Every finding on record at Whitney Oaks Care Center

Based on observation, interview, and record review, the facility failed to have proper training, written policies, procedures, or guidelines on handling Hazardous Drugs (HD) and pharmaceutical products when:Licensed Nurse (LN) 2 did not demonstrate how to don appropriate Personal Protective Equipment (PPE) when needed for handling HD.LN 3 also did not wear gloves when administering an HD.Loose pills were found at Resident 68's bedside, indicating improper handling and storage of medications. These failures increased staff's risk of exposure to HD and surface contamination and increased the risk of other residents being exposed to pharmaceutical products. Findings: 1. During an observation of medication administration on 8/30/26 at 8:40 a.m., Licensed Nurse (LN) 2 was observed preparing and administering Resident 100's morning medications which included finasteride (a hazardous medication used to treat an enlarged prostrate) without wearing any glove. During an interview on 8/30/26 at 12:05 p.m. with LN 2, LN 2 stated, the blister pack containing finasteride had an auxiliary label indicating the drug was a hazardous medication. LN 2 also stated she would have used gloves if the hazardous medication had fallen out of the medication cup during medication pass. 2. During an observation of medication administration on 8/30/26 at 9:09 a.m., LN 3 was observed preparing and administering Resident 97's morning medications which included finasteride without wearing any glove. During an interview on 8/30/26 at 9:30 a.m. with LN 3, LN 3 acknowledged that gloves were not used during the medication pass and she should have worn gloves when she popped the medication out of the blister pack. