were explained. [Responsible Party] was notified and acknowledged understanding of the patient's condition and recommendations. She requested ambulance transfer to be arranged for 01/31/2026 at 9:00 AM. Declined ER (emergency room) transfer tonight 1/30/26. Laboratory results are still pending at this time. The patient will remain under close monitoring pending transfer, with instructions to escalate care immediately should the condition worsen. Closely. During a review of Resident 1's progress notes dated 2/1/26 indicated, resident was transferred to hospital at 11AM. During a review of the facility's policy and procedure titled, Administering Medications, revised date 4/2019, indicated, Policy Statement Medications are administered in a safe and timely manner, and as prescribed.1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so.4. Medications are administered in accordance with prescriber orders, including any required time frame.7. Medications shall be administered in accordance with their prescribed schedule, ensuring timely delivery unless specific instructions indicate otherwise.

Based on observation, interview and record review, the facility failed to ensure one out of five sample residents (Resident 1) was provided with needed care and services in accordance with resident's preferences when Resident 1 was asking for help but was not attended by staff during shift change.This failure had the potential to put Resident 1 at risk for physical and psychosocial harm.During a concurrent observation and interview on 4/9/26 at 2:53 p.m. outside Resident 1's room, Resident 1 can be heard shouting Help while the door was open. Staff were observed doing reports for the shift change. Certified Nurse Aide (CNA) A was using a tablet attached to the wall along the hallway of Resident 1's room. Multiple staff were observed to pass by Resident 1's room without checking on Resident 1. CNA A was asked if it was acceptable not to check on Resident 1 when he was shouting for help, CNA A stated, He's always like that. When CNA B was asked if Resident 1 should be checked when he was asking for help, CNA B stated, He just says things. A review of Resident 1's medical record indicated an admission date of 7/4/25. Resident 1's diagnoses included but were not limited to Cauda Equina Syndrome (a rare medical emergency where the bundle of nerves at the base of the spine is severely compressed), atherosclerotic heart disease of native coronary artery without angina pectoris {(plaque [cholesterol, fat] has built up in the original heart arteries, narrowing them. It is a silent form of coronary artery disease [CAD] where blood flow is restricted, but the patient does not experience chest pain)}, bilateral primary osteoarthritis of knee (a common, age-related condition where the protective cartilage in both knees gradually wears away), dementia (memory-loss disorder) in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Alzheimer's disease, unspecified (a progressive brain disease that acts like a slow, irreversible decline in memory, thinking, and reasoning skills), and syncope and collapse (fainting or passing out). A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 3/26/26, indicated a brief interview for mental status score of 3 [BIMS, a tool used to assess cognition (knowing, learning, and understanding), a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. During an interview on 4/9/26 at 3:18 p.m. with the Director of Nursing (DON) and the Administrator (ADM), the DON stated staff must check on residents asking for help. The DON also stated staff must always be polite and professional. The ADM stated Resident 1 usually yells for help even if it's nothing, but staff must always check on Resident 1 to ensure assistance is given when needed. A review of facility's job description for Certified Nursing Assistant indicated, Purpose of Your Job Position: The primary purpose of your job position is to provide each of your assigned residents with routine daily activities and nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisors.Duties and Responsibilities:Administrative Functions:.Monitor and supervise residents at all times to ensure resident safety. A review of facility's policies and procedures (P&P) entitled Resident Rights revised December 2016, the P&P indicated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:.b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation.

Based on observation, interview, and record review, the facility failed to provide necessary services to maintain grooming and personal care to one of two sampled residents (Resident 1) when Resident 1's skin in bilateral (involving or affecting two side, or parts) lower legs especially the heel areas were very white, and scaly (a symptom where the top layer of skin becomes, dry, rough, and sheds in flakes, often resembling fish scales) due to dryness, and her fingernails and toenails were long.These failures had the potential to affect Resident 1's health and well-being.Findings:1a. Review of Resident 1's clinical record titled, admission Record, dated 2/25/2026, indicated Resident 1 was admitted to the facility with diagnoses including respiratory failure (a condition when lungs cannot release oxygen to blood causing shortness of breath) with hypoxia (occurs when oxygen level in the body organs are low), methicillin resistant staphylococcus aureus infection (MRSA - a bacteria that does not respond to antibiotics), tracheostomy status (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube), and gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).Review of Resident 1's quarterly minimum data set (MDS - a federally mandated resident assessment tool) assessment, dated 1/26/2026, indicated Resident 1 had long term memory (the brain's system for storing, managing, and retrieving information for long periods - from a few minutes to a lifetime) and short-term memory (a temporary storage space that holds limited amount of information for a few seconds to minutes) problems. Further review indicated Resident 1 was dependent on all her activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a concurrent observation and interview with licensed vocational nurse A (LVN A) on 3/4/2026 at 11:58 a.m., inside Resident 1's room, Resident 1 was observed in bed, eyes opened and her bilateral lower legs' skin, especially the heels were white and scaly due to dryness. LVN A confirmed above observation and stated certified nursing assistants (CNAs) should have moisturized Resident 1's skin. LVN A further stated, if the CNAs could not moisturize residents' skin, licensed nurses should do it.During a concurrent observation and interview with registered nurse B (RN B) on 3/20/2026 at 10:54 a.m., inside Resident 1's room, Resident 1's bilateral lower legs and heels' skin were white, and scaly. RN B confirmed observation and stated CNAs should have moisturize Resident 1's skin during ADL care.During an interview with certified nursing assistant C (CNA C) on 3/26/2026 at 10:18 a.m., CNA C stated we (CNAs) should moisturize residents' skin after ADL care.During a phone interview with the director of nursing (DON) on 4/2/2026 at 10:37 a.m., DON stated the CNAs should moisturize residents' skin during ADL care, after bed bath, showers, and when needed.During a review of the facility's policy and procedure titled, Bath, Shower/Tub, date revised 2/2018, indicated, The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.The following equipment and supplies will be necessary when performing this procedure. 1. Portable bath chair; 2. Lotion.1b. During a concurrent observation and interview with RN B on 3/20/2026 at 10:54 a.m., inside Resident 1's room, Resident 1 was in bed and the following were observed: Resident 1's left first/great toenail was long, thick, light yellow in color; the left second toenail had brown/black discoloration, long and curved; the right first/great toenail was long and thick; and both right and left fingernails were long and thick. RN B confirmed the observations and stated, oh yes, they are long. RN B stated CNAs should have trimmed Resident 1's fingernails and toenails. RN B further stated Resident 1 did not have diabetes (a disease that occurs when the blood sugar is too high).During an interview with the director of subacute (DSA) on 3/20/2026 at 11:06 a.m., the DSA stated their podiatrist (a doctor who specializes in caring for feet and ankles) visited the facility once a month and their CNAs trimmed their resident's toenails (if not complicated) and fingernails every Saturday. The DSA further stated CNAs and licensed nurses (LNs) were responsible for nail trimming, and they could also do it during shower days. The DSA confirmed Resident 1's shower days were every Wednesday and Sunday night.Review of Resident 1's clinical record titled, Order Summary Report, order dated 8/25/2025, indicated there was an order for podiatry appointment.During an interview with social services D (SS D) on 3/20/2026 at 11:32 a.m., SS D stated Resident 1 had an insurance which did not cover the facility's podiatrist, and the family was responsible to pay privately. SS D further stated Resident 1's family owed their podiatrist $130 and would never provide the service until the family would pay. SS D confirmed the administrator was not aware about this concern, and they never notified him to address the concern.During a concurrent interview with nursing supervisor (NS) and record review on 3/20/2026 at 2:55 p.m., NS reviewed Resident 1's Shower Day Skin Inspection record dated 3/18/2026 which was completed by Resident 1's CNA. It indicated Resident 1 had a shower on 3/18/2026, her fingernail did not need clipping, and her toenails for need clipping was left unmarked. NS confirmed both fingernails and toenails should have been marked, yes for need clipping.During concurrent observation and interview with licensed vocational nurse E (LVN E) on 3/26/2026 at 10:20 a.m., inside Resident 1's room, Resident 1's toenails were still long, and thick. LVN E confirmed above observation and stated the podiatrist did not visit yet.During a phone interview with the DON on 4/2/2026 at 10:37 a.m., the DON stated nail trimming should have been done by LNs or CNAs if residents did not have any problem that would not require them to trim residents' fingernails and toenails. DON further stated CNAs or LNs should trim residents' toenails if a resident was not diabetic. DON stated CNAs should notify the LNs if a diabetic resident needed toenail trimming and LNs should notify SS. DON further stated SS should have brought up this concern in their daily morning meetings to get some guidance on how to proceed.Review of Resident 1's podiatry note dated 4/1/2026, indicated, Nails are long and thickened x 1' [one inch long]. R [right] hallux [big toe] nail has a bruise [or contusion, a common injury resulting from broken small blood vessels that leak blood into surrounding tissues].L [left] 2nd toe has a mild ingrown [a nail that has grown abnormally into the surrounding skin/flesh, often causing pain, inflammation, and infection].During a review of the facility's policy and procedure titled, Fingernails/Toenails, Care of, date revised 2/2018, indicated, Nail care includes daily cleaning and regular trimming. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Watch for and report any changes in the color of the skin around the nail bed,.Stop and report to the nurse supervisor if there is evidence of ingrown nails.or nails are too hard or too thick to cut with ease.During a review of the facility 's policy and procedure titled, Foot Care, date revised 10/2022, indicated, Residents are provided with foot care and treatment in accordance with professional standards of practice.Residents are assisted in making appointments and with transportation to and from specialists (podiatrist.) as needed. Trained staff may provide routine foot care (e.g., toenail clipping) within professional standards of practice for residents without complicating disease processes.During a review of the facility's policy and procedure titled, Activities of Daily Living (ADL), Supporting, date revised 3/2018, indicated, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (. grooming.).

Based on observation, interview, and record review, the facility failed to ensure infection control practices was implemented when licensed vocational nurse E (LVN E) used a non-dedicated battery-operated blood pressure apparatus (BP app - a manual or automated devices intended for general, or multi-user rather than a specialized, single patient, or permanently installed in the room) to Resident 1 who was on Contact Precaution [infection control measures used in healthcare to prevent the spread of germs passed by direct touching (patient) or indirect touching (contaminated surfaces/equipment)], and did not clean and sanitize (a substance designed to reduce or eliminate germs, bacteria, and microorganisms on surfaces or skin to safe levels) the equipment before leaving the room.This failure had the potential to compromise resident's health and safety, and spread infections to residents, staff, and visitors.Findings:Review of Resident 1's clinical record titled, admission Record, dated 2/25/2026, indicated Resident 1 was admitted to the facility with diagnoses including respiratory failure (a condition when lungs cannot release oxygen to blood causing shortness of breath) with hypoxia (occurs when oxygen level in the body organs are low), methicillin resistant staphylococcus aureus infection (MRSA - a bacteria that does not respond to antibiotics), tracheostomy status (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube), and gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).Review of Resident 1's Order Summary Report, indicated a physician's order dated 1/1/2025, indicated, CONTACT PRECAUTIONS SECONDARY TO DX [diagnosis]: Carbapenemase-producing organisms [CPO - are highly-resistant bacteria that produce enzymes (carbapenemases) which pose an urgent public health threat, causing difficult-to-treat infections] every shift.During an observation on 2/25/2026 at 11:08 a.m., in Station AA, in front of Resident 1's room, there was a facility made Contact Isolation signage posted at Resident 1's entrance door.During an interview with licensed vocational nurse A (LVN A) on 2/25/2026 at 11:11 a.m., LVN A confirmed Resident 1 was on contact isolation due to having microorganism resistant to antibiotics.During an interview with registered nurse F (RN F) on 2/25/2026 at 11:14 a.m., RN F stated she was assigned to Resident 1, and the resident was on contact isolation due to CRO [carbapenem-resistant organisms are highly drug-resistant bacteria, often found in healthcare settings that cause infections] in her urine.During an observation on 3/26/2026 at 10:20 a.m., inside Resident 1's room, the following were observed: LVN E donned (put on) gown and gloves before she entered the room, carried the battery operated BP app which she took from the medication cart, placed the device on Resident 1's foot part of the bed, and wrapped the BP cuff on Resident 1's right lower leg to obtain the blood pressure. After LVN E took Resident 1's blood pressure, she carried the device, removed her gown and right glove, she hugged the device into her chest with her right forearm and removed the left glove with use of right hand, carried the BP app with her bare hands, took it out of the room without cleaning and sanitizing the equipment, and placed it on top of the medication cart.During an interview with LVN E on 3/26/2026 at 10:45 a.m., LVN E confirmed above observations. LVN E stated there was no dedicated BP app in Resident 1's room and there was another contact isolation room that had one that family brought from home. LVN E further stated there should have been a dedicated BP app in each contact isolation room. She stated she should have cleaned and sanitized the BP app she used before she took it out of Resident 1's room.During an interview with the director of sub-acute (DSA) on 3/26/2026 at 11:00 a.m., the DSA stated they have a dedicated BP app which they were charging at the hallway. The DSA further stated they cleaned the dedicated BP app after each usage. The DSA confirmed the LVN E should have used the dedicated BP app for contact isolation residents.During an interview with the infection preventionist (IP) on 3/26/2026 ay 1:40 p.m. the IP stated nurses should always use the dedicated BP app in contact isolation rooms.During a review of the Centers for Disease Control and Prevention (CDC) signage for Contact Precautions, it indicated, EVERYONE MUST: Use dedicated or disposable equipment.During a review of CDC's Infection Control titled, Transmission-Based Precautions, dated 4/3/2024, indicated, Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission.Use disposable or dedicated patient-care equipment (e.g. blood pressure cuffs). If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on an another patient.During a review of the facility's policy and procedure titled, Multidrug-Resistant Organisms [MDRO - bacteria or fungi resistant to one or more classes of antimicrobial drugs], date revised 8/2019, indicated, Dedicate non-critical medical items to use on individual residents known to be infected or colonized with an MDRO .Enhanced Environmental Measures 1. Non-critical equipment is dedicated to the MDRO cohort unit and is not utilized outside of the designated area. When resident-specific equipment is not feasible, unit-dedicated equipment is used and cleaned and disinfected between each resident use in accordance with facility infection prevention and control policies to minimize risk of cross-contamination.

Based on interview and record review, the facility failed to provide services according to professional standards for one of two sampled residents (Resident 1) when registered nurse A (RN A) and licensed vocational nurse B (LVN B) re-inserted Resident 1's gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) without proper training and demonstration of competency in this procedure, using a bigger size of GT and did not have a detailed confirmation of GT placement (verifying if the tube is in the stomach using methods like checking for stomach contents, easy rotation of the tube, and lack of leakage. The most common method is attaching a syringe, pulling back to see gastric content, and performing a air bolus test, where 5-10 milliliters [ml - volume of measurement] of air is injected while listening to the stomach with a stethoscope [Medscape [DATE] - Gastrostomy Tube Replacement Technique]).These failures resulted in Resident 1's desaturation (drop of oxygen concentration), abdominal distension (visible or measurable swelling and enlargement of the abdomen beyond its normal size), respiratory distress (difficulty breathing, labored breathing, or the need for increased effort to breathe, often resulting in low oxygen levels) due to GT malpositioning (the feeding tube is not properly located within the stomach, having been misplaced during reinsertion), cardiac arrest (a medical emergency where the heart suddenly stops beating, cutting off blood flow to the brain and body) and Resident 1 was sent to acute hospital via 911 where Resident 1 ended up in the hospital's intensive care unit (ICU - a specialized hospital department with high-level monitoring and advanced life support for patients with life-threatening illnesses or injuries) with severe septic shock (a life-threatening stage of sepsis, caused by infection which resulted to a rapid drop in blood pressure and organ failure) due to catastrophic intra-abdominal process (or abdominal catastrophe, a sudden, severe, and life-threatening medical emergency involving the organs within the belly that requires immediate surgical intervention) from misplaced G tube. Resident 1's misplaced GT had the potential to affect her quality of life due to considerable pain, and possible multiple surgeries to address the problem. Resident 1 passed away on [DATE] at 11:55 p.m.Findings:Review of Resident 1's clinical record titled, admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure (a long-term progressive condition where the lungs cannot properly move oxygen into the blood or remove carbon dioxide) with hypoxia (a dangerous condition where the body tissues and organs do not receive enough oxygen to function properly), dependence on respirator status (use of ventilator, a life-support machine that breathes for patients who cannot breathe sufficiently on their own), Ogilvie syndrome (also called acute colonic pseudo-obstruction, a sudden, severe swelling [dilatation] of the large intestine without any physical blockage), and encounter for attention to gastrostomy.Review of Resident 1's admission minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 1 had short term memory (a temporary storage space that holds limited amount of information for a few seconds to minutes) and long term memory (the brain's system for storing, managing, and retrieving information for long periods - from a few minutes to a lifetime) problem.Review of Resident 1's nursing alert charting dated [DATE], indicated that at 4:00 p.m., Resident 1's GT was out and RN A did not find Resident 1's GT size which was 16 French (Fr - is a medical measurement used to determine the outer diameter of catheters, or tubes. A higher French number means a wider tube; a lower number means a narrower tube). Further review indicated that RN A re-inserted Resident 1's GT with use of 20 Fr and the stoma site (surgically created opening in the tummy) had a scant amount of bleeding. It indicated, confirmed GT placement by 2 nurses. G tube was in. MD [medical doctor] notified. stated ok to continue feeding.Review of Resident 1's clinical record titled, SBAR [Situation, Background, Assessment, Recommendation, a communication tool used by healthcare workers when there is a change of condition among the residents] & INITIAL COC [change of condition]/ALERT CHARTING & SKILLED DOCUMENTATION, dated [DATE] at 12:30 p.m., indicated Resident 1's oxygen level was low, and had abdominal distension. It indicated at 1:20 p.m. Resident 1 had respiratory distress, 911 was called, CPR (Cardiopulmonary Resuscitation, an emergency lifesaving procedure performed when the heart stops beating or breathing ceases) was initiated by facility staff while waiting for 911 to arrive, and she was transferred out to the hospital for further evaluation.During an interview with licensed vocational nurse C (LVN C) on [DATE] at 1:17 p.m., LVN C stated there should always be two nurses in re-insertion of GT wherein one nurse should push 10 ml of air through the GT into the stomach and the other nurse should listen for the whooshing sound with use of stethoscope in the resident's abdomen. LVN C further stated, this validation of placement should have been done twice and there should have been a standing order of x-ray to confirm the correct placement of GT.During a concurrent observation and interview with LVN C on [DATE] at 1:25 p.m., inside the facility's central supply room, LVN C showed the difference between Fr 20 and F16 of GT. LVN C confirmed, GT Fr 20 had bigger tube which could hold 7-10 ml of sterile water (a highly purified water free from viable microorganisms, bacteria, and viruses), while GT Fr 16 could hold 3-5 ml of sterile water. LVN C stated, if they ran out of GT Fr 16 and the resident needed Fr 16, we tried to use the smaller size, we do not want to use a bigger one because it might rupture something.During a phone interview with RN A on [DATE] at 1:44 p.m., RN A stated she was assigned to Resident 1 on [DATE] when the GT was pulled out. RN A further stated, she couldn't find GT Fr 16 and used Fr 20 instead. She stated she just assisted Resident 1's GT reinsertion, and it was LVN B who reinserted the GT. RN A stated, they both verified the placement of the GT. RN A confirmed there was a scant amount of bleeding in the GT site.During a phone interview with the medical doctor (MD) on [DATE] at 10:59 a.m., the MD confirmed she had given the order on [DATE] to reinsert Fr 20 GT because the facility did not have Fr 16. MD stated they usually would use the closest size, which was Fr 18, but they did not have it at that time. MD further stated since Resident 1 had the GT for a long time, she did not order to transfer her out to hospital for GT reinsertion. When asked how the GT was checked for placement, the MD stated there should be a residual (the amount of formula, fluid, and secretions remaining in the stomach) and they could gradually introduce the feeding tube formula (a specialized liquid mixture providing comprehensive nutrition-protein, carbohydrates, fats, vitamins, and minerals- directly to the stomach) at 15 ml for an hour until they reached the desired feeding rate (the specific, prescribed speed at which the liquid formula is delivered through a feeding tube). MD further stated, it is a standard practice. MD stated there was no need to perform an x-ray but because of the incident with Resident 1, the facility have to do a KUB (Kidneys, Ureter, and Bladder - a diagnostic imaging test that captures a single image of the abdominal area while the patient is lying on his/her back) x-ray before nurses could use the GT to make sure it was in the right place.During a phone interview with LVN B on [DATE] at 3:35 p.m., LVN B confirmed he re-inserted Resident 1's GT. LVN B stated there was no available Fr 16, and he used Fr 20 because that was the only available size. LVN B further stated they verified the GT placement when there was stomach content drawn from the GT and there was a whooshing sound when he injected 40 ml of air into the GT. LVN B stated he did not have to document anything because he was not the nurse assigned to Resident 1.During a concurrent interview with the director of staff development (DSD) and record review of five licensed nurses' employee files (RN A, LVN B, RN D, RN E, and RN F) on [DATE] at 1:20 p.m., the DSD confirmed RN A and LVN B did not have a training and competency checklist for reinsertion of GT, until [DATE]. DSD stated RN D, RN E, and RN F were mostly assigned in the subacute area and did not have the training and competency checklist for reinsertion of GT. The DSD further stated, these nurses were not allowed to re-insert the GT unless they had the training and competency in reinsertion of GT.Review of Resident 1's clinical record from the hospital titled, ICU's [intensive care unit] Advance Care Planning, dated [DATE], indicated, Patient with severe septic shock due to catastrophic intrabd [intraabdominal] process from misplaced G tube.Review of Resident 1's acute hospital clinical record titled, MICU [Medical Intensive Care Unit] RESIDENT PROGRESS NOTE, dated [DATE], indicated Resident 1, who was BIBA [brought in by ambulance] from SNF [skilled nursing facility] following cardiac arrest, found to have septic shock likely 2/2 [secondary to] intraabdominal infection [a bacterial or fungal infection that occurs inside the abdominal cavity, often caused by the leakage of stomach contents] in setting of malpositioned PEG (Percutaneous Endoscopic Gastrostomy tube, also known as GT, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). Further review indicated, the abdomen was significantly distended and tense [the abdomen is swollen, stretched out, and rigid due to internal pressure] . It indicated Resident 1's result of abdomen CT scan (computed tomography scan - noninvasive diagnostic imaging procedure used to detect diseases, injuries, and infections), The PEG enters into the peritoneum [a serous membrane that lines the abdominal cavity], and there is free fluid and contrast within the peritoneal cavity [the presence of abnormal fluid floating freely inside the abdominal space surrounding organs] .Review of Resident 1's Death Summary, dated [DATE], indicated, Per surgery, while ex lap [exploratory laparotomy, a major surgical procedure involving a large incision in the abdomen, allowing doctors to physically examine organs to diagnose and treat issues] could address PEG misplacement, it would likely require multiple surgeries and would not improve quality of life but add considerable pain to patient's remaining life. Further review indicated that Resident 1 passed away on [DATE] at 11:55 p.m.During a review of the facility's policy and procedure titled, Changing a Percutaneous endoscopic Gastrostomy (PEG) Tube, date revised 11/2018, indicated, PEG tube replacement must be performed by a licensed nurse who has received training and demonstrated competency in this procedure.The person performing this procedure should record the following information in the resident's medical record: 1. The date and time the procedure was performed.3. The name and title of the individual(s) who performed the procedure. 4. All assessment data obtained during the procedure. 5. How the resident tolerated the procedure.

Based on interview and record review, the facility failed to implement Resident 1's insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep) care plan. This failure had the potential to not meet care needs for Resident 1.Findings:Review of Resident 1's clinical record titled, admission Record, indicated Resident 1 was admitted with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (a condition that causes partial paralysis or weakness on one side of the body) following cerebral infarction (a type of stroke caused by a blockage in brain blood vessels, resulting in a lack of oxygen and brain cell death) affecting right dominant side (the side of the body that a person prefers, uses more frequently, and is stronger or more skillful with), aphasia (a disorder that makes it difficult to speak), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental illness that causes constant fear) and insomnia.Review of Resident 1's order summary report, it indicated an order dated 9/16/2023, Zolpidem Tartrate [Ambien, brand name - a prescription sedative-hypnotic medication for insomnia] Tablet 5 MG [milligram - unit of measurement] Give 1 tablet by mouth as needed for Insomnia for 14 days May give 1 to 2 tablets as needed.Review of Resident 1's care plan for insomnia, date initiated 9/12/2023, indicated, Indicate & provide non-pharmacological intervention: 1. Reposition/limb elevation 2. Snacks/drinks 3. Redirect/reassurance/emotional support.8 Deep breathing/relaxation exercises.Monitor and record number of hours of sleep.Try non-pharmacological measures: avoid heavy meals, caffeine, large fluid intake before sleep and offer milk.Review of Resident 1's September 2023's nursing progress notes and medication administration record (MAR -a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), indicated there was no documentation of Resident 1's monitoring of hours of sleep and no documentation that the non-pharmacological interventions were provided.During a concurrent interview with the infection preventionist (IP) nurse and record review on 3/26/2026 at 1:15 p.m., the IP reviewed Resident 1's September 2023 nursing progress notes and MAR and stated there was no documentation of hours of sleep monitoring and no documentation that the non-pharmacological interventions were provided. The IP confirmed Resident 1's insomnia care plan was not implemented.During a phone interview with the director of nursing (DON) on 4/2/2026 at 10:43 a.m., the DON stated if it was care planned that nurses should monitor residents' hours of sleep and should provide non-pharmacological interventions, nurses should have implemented these interventions. The DON further stated the intervention provided to residents should have been documented in nurse's notes or MAR.During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, date revised March 2022, indicated, .a person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.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.

Based on observation, interview, and record review, the facility failed to ensure the call light (a visible and audible alarm activated by a call button) alternative (call bell) is available for one of three residents (Resident 1). This deficient practice had the potential to result in a delay in meeting Resident 1's needs for toileting and activities of daily livingDuring a concurrent observation and interview on 8/15/25 at 11:35 a.m., in Resident 1's room. Resident 1 was lying in her bed. There was an overbed table next to her bed and there was no alternative for the call light. Resident 1 stated the call light is not working for two weeks now. Resident 1 stated she doesn't have the call bells. Resident 1 further stated it's okay to ask the staff to check if she has a call bell at bedside. Resident 1 stated she has to call the front desk for help, and it takes time.During a concurrent observation and interview on 8/15/25 at 11:40 a.m., in Resident 1's room with the Treatment Nurse (TN), the TN searched Resident 1's overbed table, drawers, and bedside for a call bell. The TN confirmed there was no call bell for Resident 1. The TN further stated Resident 1 should have a call bell next to her [resident] until they fixed the call lights. The TN confirmed the call lights were not working in Resident 1's room.During a review of Resident 1's admission record on 8/15/2025, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (Hemiplegia and hemiparesis both refer to weakness or paralysis on one side of the body, but they differ in severity. Hemiplegia is a more severe form, characterized by a complete loss of strength or paralysis, while hemiparesis is a weakness or partial loss of strength on one side).During a review of Resident 1's Brief Interview for Mental Status dated 6/25/25 BIMS score is 15 [BIMS, a tool used to assess cognition (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact)]During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) Functional Abilities, dated 6/25/25, indicated Resident 1 was Setup or cleaning up assistance with eating, Supervision or touching assistance with oral hygiene, dependent with toileting hygiene and shower/bathing self, substantial/maximal assistance with upper body dressing, dependent with lower body dressing, dependent with putting on/taking off footwear, and partial/moderate assistance with personal hygiene. A further review of Resident 1's MDS Functional Abilities indicated Resident 1 was partial/moderate assistance with rolling left and right and sit to lying, substantial/maximal assistance with lying to sitting on side of bed, dependent with sit to stand and chair/bed-to-chair transfer.During an interview on 8/15/25 at 1:17 p.m., with the Director of Nursing (DON), the DON stated in July 2025 they provided bells to all residents in station AA. The DON stated she expected them [residents] to have a bell at bedside. During a review of the facility's policy and procedures (P&P) titled, Answering the Call Light, revised date 9/ 2022, indicated, The purpose of this procedure is to ensure timely responses to the resident's request and needs .5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.During a review of the facility's (P&P) titled, Accommodation of Needs, revised date 3/2021, indicated, .2. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated and upon admission and reviewed on an ongoing basis. 3. In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received therapy services as ordered by a physician.The failure decreased the facility's potential to ensure Resident 2 reached his highest rehabilitation potential. During an interview on 7/18/25 at 12:49p.m., with Resident 2, he stated issue with the manpower in therapy, they are skipping on therapy to 4x a week and then until 3x a week. Resident 2 stated the staff said they don't have enough staff in therapy when he spoke to one of the therapists. Resident 2 stated the therapy is helping with self-care and he needed more therapy, and he ran out of Medicare (a health insurance program) days.During a review of Resident 2's admission record on 7/18/2025, dated 5/29/2025 indicated Resident 2 was admitted to the facility with diagnosis including muscle weakness.During a review of Resident 2' s physician's order indicated an order dated 5/30/25 Occupational Therapy clarification: skilled OT (occupational therapy- a therapy aimed at helping individuals perform daily activities and improve functional independence) 5x/week, 8 weeks may include 97166 OT mod complex (moderate complexity needs) 97530 ther act (Therapeutic activities), 97535 self care mgmt. (Management)., 97533 sensory.During a review of Resident 2's Brief Interview for Mental Status (BIMS, a short performance-based cognitive screener for nursing home (NH) residents.), dated 6/5/25 BIMS is 14 (the range of 13-15, which suggests that the person is cognitively intact.)During a review of Resident 2's Occupational Therapy (OT) notes are as follows:Date of Service (DOS), DOS 7/8/25 to 7/14/25-7/14/25-7/11/25-7/10/25-7/8/25 DOS 6/27/25 to 7/3/25 -7/3/25-7/2/25-7/1/25-6/28/25 DOS 6/20/25 to 6/26/2025 -6/26/25-6/25/25-6/24/25-6/23/25DOS 6/13/25 to 6/19/25-6/19/25-6/18/25-6/13/25DOS 6/6/25 to 6/12/25-6/12/25-6/11/25-6/10/25-6/9/25 DOS 5/30/25 to 6/5/25-6/5/25-6/4/25-6/3/25-5/30/25Indicated Resident 2 received OT 4x a week on 5 occasions and 3x a week on 1 occasion.During an interview on 7/18/25 at 1:27 p.m., with the Assistant Director of Rehab (ADOR), the ADOR stated if the order for OT is 5x a week they [resident] will receive 5x a week of therapy. During a concurrent interview and record review on 8/15/25 at 11:48 a.m., with the Director of Rehab (DOR), the DOR reviewed Resident 2's Occupational Therapy notes and confirmed the following date of service (DOS ) is missing, DOS 5/30/35 to 6/6/25, 4 times seen missing 6/2/25 unavailable, DOS 6/6/5 to 6/12/25 missing 6/6/25 unavailable, DOS 6/13/25 to 6/19/25 missing 6/16/25 unavailable no reason, DOS 6/20/25 to 6/26/25 missing 6/20/25 unavailable, DOS 6/27/25 to7/3/25 missing 6/30/25 unavailable no reason, (DOS) 7/8/25 to 7/14/25, The DOR stated missing 7/9/25 unavailable no reason. The DOR confirmed Resident 2's physician's order is OT 5 days a week, The DOR further stated doesn't look like Resident 2 is getting 5x a week OT. During an interview on 8/15/25 at 1:21 p.m., with the Director of Nursing (DON), the DON stated if the OT order is 5x a week they should be following the doctor's order.During a review of the facility's (P&P) titled, Scheduling Therapy Services, revised date 7/2013, indicated, Therapy services shall be scheduled in accordance with the resident's treatment plan.

Based on interviews, and record review, the facility failed to implement their abuse policy and procedure for one of one resident (Resident 1) when the facility did not report Resident 1's injury of unknown source. This failure resulted in Resident 1's injury of unknown source not reported to required agencies (California Department of Public Health [CDPH], law enforcement agency, and Long-Term Care Ombudsman). This failure had the potential to compromise the safety of the residents in the facility. Findings: Review of Resident 1's clinical record titled, admission Record, dated 4/17/2025, indicated Resident 1 was admitted to the facility with diagnoses including COVID-19 (Coronavirus disease, an infectious disease caused by the SARS-CoV-2 virus, which can be very contagious, and spread quickly), hemiplegia (paralysis of one side of the body), and hemiparesis (a condition that causes partial paralysis or weakness on one side of the body) following cerebral infarction (commonly referred to as stroke) affecting right dominant side (refers to the side of the body that tends to be stronger, faster, and more precise for tasks like writing, throwing, or brushing teeth), dysphagia (difficulty in swallowing), and encounter for attention to gastrostomy (a surgical procedure that creates a stoma [an opening] in the stomach, usually for the purpose of inserting a gastrostomy tube [G-tube/GT - this tube allow for the delivery of nutrition, fluids, and medications directly to the stomach]) Review of Resident 1's admission minimum data set (MDS- a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 1's speech was clear, she had the ability to make herself understood and had the ability to understand others. Resident 1's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 11 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During a phone interview with Resident 1's family member (FM) on 4/2/2025 at 12:54 p.m. Resident 1's FM stated she was called to let her know that Resident 1 had a discoloration to the right side of face, and right side of ear. Resident 1's FM further stated she was told a feeding pump fell on Resident 1's face, and she never believed them because the feeding pump was positioned to the left side of Resident 1's bed. Resident 1's FM stated the bruise could also be seen inside Resident 1's right ear. Review of Resident 1's clinical record titled, SBAR [situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents] & INITIAL COC [change of condition]/ALERT CHARTING & SKILLED DOCUMENTATION, dated 3/3/2025, indicated, Describe the problem/symptom: right side of face skin discoloration, right side eye discoloration .pt received with discoloration on right side of face and right ear .pt unaware of what happened .no falls reported. Further review indicated, discoloration to right side of face and ear eye 3.3 x 2.5 [measurement of length by width] ear 4.5 x 3.2. Review of Resident 1's clinical record titled, IDT [interdisciplinary team, a team composed of members from different departments involved in resident's care] - SKIN INTEGRITY (PRESSURE INJURY, OTHER WOUNDS), dated 3/6/2025, indicated Resident 1 had a right ear and right eye discoloration. It further indicated, Risk factors: -MUSCLE WEAKNESS (GENERALIZED) .Chronically bed bound .Fragile compromised skin integrity -High risk for unavoidable d/t [due to] risk factors .IDT determined resident noted to be combative pulling on feeding tubes and GT. Review of Resident 1's clinical record titled, ALERT CHARTING, dated 3/5/2025 at 11:30 a.m., indicated, .Noted before breakfast served swelling on right side of face ice compress applied and monitor patient . Review of Resident 1's medication administration record (MAR - (MAR - a daily documentation record used by a licensed nurse to document medications, treatments given to a resident and resident's monitoring), dated 2/2025 and 3/2025, indicated Resident 1 had a behavior monitoring for verbalization of anxiousness and yelling leading to exhaustion. Further review indicated Resident 1 did not demonstrate these behaviors in 2/2025 and 3/2025. During a phone interview with licensed vocational nurse A (LVN A) on 4/17/2025 at 10:06 a.m., LVN A confirmed she worked with Resident 1 on 3/3/2025, in the evening shift and found Resident 1 with right eye and right ear bruising. LVN A stated, the cause of bruising was undetermined. LVN A further stated, Resident 1 was not even restless during the shift, there was no behavior and Resident 1 told her that she did not know what happened. LVN A confirmed she reported her findings to the doctor and to the unit manager (assistant director of nursing B - ADON B). LVN A confirmed she did not report her findings to the police or to the state because there is nothing suspicious. During a concurrent interview with assistant director of nursing C (ADON C) and record review on 4/17/2025 at 10:17 a.m., ADON C reviewed Resident 1's IDT dated 3/6/2025 and March 2025 MAR. ADON C confirmed she was a part of the IDT on 3/6/2025 and stated the possible contributing factor of Resident 1's discoloration to the face was not included in the IDT notes. ADON C further confirmed she did not know how Resident 1 sustained the discoloration to the right side of the face. ADON C confirmed the following: Resident 1 was not on any anticoagulant medications (AC - medications that prevent blood from clotting too easily which can increase the risk of bleeding or bruising); Resident 1 did not have any documented behavior in March 2025; and there was no care plan related to Resident 1's bruising. When ADON C was asked if she should have reported Resident 1's bruising with no known cause, ADON C stated she did not want to decide if she should have reported it and would just ask the team's decision. ADON C confirmed she was aware that she was a mandated reported [an individual who holds a professional position that is required by law to report suspected or known instances of abuse to state agencies and local law enforcement]. During an interview with ADON B on 4/17/2025 at 10:51 a.m., ADON B confirmed Resident 1's discoloration to the right side of face was reported to her. ADON B stated Resident 1 had a history of pulling the GT and when she asked Resident 1 of what happened, Resident 1 stated she did not know what happened. ADON B confirmed she investigated the possible cause of the discoloration on Resident 1's face and stated Resident 1's feeding pole fell on to Resident 1 and she confirmed nobody witnessed it. When asked why nobody witnessed the incident, ADON B stated Resident 1 was able to pull the feeding pole back up. When asked if she should have reported the unusual bruise on Resident 1's face, ADON B stated this case was new to her, and it should have been reported to CDPH, but she would find out the answer. During an interview with director of nursing (DON) on 4/17/2025 at 11:05 A.M., DON stated ADON B reported Resident 1's bruise, and she would pull her GT. DON further stated, it was a quick decision that it was the pump [feeding pump] that fell on her. DON confirmed it was not reported to state agencies because she heard' from staff that they determined the cause of the injury. During an interview with social services (SS) on 4/17/2025 at 11:19 a.m., SS stated he did not get a report about the bruise with unknown cause. Informed SS that he was a part of the IDT held in 3/6/2025, SS stated he could not recall the IDT because they had a lot. During an interview with the facility's administrator (ADM) on 4/17/2025 at 11:51 a.m., ADM stated ADON B talked to him about Resident 1's bruise and Resident 1 had a history of pulling of tubes, throwing meal trays, and making frantic movements. ADM confirmed that whenever an SBAR was made, the IDT would review them the following day. ADM further confirmed he did not investigate the cause of Resident 1's injury and he did not report it to state agencies. When asked about Resident 1's SBAR was completed on 3/3/2025 which was a Monday, why did the IDT reviewed it on 3/6/2025 (3 days after), ADM stated that he would get back to the nurse surveyor and he would talk to ADON B. During an interview with licensed vocational nurse D (LVN D) on 4/30/2025 at 10:45 a.m., LVN D confirmed he took care of Resident 1, and she did not have any behavior except the refusal to eat. During a concurrent interview with registered nurse E (RN E) and record review on 4/30/2025 at 11:03 a.m., RN E reviewed Resident 1's March 2025 evaluations and nurse's progress notes and confirmed Resident 1 had bluish discoloration on 3/3 to the right side of her face. RN E further confirmed she was not sure how Resident 1 sustained the bruise to her face. When asked if the unknown cause of Resident 1's bruise should have been reported, RN E stated, no, but she was aware that everyone was a mandated reporter. RN E confirmed that no one witnessed that a feeding pole fell on to Resident 1 and if it happened, Resident 1 would not be able to pull the pole back up. During an interview with certified nursing assistant F (CNA F) on 4/30/2025 at 12:21 p.m., CNA F confirmed he was assigned to Resident 1 on 3/3/2025, in the morning shift, and stated Resident 1 had periods of refusal with medications, to be changed and with meals. CNA F further stated, I don't think she can pull her GT because her right side is weak. She can only move the left arm. CNA F confirmed Resident 1 did not have any discoloration on her face in the morning of 3/3/2025. During an interview with licensed vocational nurse G (LVN G) on 4/30/2025 at 12:38 p.m., LVN G confirmed he worked with Resident 1 in March 3/2025 when he was still a CNA. LVN G stated, Resident 1 refused to eat but she never hit anyone. LVN G further stated, he noticed Resident 1 had a purplish discoloration to her face when he helped another CNA to reposition Resident 1 in bed. LVN G stated he did not ask what happened to her face because he assumed it was already reported. During a concurrent interview with licensed vocational nurse H (LVN H) on 7/9/2025 at 10:14 a.m., LVN H reviewed Resident 1's ALERT CHARTING notes on 3/5/2025, and LVN H confirmed she was the one who documented about the swelling and discoloration on Resident 1's face. LVN H stated she did not know how Resident 1 sustained that discoloration, and she did not report it because it was up to the administration's decision. LVN H further stated, nurses just had to do the SBAR and report to MD. During a review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, date revised April 2021, indicated, All reports of resident abuse including injuries or unknown origin) .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. If resident abuse .or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman .d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials . Immediately is defined as: .b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Verbal/written notices are submitted via special carrier, fax, e-mail, or by telephone .Upon receiving any allegations of abuse, .or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents .The administrator, or his/her designee, provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.

Based on observation, interview, and record review, the facility failed to ensure their infection prevention practices were implemented when: 1. A urinary catheter (a semi-flexible plastic tube, one end inserted into the bladder [body organ that stores urine] and the other end is attached to a bag that collects urine) drainage bag touched the floor; 2. Hand hygiene (the practice of cleaning your hands to prevent the spread of germs and illness) and the removal/change of isolation gowns (a type of personal protective equipment (PPE) used in healthcare settings to protect healthcare personnel and patients from the spread of infection or illness, particularly from contact with blood and body fluids) was not completed between tasks; 3. There was no notification to the Dialysis center of the resident's isolation precautions (measures taken to protect both patients and healthcare personnel from infection by isolating individuals who are either infected or potentially infected with a contagious disease) and type of infection. 4. The shared room for Residents 28 and 195 had no appropriate notification from Centers for Disease Control and Prevention (CDC - a set of measures aimed at preventing the spread of infections that can be transmitted through direct or indirect contact with a patient or their environment] Contact Precaution posted on the room entrance door for staff and visitors to be aware of the precaution and there was no easily accessible isolation cart (a cart used in healthcare settings to store supplies needed when caring for patients in isolation to prevent the spread of infectious diseases) placed right outside the room for quick access to needed items; 5. Certified nursing assistant Y (CNA Y) did not don (put on) the proper personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) prior to entrance to the contact isolation room, and used the purple top Super Sani -Cloth (a disinfectant chemical wipes for cleaning) wipes for hand hygiene after stepping out of the COVID-19 (an infectious disease caused by a virus) isolation room; 6. Registered nurse Z (RN Z) wore a double mask: N-95 (a type of PPE, a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) mask on top of a surgical mask (known as a face mask, a loose fitting, disposable device that creates a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment) before entrance to a COVID-19 isolation room; 7. Certified nursing assistant AA (CNA AA) did not don the proper PPE prior to entrance in the contact isolation room of Resident 195 with clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) infection and did not wash hands with soap and water upon exiting the room; 8. Certified Nursing Assistant B (CNA B) failed to perform hand hygiene when assisting Resident 194 during meal time; 9. Licensed vocational nurse U (LVN) did not wear gloves during Resident 217's urine bag care and did not perform hand hygiene before doing another task; 10. Pulmonary nurse (PN) did not wear proper PPE inside Resident 60's room who was on Contact Precaution; 11. Resident 127's oxygen nasal cannula was esposed and placed at the side of bed; 12. Physical therapy assistant (PTA) did not wear proper PPE during therapy treatment with Resident 60 in the rehabilitation (rehab) therapy room (also called the gym); 13. Resident 31's oxygen tubing observed lying on floor; 14. Resident 50's oxygen tubing observed entangled in wheel of a steel pole; 15. The tips of two Residents (145 and 209) enteral feeding tubing were left uncapped and exposed; and 16. One of three licensed nurses (LVN E) cleaned and disinfected a shared glucometer (a portable devices that measure blood glucose levels) with the appropriate disinfectant. This failure had the potential to result in the spread of bloodborne infections such as hepatitis B (a serious liver infection caused by the hepatitis B virus that is most commonly spread by exposure to infected body fluids), hepatitis C (viral liver infection caused by the hepatitis C virus), human immunodeficiency virus (HIV, is a virus that attacks the body's immune system), and other infections among residents. These failures had the potential to result in the spread of infection throughout the facility. Findings: 1. During an observation and concurrent interview on 4/16/25 at 10:10 a.m. with the Infection Preventionist (IP) (a specialized healthcare professional whose primary role is to prevent and control the spread of infections within a healthcare setting) in the hallway near Resident 346's room, Resident 346 was sitting in the wheelchair with his urinary catheter bag touching the floor, under the wheelchair. The IP immediately adjusted the catheter bag, confirming the bag should not be touching the floor. Review of the facility's policy & procedure titled Catheter Care, Urinary, dated 8/2022, indicated, Infection Control . Be sure the catheter tubing and drainage bag are kept off the floor. 2. During an observation on 4/16/25 at 1:11 p.m., Certified Nursing Assistant (CNA) Q was in the room with Resident 26 and Resident 27. CNA Q was observed in a gown and gloves placing a meal tray on Resident 27's tray table and arranging it within reach of Resident 27. CNA Q then took a tray to Resident 26 and arranged the tray within reach. CNA Q returned to Resident 26, opening a container on her tray. CNA Q removed her gown and gloves and noted there was no trashcan available to dispose of the gown. She removed it from the room to dispose of it, then cleaned her hands with the nearest hand sanitizer. During a concurrent interview CNA Q confirmed she did not change her gown, change her gloves or clean her hands between the residents, also confirming one of the residents were on contact isolation (using specific practices to prevent the spread of infections that are transmitted through direct or indirect contact with a patient or their environment). CNA Q stated she should have had cleaned her hands and removed her gown between residents. Review of the facility's policy & procedure titled, Isolation - Categories of Transmission-Based Precautions, dated 9/2022 revised, indicated, The individual on contact precautions is placed in a private room if possible. If a private room is not available, the infection preventionist will assess various risks associated with other resident placement options (e.g., Cohorting, placing with a low risk roommate) Staff and visitors wear gloves (clean, non-sterile) when entering the room. a. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). b. Gloves are removed and hand hygiene performed before leaving the room. c. Staff avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. 3. During an interview on 4/17/25 at 10:14 with the Infection Preventionist (IP), the IP stated, Resident 398 was positive for COVID -19 (an infectious disease caused by a virus). The IP stated the dialysis center was not notified of Resident 398's infection or isolation status, transport was endorsed and was to communicate with the dialysis center. During an interview on 4/18/25 at 1:02 p.m. with the IP, the IP stated, the dialysis center was not notified of Resident 398's type of isolation and infection because the resident was already on dialysis. Review of Resident 398's Medial Record, dated 4/9/25, the progress notes indicated, Resident 398 was admitted [DATE], after being hospitalized for a traumatic brain injury, was found to have COVID- 19. Resident 398 has a history of End Stage Renal Disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life)(ESRD), he is on dialysis, (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) that he received while in the hospital. During a review of the facility's policy and procedure titled, Isolation - Categories of Transmission-Based Precautions, dated Revised August 2013, indicated If the res ident is transported to another unit within the facility or to another facility, the infection preventionist (or designee) will notify the unit or facility of the type of precautions the resident is on and the resident's suspected or confirmed type of infection. The facility is also responsible for notifying transport staff of residents that require special care due to infectious conditions. 44583 4. During a concurrent observation and interview with the facility's IP on 4/14/2025 at 11:28 a.m., in front of Residents 28 and 195 shared room, IP confirmed the shared room was on Contact Precaution because Resident 195 was positive for C-diff infection. The following were observed: a. there was no signage of Contact Precaution posted at the entrance door of the shared room, b. there was one signage of the Transmission Based Precautions [TBP - an additional infection control practices, beyond standard precautions, used when patients have documented or suspected infections that can spread through contact, droplet, or airborne routes] posted at the left side of the entrance door, above Residents 28 and 195's name. The signage was in a regular size of paper, which indicated a small, checked mark on Contact, and not easily visible to staff and visitors, c. no isolation cart located outside the shared room. IP confirmed above observations and stated he did not put a sign at the door because the door was always open. IP further stated, staff had access to the PPE located at the hallway's wall wherein staff who cared for a resident in contact isolation had to stepped out of the isolation room and obtain another PPE to care for the other resident. IP confirmed resident's environment inside the contact precaution isolation room were considered contaminated that was the reason staff and visitors should wear the proper PPE before they entered the room. During other observations on 4/15/2025 at 12:50 p.m. and 4/16/2025 at 8:35 a.m., in front of the shared room of Resident 28 and 195, there was still no visible sign of the Contact Precaution posted at the entrance door, and no isolation cart positioned outside the isolation room door for easy accessibility of staff and visitors. During a follow up interview with IP, in the presence of the director of nursing (DON) on 4/16/2025 at 8:37 p.m., IP confirmed they still used the same signage for contact precaution isolation rooms that they had used for years, and no signage posted at the door for contact precautions. IP confirmed they did not put an isolation cart to each of the contact precaution isolation rooms because it would be a lot at the hallway combined with the enhance barrier precaution (EBP - infection control measures that involve using gowns and gloves during high-contact resident care activities, in addition to standard precautions) rooms. During a review of the facility's policy and procedure titled, Isolation - Categories of Transmission-Based Precaution, date revised 9/2022, indicated, When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for the type of precaution. a. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. 5. During an observation on 4/14/2025 at 12:48 p.m., in front of the shared contact precaution isolation room, CNA Y entered the contact precaution isolation room without donning isolation gown and gloves. CNA Y placed Resident 28's lunch tray on his overbed table and moved the overbed table closer to Resident 28. CNA Y stepped out of the room and washed her hands with soap and water at the hallway's sink. At 12:58, CNA Y was observed stepping out of the COVID-19 isolation room and used a purple top Super Sani-Cloth wipes to clean her hands then walked across the room's hallway and performed hand hygiene with the used of the hand sanitizer. During an interview with CNA Y on 4/14/2025 at 1:03 p.m., CNA Y confirmed above observations and stated she did not wear PPE in the contact precaution room because she just served Resident 28's lunch tray. CNA Y stated she used the purple top Super Sani-Cloth to clean her hands because there was no hand sanitizer in the isolation cart, but she used a hand sanitizer which was across the room after. CNA Y confirmed the purple top Super Sani-Cloth wipes should not be used in bare skin. During an interview with DON on 4/18/2025 at 12:34 p.m., DON confirmed the purple top Super Sani-Cloth wipes should not be used for hand hygiene. DON stated the wipes should only be used for surface and equipment cleaning. During a review of CDC's Infection Control guidelines titled, Transmission-Based Precautions, dated 4/3/2024, indicated, Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission. Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon entry and properly discarding before exiting the patient room is done to contain pathogens. Review of the purple top Super Sani-Cloth wipes container label indicated it was a germicidal disposable wipe not intended for skin or baby wipe. Review of Super Sani-Cloth Germicidal Wipes Safety Data Sheet date revised 9/7/2023, indicated, Recommended use Use as a disinfectant on hard, non-porous surfaces. Read and understand the entire label before using. Use only according to label directions. It is a violation of Federal law to use this product in a manner inconsistent to label directions. Warning Hazard statements Causes serious eye irritation. May cause drowsiness or dizziness .Precautionary Statements - Prevention Wash face, hands, and any exposed skin thoroughly after handling. Description of first aid measures Skin contact Wash skin with water. Get medical attention if irritation develops or persists. 6. During an observation on 4/15/2025 at 9:21 a.m., outside the COVID-19 isolation room, RN Z donned an isolation gown, gloves and N-95 on top of the surgical mask before she entered the room. RN Z stepped out of the COVID-19 isolation room without her PPE and only the surgical mask left in placed. During an interview with RN Z on 4/15/2025 at 9:48 a.m., RN Z confirmed above observation and stated she wanted to make sure that both masks would give her protection. RN Z confirmed she was fit tested (a test used to confirm the fit of the N-95 to ensure that a tight seal forms on the wearer's face before it is used in the workplace) for the N-95 mask she wore. During an interview with IP on 4/16/2025 at 8:37 p.m., IP confirmed double masking was not allowed. IP stated staff should wear only N-95 mask whenever they entered the COVID-19 isolation room. During a review of CDC's Personal Protective Equipment guideline titled, How to Use Your N95 Respirator, dated 3/12/2025, indicated, Your N95 respirator must form a seal to your face to work properly. Your breath must pass through the N95 respirator and not around its edges .Gaps can also occur if your N95 respirator is too big, too small, or it was not put on correctly. 7. Review of Resident 195's physician order dated 3/25/2025, indicated an order of contact precautions secondary to the diagnosis of C-diff. During an observation on 4/15/2025 at 12:50 p.m., outside the shared contact precaution room of Residents 28 and 195, CNA AA entered the contact precaution room without donning an isolation gown and gloves. CNA AA set up Resident 195's lunch tray on top of his overbed table and moved the overbed table towards Resident 195. CNA AA stepped out of the room and used the hand sanitizer for hand hygiene. During a follow up interview with CNA AA on 4/15/2025 at 12:51 p.m., CNA AA confirmed above observations and stated she just dropped off Resident 195's lunch tray. CNA AA further stated Resident 195 was just on isolation because he was on chemotherapy (medicines used to treat cancer) medications, and she used the hand sanitizer because her hands were not visibly soiled. During an interview with IP on 4/16/2025 at 8:37 a.m. regarding used of hand sanitizer after lunch set up inside a C-diff (+) resident without gloves and gown, IP stated used of hand sanitizer was good enough as long as the staff hands were not visibly soiled. IP further stated staff should only washed their hands with soap and water when their hands were visibly soiled. IP confirmed staff should have worn isolation gown and gloves even when setting up Resident 195's lunch tray. During a review of CDC's guidelines titled, Preventing C. diff, dated 12/18/2024, indicated, Washing your hands with soap and water is the best way to prevent the spread of C. diff from person to person .C-diff can live on people's skin. In a healthcare setting *Make sure all healthcare professionals clean their hands before and after caring for you .*While caring for you and other patients with C. diff infection, healthcare professional will use certain precautions like wearing a gown and gloves. This will prevent the spread of C. diff to themselves and other patients. * Wash your hands with soap and water every time you use the bathroom and before you eat, 46939 8. During an observation on 4/14/25, at 1:01 p.m., in Station 5 dining room, CNA B was observed assisting a resident to eat, after a few minutes CNA B assisted Resident 194 without performing hand hygiene. During an interview on 4/14/25. At 1:02 p.m., with CNA B, CNA B stated, we are supposed to use hand hygiene before helping each resident to eat, I did not use hand sanitizer before helping Resident 194 from the previous resident. During an review of the facility's Policy and Procedure (P&P) titled, Handwashing/Hand Hygiene dated, 2019, the P&P indicated, This facility considers hand hygiene the primary means to prevent the spread of infections.7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .o. Before and after assisting resident with meals. 49345 9. During a concurrent observation and interview on 4/14/25 at 9:47 a.m. with Licensed Vocational Nurse (LVN) U at Resident 217's bedside, LVN U touched Resident 217's urine bag without gloves and proceeded to take Resident 217's water pitcher from the bedside table out of the room. LVN U stated he should have worn gloves before touching a resident's urine bag. LVN U also stated hand hygiene should have been done prior to touching Resident 217's pitcher. A review of facility's policy and procedure (P&P) entitled Handwashing/ Hand Hygiene revised August 2019, the P&P indicated, .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: e. Before and after handling an invasive device(e.g., urinary catheters ) 10. During an observation on 4/14/25 at 9:50 a.m., Pulmonary Nurse (PN) was inside Resident 60's side of the room providing treatment. PN was not wearing gown and gloves inside the room. A sign for Contact Precaution was posted on Resident 60's room by the entrance. The sign indicated, gown, gloves and mask must be worn prior to entry. During an interview on 4/14/25 at 9:55 a.m. with PN, PN stated she should have worn gown and gloves when she entered Resident 60's room. A review of facility's policy and procedure (P&P) entitled Departmental (Respiratory Therapy)- Prevention of Infection revised November 2011, the P&P indicated, The following equipment and supplies will be necessary when performing tasks related to this procedure: 2.Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed) . 11. During a concurrent observation and interview on 4/14/25 at 10:53 a.m. with Case Manager N (CM N) at Resident 137's bedside, an oxygen nasal cannula was exposed on Resident 137's side of the bed. Resident 137 stated oxygen was not in use. CM N stated, oxygen cannula not in use must be kept in a Ziploc bag (a type of flexible, plastic bag with a special seal that allows you to close it and reopen it multiple times) and labeled. 12. During a concurrent observation and interview on 4/15/25 at 2:06 p.m. with the DON and IP Resident 60 was in the Rehab Therapy Room getting treatment from a PTA. PTA was not wearing facial mask, gown, and gloves. The DON and IP verified Resident 60 was on Contact Precaution and Personal Protective Equipment (PPE) should have been worn by PTA while providing treatment to Resident 60. The DON verified PTA was in close contact with Resident 60 during the treatment. During an interview on 4/15/25 at 2:20 p.m. with the PTA, PTA stated she was aware that Resident 60 was on Contact Precaution. A review of facility's document entitled Job Description: Infection Control indicated, .Responsibility: Monitoring and surveillance: You will conduct regular inspections and surveillance to identify potential sources of infections, assess compliance with infection control measures . A review of facility's policy and procedure (P&P) entitled Isolation- Categories of Transmission-Based Precautions revised September 2022 indicated .7. Staff and visitors wear gloves (clean, non-sterile) a.While caring for a resident 50135 13. During a concurrent observation and interview on 4/14/25 at 4:20 p.m. in the room of Resident 31 with the Respiratory Therapist FF (RT FF), Resident 31 pointed to the end of her oxygen tubing that connects to her tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube) lying on the floor. Resident 31 showed no signs or symptoms of distress. RT FF ran into the room of Resident 31 from the hallway while passing by the room. RT FF stated, Oh no! RT FF immediately checked Resident 31's oxygen saturation (the measurement of how well the lungs are working) then stated the oxygen tubing needed to be replaced with a new one to prevent any infections. 14. During a concurrent observation and interview on 4/14/25 at 2:15 p.m. in the room of Resident 50 with the Certified Nursing Assistant EE (RNA EE) Resident 50's oxygen tubing was observed entangled between the wheel of her roommate's intravenous pole (a medical device typically made of stainless steel used to support medical equipment). RNA EE stated the tubing, Should not be like that. RNA EE immediately untangled Resident 50's oxygen tubing from the wheel of the pole. A review of the facility's policy titled, Oxygen Administration, revised 10/2010, indicated, Steps in the Procedure .7. Check the tubing connected to the oxygen cylinder to assure that it is free of kinks. 15. During an observation on 4/14/25 at 1:38 p.m., the tips of the enteral feeding tubing (a flexible medical device used to deliver liquid food directly into the stomach or intestine) for Resident 145 and Resident 209 were exposed and not covered while feedings were turned off. During a concurrent observation and interview on 4/14/25 at 2:00 p.m. in the room of Resident 145 and Resident 209 with the Assistant Director of Nursing DD (ADON DD), ADON DD confirmed the tips of Resident 145's and Resident 209's enteral feeding tubing were exposed and not covered while feedings were turned off. The ADON DD stated the tips of the tubing should have plastic caps on them when the feedings are turned off to prevent the spread of infections. A review of the facility's policy titled, Infection Prevention and Control Program, revised 10/2018 indicated, .11. Prevention of Infection: a. Important facets of infection prevention include . (3)educating staff and ensuring that they adhere to proper techniques and procedures. 51865 16. On 4/14/25 at 4:25 p.m., at Resident 497's bedside, LVN E was observed pricking the resident's right point finger to obtain a blood sugar reading by using the glucometer. On 4/14//25 at 4:27 p.m., LVN E was observed at the medication cart removing an alcohol wipe from the alcohol prep pad. LVN E used the alcohol wipe to clean and disinfect the glucometer, which she had just used on Resident 497, then placing the glucometer inside the medication cart. During an interview on 4/14/25 at 4:47 p.m., LVN E stated that she just finished the blood sugar checks on 4 residents using a shared glucometer and cleaned it with alcohol wipe between resident uses. During an interview with the Infection Preventionist (IP) on 4/14/25 at 5:12 p.m., the IP stated alcohol wipe cannot be used for glucometer. The IP stated, It's not okay to use the alcohol wipes because it does not kill certain bacteria. They should use purple-top wipe [referring to the Super Sani-Cloth, which is a surface disinfectant cleaner] with 2 minutes dwell time. A review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated September 2022, the P&P indicated, Reusable items are cleaned and disinfected or sterilized between residents. A review of a publication by the United States Food and Drug Administration (FDA) titled Blood Glucose Monitoring Test Systems for Prescription Point-of-Care Use, dated September 29, 2020, it indicated in part, The disinfectant product you choose should be effective against HIV, Hepatitis B, and Hepatitis C viruses. Of these viruses, Hepatitis B virus is the most difficult to kill and prior outbreak episodes associated with blood glucose meters have been due to transmission of Hepatitis B viruses. Therefore, disinfection efficacy studies should be performed to demonstrate effectiveness of the chosen disinfectant against Hepatitis B virus. Please note that 70% ethanol [alcohol] solutions are not effective against viral bloodborne pathogens .

Based on observation, interview and record review, the facility failed to ensure dignity and privacy was upheld for residents when: 1. Resident 23's privacy curtain was not fully drawn when Resident 23 removed her facility gown; 2. Assistant Director of Nursing (ADON) A referred to Resident's clothing protector as bibs in front of approximately 15 residents; and, 3. Certified Nursing Assistant (CNA) B was observed to assist feeding Resident 194 while standing over her. These failures had the potential for adverse effects on the psychosocial well-being and health of Resident 23, Resident 194 and approximately 14 others residents in the dining room during mealtime. Findings: 1. Review of Resident 23's clinical record titled, Admission Record, dated 4/16/2025, indicated Resident 23 was admitted to the facility with diagnoses including obstructive hydrocephalus (a condition where the normal flow of cerebrospinal fluid [CSF - a clear, colorless liquid that surrounds and cushions the brain and spinal cord] is blocked within the ventricles [fluid-filled spaces] of the brain), benign neoplasm (a non-cancerous growth of cells) of spinal cord, other specified disorders of brain, dysphagia (difficulty swallowing) , and encounter for attention to gastrostomy (a surgical procedure that creates an opening (stoma) into the stomach for the insertion of a feeding tube. Review of Resident 23's admission minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 23's brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 00 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During an observation on 4/16/2025 at 9:15 a.m., inside Resident 23's room, the privacy curtain was half drawn and Resident 23 was observed in bed, half naked, and right upper chest was exposed. There were no family members observed at bedside. Resident 23's bed was located near the bedroom door, and she could easily be seen by her roommates' visitors in beds B and C. During a concurrent interview and observation with certified nursing assistant F (CNA F) on 4/16/2025 at 9:39 a.m. inside Resident 23's room, CNA F confirmed above observation and stated Resident 23 stripped off her facility gown. CNA F further confirmed Resident 23's privacy curtain was half drawn. During an interview with social services G (SS G) on 4/17/2025 at 11:30 a.m., SS G confirmed Resident 23 had a behavior of pulling off her clothes and stated they did not have a plan of care for such behavior. During another interview with CNA F on 4/18/2025 at 8:43 a.m., CNA F stated staff should make sure Resident 23 was checked frequently especially if her family member was not at bedside to prevent her from pulling off her facility gown and exposing herself to other residents and visitors. During a review of the facility's policy and procedure titled, Dignity, date revised 2/2021, it indicated, Residents are treated with dignity and respect at all times . Staff are expected to treat cognitively impaired residents with dignity and sensitivity; for example: a. addressing the underlying motives or root causes for behavior . 46939 2. During an observation on 4/14/25, at 12:21 p.m., in Station 5's second dining room, ADON A was observed assisting residents with set up of lunch time meal. ADON A was observed speaking with other staff members in the second dining room asking, Where are the bibs?, get some more bibs. During an interview on 4/14/25, at 12:22 p.m., with ADON A, ADON stated, she asked the other staff members for more bibs for the residents, to place them on before they eat. 3. During an observation on 4/14/25, at 1:01 p.m., in Station 5's second dining room, CNA B was observed assisting Resident 194 to eat lunch while standing over the resident. During an interview on 4/14/25, at 1:02 p.m., with CNA B, CNA B stated, she assisted Resident 194 to eat lunch while standing, and they are supposed to sit down while assisting residents to eat. During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 2021, the P&P indicated, Each resident shall be free cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. During a review of the facility's P&P titled, Assistance with Meals dated 2022, the P&P indicated, Dining Room Residents: 3. Resident who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. not standing over residents while assisting them with meals.

Based on interview and record review the facility failed to protect two of 36 sampled residents (Resident 21 & Resident 445) from physical abuse. When: 1.Resident 231 was observed to physically hit Resident 21 2. Resident 231 was observed to physically hit Resident 445 These failures resulted in Resident 21 & Resident 445 to be physically abused by Resident 231. Findings: 1. During a review of the facility's SOC 341 (mandated report of suspected dependent adult/elder abuse form) dated 4/12/25, indicated an abuse allegation was reported to the California Department of Public Health (CDPH). SOC 341 indicated, Victim [Resident 21].suspected abuser [Resident 231]. SOC 341 indicated, At approximately 8:05 AM on 4.12.25, Resident [231] had hit another resident [Resident 21] in the face and pushed her to the floor. CNA had witnessed the incident and immediately ran over, called for help and separated both residents. SOC 341 indicated, Reported Type of Abuse Physical. Abuse resulted in Minor medical Care During a review of Resident 231's Change in Condition assessment dated [DATE], Assessment indicated, 0715 [7:15 a.m.] received resident awake, alert, and responsive. Ups and ambulates along the hallway of the unit with anger outburst with staff, pacing around the unit.0805 [8:05 a.m.] Resident was walking down the hallway when he struck another resident [Resident 21} in the face and pushed her to the ground. Resident [231] also tried to hit the charge nurse and chased her. Resident is not easily redirectable. Resident becomes very aggressive toward staff and other residents. CNA witnessed the incident. During a review of Resident 21's Change in condition assessment dated [DATE], assessment indicated, Resident was hit in the face by another resident. Redness to the left side of face. During an interview on 4/17/25 at 9:42 a.m, with Certified Nursing Assistant (CNA) C, CNA C stated, she saw Resident 231 walking in the hallway toward the activity room and Resident 21 was walking back to her room. CNA C stated, they crossed paths (Resident 21 and 231) and out of nowhere Resident 231 slapped Resident 21 on the side of the face without being provoked and just kept walking. CNA C stated Resident 21 fell on to the floor from being slapped by Resident 231. CNA C stated, she had witnessed Resident 231 be aggressive in the past, she stated she observed him try to pick up a chair and hit her when cleaning his meal tray after a meal. During a review of the Facility's Investigative Report for Resident 21 and Resident 231's abuse incident dated, 4/15/25, report indicated, from witness account interviews. The incident occurred between Resident [231] and Resident [21] as they crossed paths in the hallway. 2. During a review of the facility's SOC 341 dated 4/15/25, report indicated, Victim [Resident 445] . Suspected Abuser [Resident 231]. At approximately 3:30 PM on 4.14.25. CNA was also present during the time of incident. Here is his account of the events: Resident [231], (perpetrator) was not in activities room. Resident [231] had then ran into the activities room, sat on the table where Resident [445] (victim) was sitting and slapped resident twice on her head. reported type of abuse physical. During a review of Resident 445's Change in condition assessment dated [DATE], assessment indicated, Resident was hit by another resident in the activity room. at approximately 3:15 pm. [Resident 445] was sitting in the activity room watching tv and [Resident 231] went into the room and suddenly without provocation he hit her in the leftforehead [sic]. [Resident 445] sustained a redness on the LEFT forehead. During an interview on 4/16/25, at 3:15 p.m., with Certified Nursing Assistant (CNA) H, CNA H stated, he was in the activity room on 4/15/25 at around 3:15 p.m., and witnessed Resident 231 come into the activity room table where Resident 445 was sitting calmly. CNA H stated, he saw Resident 231 out of nowhere slap Resident 445 several times. During a review of the Facility's Abuse investigation report dated, 4/17/25, report indicated, At approximately 3:30 PM on 4.15.25 Resident [445] was sitting in the activities room participating. CNA was present during the time of the incident and these are his accounts of the event: Resident [231] was not in the dining room participating in activities. Resident [231] ran into the activities room, sat on the table where Resident [445] was sitting and slapped resident [445] twice on her head. During a review of the facility's Policy & Procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2021, the P&P indicated, Resident have the right to be free from abuse. this includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse. The resident abuse, neglect and exploitation program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse. by anyone including. other residents.

Based on interview, and record review, the facility failed to notify The Office of the State Long -Term Care (LTC) Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) of resident's transfer or discharge in a timely manner when: 1. The Office of the State LTC Ombudsman was not notified for 16 of 51 discharged residents (Residents 151, 166, 237, 233, 183, 408, 103, 409, 410, 411, 404, 412, 414, 415, 416, and 417); and, 2. The facility's notification to The Office of the State LTC Ombudsman for six of 51 discharged residents (Residents 418, 419, 420, 421, 404, 422, and 423) were submitted late. These failures resulted in the State LTC Ombudsman not being informed in a timely manner and removed the opportunity for the State LTC Ombudsman (LTC-O) to advocate on resident's behalf. Findings: During a phone interview with LTC-O on 4/3/2025 at 10:12 a.m., LTC-O stated the facility's resident discharges were not reported to their office since 12/2024. During another phone interview with LTC-O on 4/7/2025 at 8:00 a.m., LTC-O stated she reviewed all the reported resident discharges in their office and revealed they only received less than 10 discharged residents in a month since 7/2024. LTC-O further stated, it was unusual to have less than 10 discharged residents because, this is a big facility. 1A. Review of Resident 151's Medical Record indicated Resident 151 was admitted 2 years ago with multiple diagnoses including osteoarthritis and generalized muscle weakness. The Minimum Data Set (a standardized assessment tool that measures health status in nursing home residents) (MDS) dated [DATE] indicated Resident 151 was cognitively intact. Review of Resident 151's Medical Record, dated 3/20/25, the Social Services progress note indicated Social Services spoke to Resident 151 about discharge planning. Review of Resident 151's Medical Record, dated 3/23/25, the Case Manager progress notes indicated the Resident had been assessed by the team and determined that a lower level of care is appropriate. Review of Resident 151's Medical Record, dated 4/9/25, the Social services progress note indicated Social Services G (SS G) spoke to Resident 151's Power of Attorney (POA) about the right to appeal [the facility initiated discharge]. During an interview on 4/15/25 at 10:48 a.m. with Social Services W, SS W stated she communicated with Resident 151's POA about the pending discharge and filing for an appeal. SS W stated there is a Board and Care that has accepted him and currently holding a bed. During an interview on 4/18/25 at 9:48 a.m. with the Case Manager (CM) N, CM N stated, Do not need to notify ombudsman because we are not sending the Resident 151 out, there was a Board and Care for him as of 4/12/25 but he did not want to go. 1B. Review of Resident 166's Notice of Transfer/discharge date d 4/4/25 indicated Resident 166's Responsible party (RP) was notified of the transfer/discharge on [DATE] [to a Board & Care], the effective date of discharge was 4/7/25. The notification by fax to the Ombudsman was 4/18/25. 1C. Review of Resident 237's Notice of Transfer/discharge date d 4/11/25 indicated Resident 237 was notified of the transfer/discharge on [DATE] [to a Board & Care], the effective date of discharge was 4/13/25. The notification by fax to the Ombudsman was 4/11/25. 1D. Review of Resident 233's Notice of Transfer/discharge date d 4/2/25 indicated Resident 233's RP was notified of the transfer/discharge on [DATE] [to a Board & Care], the effective date of discharge was 4/5/25. The notification by fax to the Ombudsman was 4/11/25. 1E. Review of Resident 183's Notice of Transfer/discharge date d 4/14/25 indicated Resident 183 was notified of the transfer/discharge on [DATE] [to a Board & Care, assisted living group home], the effective date of discharge was 4/15/25. The notification by fax to the Ombudsman was 4/16/25. During an interview on 4/18/25 at 3:46 p.m. with Social Services (SS) G, SS G stated a Notice of Transfer/Discharge is completed 1 day prior to discharge and sent to the ombudsman. During a follow up interview on 4/18/25 at 4:25 p.m. with SS G, SSG stated, The notice of Transfer/Discharge can be faxed to the Ombudsman in 30 days. SS G was not able to explain how the Ombudsman would assist the Resident when notified was 30 days after the discharge. Review of the facility's Policy and Procedure titled, Transfer or Discharge, Facility-Initiated, dated, 10/2022, indicated, Notice of Transfer or Discharge (Planned) A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative 4. If information in the notice changes, the facility will update the recipients of the notice as soon as practicable with the new information to ensure that residents and their representatives are aware of and can respond appropriately. 5. For significant changes, such as a change in the transfer or discharge destination, a new notice will be given that clearly describes the change(s) and resets the transfer or discharge date in order to provide 30-day advance notification and permit adequate time for discharge planning. During a concurrent interview with both social services G (SS G) and social services V (SS V) on 4/18/2025 at 11:33 a.m., both SS G and SS V stated they notified LTC-O daily with their discharged residents. SS G stated they LTC-O was notified with all their discharged residents regardless of where their destination. Both SS G and SS V further stated, they would fill out a Notice of Transfer/Discharge form and then would fax the form to the LTC-O office. During a concurrent interview with SS G and review of randomly selected residents who were discharged from 7/2024 - 4/2025 on 4/18/2025 at 3:45 p.m., SS G reviewed the list of residents discharged and their fax transaction report. SS G confirmed that the following resident's discharge were not reported to the LTC-O: 1F. Resident 408 was admitted to the facility on [DATE] and was discharged to home or apartment (apt.) with no home health services (HHS - medical care provided to individuals in their own home) on 2/6/2025; 1G. Resident 103 was originally admitted to the facility on [DATE] and was discharged to home or apt. with HHS on 7/1/2024; 1H. Resident 409 was admitted to the facility on [DATE] and was discharged to home or apt. with no HHS on 2/27/2025; 1I. Resident 410 was admitted to the facility on [DATE] and was discharged to home or apt. with no HHS on 7/16/2024; 1J. Resident 411 was admitted to the facility on [DATE] and was discharged to independent living facility (ILF - a type of senior housing where residents maintain their independence and do not require assistance with activities of daily living [ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves] or medical care) on 7/28/2024; 1K. Resident 404 was re-admitted to the facility on [DATE] and was discharged to home or apt. with no HHS on 3/18/2025; 1L. Resident 412 was admitted to the facility on [DATE] and was discharged to ILF on 7/12/2024; 1M. Resident 414 was admitted to the facility on [DATE] and was discharged to acute care hospital on 9/22/2024; 1N. Resident 415 was admitted to the facility on [DATE] and was discharged to home or apt. with no HHS on 7/31/2024; 1O. Resident 416 was re-admitted to the facility on [DATE] and was discharged to home or apt. with no HHS on 7/9/2024; and 1P. Resident 417 was re-admitted to the facility on [DATE] and was discharged to home or apt. with no HHS on 10/13/2024. Further interview with SS G, he stated nurses are responsible for the notice of transfers to LTC-O when residents were transferred to the hospital while social services were the ones who notified LTC-O for any planned discharges. Further interview with SS G and review of the list of discharged residents and the facility's fax transaction report, SS G confirmed that the following resident's discharge notification to LTC-O were submitted late: 2A. Resident 418 was discharged to home with HHS on 8/5/2024 and the fax transaction report to the LTC-O was dated 10/24/2024 (two months late); 2B. Resident 419 was discharged to home with HHS on 8/24/2024 and the fax transaction report to the LTC-O was dated 10/24/2024 (two months late); 2C. Resident 420 was discharged to acute care hospital on [DATE] and the fax transaction report to the LTC-O was dated 1/29/2025 (three months late); 2D. Resident 421 was discharged to acute care hospital on [DATE] and the fax transaction report to the LTC-O was dated 1/29/2025 (three months late); 2E. Resident 404 was discharged to acute care hospital on [DATE] and the fax transaction report to the LTC-O was dated 1/29/2025 (three months late); 2F. Resident 422 was discharged to acute care hospital on [DATE] and the fax transaction report to the LTC-O was dated 1/29/2025 (three months late); and 2G. Resident 423 was discharged to acute care hospital on [DATE] and the fax transaction report to the LTC-O was dated 1/29/2025 (three months late).

Based on observation, interview and record review, the facility failed to provide adequate physical assistance during activities of daily living (ADL's such as bed mobility, dressing, and toileting) for one of three residents (Resident 1) when on 12/21/19, Resident 1 was not provided with two-person physical assistance during ADL care and fell out of bed. This failure resulted in Resident 1's fall, sustaining a left shin skin tear, a left knee abrasion, and a [MEDICAL CONDITION] (a deep cut or tear in the skin) requiring five stitches. Findings: Review of Resident 1's clinical record indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1's minimum data set (MDS, an assessment tool) dated 12/9/19, indicated Resident 1 was totally dependent on staff for bed mobility and toilet use and needed extensive assistance for dressing. The MDS further indicated Resident 1 needed two-person physical assistance for bed mobility, dressing, and toilet use. Resident 1 was non-verbal and cognitively impaired. Review of Resident 1's MDS dated [DATE], indicated Resident 1's had range of motion impairment on both sides of her upper (shoulder, elbow, wrist and hand) and lower (hip, knee, ankle, foot) extremities. Review of Resident 1's health status change and the SBAR (Situation, Background, Assessment and Recommendation) report, indicated Resident 1 had an actual fall on 12/21/19 at around 9:35 p.m. and sustained a laceration to the left forehead (4 centimeters (cm, a unit of measurement) x 4 cm x 0.2 cm, skin tear to the left shin (4 cm x 4 cm) and abrasion to the left knee (irregular, 2 cm x 2 cm). The report further indicated the root cause: CNA was providing care on Resident 1 and suddenly rolled over to the other side of the bed and fell . Resident 1 has poor safety awareness with communication deficit and require extensive to total (assistance) on ADL's during care, noted with special mattress and uses blood thinner. Review of Resident 1's hospital notes, indicated Resident 1 arrived in the emergency department on 12/21/19 at 10:35 p.m. Resident 1's physical exam revealed a large stellate laceration (tear in the skin cause by [MEDICATION NAME] trauma with several lines radiating from the center of the tear, like that of a star pattern) on the forehead, all four extremities with contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), and small lacerations on left knee. On 12/22/19 at 1:09 a.m., Resident 1's large stellate [MEDICAL CONDITION] had to be repaired with five sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision). During an observation on 1/7/2020 at 10:11 a.m., Resident 1 was sleeping in bed on a low air loss mattress (LAL, special bed for prevention or treatment of [REDACTED]. During an observation on 1/7/2020 at 11:57 a.m., a treatment nurse (TXN) and a second staff member were rendering care for Resident 1. Resident 1 laid in bed with both knees bent and with booties on both feet. During an interview with TXN on 1/7/2020 on 12:24 p.m., she stated Resident 1 had a [MEDICAL CONDITION] with five stitches she acquired after a fall on 12/21/19. During an interview with certified nursing assistant A (CNA A) on 1/7/2020 at 1:52 p.m., she stated Resident 1 needed a two-person assistance for ADL's. During an interview with registered nurse B (RN B) on 1/7/2020 at 1:56 p.m., he stated Resident 1 returned from the hospital on [DATE] at around 8:00 a.m. with a [MEDICAL CONDITION] with five stitches. He further stated Resident 1 required a two-person assist on all ADL's except during feeding. During a telephone interview with CNA C on 1/7/2020 at 2:29 p.m., he stated on 12/21/19, he was providing ADL care for Resident 1 while she was in bed. CNA C stated he then placed two pillows on the back side of Resident 1, Resident 1 moved and slid off the LAL mattress and onto the floor. CNA C stated the LAL mattress was slippery, the pillows also fell when Resident 1 slipped to the floor. He further stated he would normally ask for help because Resident 1 was very contracted but nobody was available to help him at that time. He confirmed he was alone while providing care for Resident 1. During an interview with assistant director of nursing D (ADON D) on 1/7/2020 at 3:00 p.m., she stated Resident 1 required two-person assist during ADL care for bed mobility, dressing and toilet use. She further confirmed, CNA C was by himself while providing ADL's to Resident 1 when Resident 1 fell on [DATE]. Resident 1 should have been assisted by two staff. During a concurrent interview with ADON [NAME] on 1/7/2020 at 3:00 p.m., she stated the LAL mattress was slippery. She further stated Resident 1 slipped and rolled over her mattress and fell to the floor. She further stated the fall could have been prevented if there were two CNA's providing care for Resident 1. During an interview with licensed vocational nurse G (LVN G) on 1/7/2020 at 3:40 p.m., she stated on 12/21/19, CNA C called her to Resident 1's room. Resident 1 on the floor and her forehead was bleeding. LVN G further stated Resident 1 needed two-person physical assist because she was contracted and did not move by herself. During a telephone interview with nurse supervisor F (NS F) on 1/9/2020 at 1:47 p.m., she stated, on 12/21/19 at around 9:35 p.m., LVN G called her for assistance with Resident 1's fall incident. NS F stated Resident 1 was on the floor, on the right side of the bed, and Resident 1 was facing the window (on the left side). Resident 1 was bleeding on the forehead. Review of the facility's policy, Activities of Daily Living (ADL), Supporting, revised on 3/2018, indicated appropriate care and services will be provided for resident who are unable to carry out ADL's independently, including appropriate support and assistance with: hygiene, mobility, elimination, dining and communication.

Based on interview and record review, the facility failed to provide adequate physical assistance to prevent a fall for one of three residents (Resident 1) when on 3/4/18, the resident stood up without physical assistance and fell . This failure resulted in Resident 1's fall sustaining a [MEDICAL CONDITION]. Findings: Review of Resident 1's quarterly minimum data set (MDS, an assessment tool), dated 1/23/18, indicated the resident had resided in the facility since 9/13/2006 with [DIAGNOSES REDACTED]. It indicated Resident 1 required one person physical assistance for transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position) and walked using a walker with supervision (oversight, encouragement, or cueing). Review of Resident 1's Activities of Daily Living report (ADL, certified nurse assistants' documentation), dated 2/15/18 to 3/4/18, indicated the resident required setup help during transfers. Review of Resident 1's ADL Weekly Summary (licensed nurses' documentation), dated 1/30/18 to 2/5/18 and 2/27/18 to 3/5/18, indicated the resident required one-person assistance during transfer. Review of Resident 1's Morse Fall Scale (an assessment tool to predict future falls) dated 1/23/18, indicated Resident 1 had a high risk for falling. Review of Resident 1's AG (activity guide) Interdisciplinary Team (IDT group of healthcare professionals from diverse fields working toward effective patient care) progress notes dated 1/25/18, indicated on 1/24/18, Resident 1 walked backwards with her front wheel walker (FWW), lost her balance, and fell . Review of Resident 1's AG IDT progress notes dated 3/4/18, indicated Resident 1 was sitting on her FWW, suddenly stood up, lost her balance, and fell on her right side. Resident 1 complained of right hip pain. Review of Resident 1's daily nurses notes dated 3/5/18, indicated on 3/4/18 at 7:25 p.m., Resident 1 was transferred to acute care hospital for further evaluation. Review of Resident 1's Discharge Summary from the acute care hospital dated 3/8/18, indicated the resident was brought to the hospital after the mechanical fall and the hip X-ray revealed a fracture. During an interview with licensed vocational nurse A (LVN A) on 5/18/18 at 1:10 p.m., she stated on 3/4/18, she was organizing her medication cart at a nursing station, and was able to see Resident 1 sitting on her FWW and talking with other residents in the hallway. She stated she saw Resident 1 standing up from her FWW but did not assist the resident. LVN A stated she was unaware Resident 1 required one-person physical assistance for transferring. During an interview on 6/29/18 at 11:00 a.m. with certified nursing assistant B (CNA B), who was involved in Resident 1's care when the resident fell , stated she was unaware Resident 1 needed one-person physical assistance during transfers. During an interview on 7/9/18 at 4:10 p.m., CNA C, stated she always watched and assisted Resident 1 when she stood up from her walker, especially when she had to turn around to grab her walker's handles or place the walker in front of her. CNA C stated she had to hold Resident 1's pants on her back to support her to stand, otherwise her gait would be unsteady. During an interview on 7/9/18 at 2:30 p.m., the MDS coordinator (MDSC) stated Resident 1 was transferring from sitting on her FWW to standing. When Resident 1 stood up from her FWW, LVN A should have overseen or assisted her to prevent a fall. She stated staff should have been aware of what type of assistance the resident required. Review of the facility's policy Activities of Daily Living (ADL), Supporting, revised on 3/18, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with mobility (transfer and ambulation, including walking). A resident's ability to perform ADLs will be measured using clinical tools, including the MDS.

The facility failed to securely fasten Resident 1 in the transport van. This failure resulted in Resident 1 sustaining a 10 centimeter (unit of measure) laceration (deep cut or tear) on anterior (front) scalp requiring 16 staples and hospital admission to the intensive care unit. Findings: Review of Resident 1's clinical record indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set (MDS: an assessment tool) dated 3/28/18 indicated she had moderately impaired cognition. Resident 1 was alert and oriented (able to make herself understood) and required one to two staff members for all her activities of daily living (ADL). Review of Resident 1's emergency department provider notes dated 5/14/18 indicated history obtained from medics: Patient was on her way to [MEDICAL TREATMENT] in a gurney van. The patient reportedly was not securely restrained in the van and it came to a hard stop. Patient fell and hit her head with full thickness (layers of skin, fat and muscle)) laceration to the back of her head. Review of Resident 1's accident report dated 5/14/18 from the transportation service, included the driver's statement which indicated: I applied my brake to avoid a collision with the vehicle that suddenly cut into my driving lane. I looked at my rear view mirror and saw that my passenger had fallen. Review of the facility's investigative summary dated 5/18/18 indicated on 5/14/18 Resident 1 was being transported to her [MEDICAL TREATMENT] appointment. During this transportation the vehicle was involved in an incident where the driver tried to avoid hitting someone who cut in front. The resident fell back resulting in her head striking a metal bar. The resident was admitted to the acute hospital with: Left frontal IPH (Intraparenchymal Hemorrhage: bleeding in the brain), right scalp laceration, questionable compression fracture of T2 (a bone of the spinal column located in the chest region). The statement from the acute hospital was that the resident was sitting unsecured in the transport van. Review of Resident 1's clinical record indicated Resident 1 was readmitted to the facility on [DATE]. Staples were removed from scalp area on 5/22/18. https://www.transit.dot.gov/regulations-and-guidance (Web based Internet site) Section 38.23(d) of the Department of Transportation (DOT) American Disabilities Act (ADA) regulations requires all ADA-compliant buses and vans to have a two-part securement system, one to secure the wheelchair, and a seat belt and shoulder harness for the wheelchair user.

Based on observation, interview, and record review, the facility failed to provide ADL care for a dependent resident when the care plan of having two people during a shower for one of three residents (1) was not implemented. This resulted in first [MEDICAL CONDITION] the left side of Resident 1's face and left side of Resident 1's chest. Findings: Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's minimum data set (MDS, an assessment tool) dated 1/5/18, indicated the resident required two-person-assistance during bathing. During a review of the clinical record for Resident 1, the care plan indicated under activities of daily living that there needed to be two people assisting the resident during bathing. During an interview with certified nursing assistant A (CNA A) on 1/12/18 at 3:11 p.m., he stated that when they give showers, there are supposed to be two people assisting the resident, a licensed nurse and a certified nursing assistant. During an interview with registered nurse B (RN B) on 1/10/18 at 9:00 a.m., she stated that it is their standard to give showers with two people, one licensed nurse and one certified nursing assistant. She also stated that there was only one certified nursing assistant who showered Resident 1 on 12/27/17. During an observation on 1/10/18 at 9:45 a.m. in Resident 1's room, the resident's left side of her face was light pink and the left side of her chest had non-adhering dressing and white [MEDICATION NAME] cream. During a review of the clinical record for Resident 1, the daily nurses notes dated 12/27/17 indicated a licensed nurse found CNA C and another licensed nurse at the bedside. Resident 1 was found lying on the bed with redness and skin peeled off on the left side of her face and redness peeled off on the left upper chest, areas moist, no bleeding, or no swelling noted. During a review of the clinical record for Resident 1, the weekly non-pressure ulcer observation tool dated 12/27/17 indicated Resident 1 was noted with redness of skin peeled off on the left side of her face post shower on 12/27/17. During a review of the clinical record for Resident 1, the nursing care plan dated 1/5/18 indicated there was redness on the left shoulder, left upper chest, left side of the face, and left ear secondary to a first degree burn. During a review of the clinical record for Resident 1, the treatment administration record dated 12/28/17 indicated because of the first degree burn, Resident 1 had to receive the treatment of [REDACTED].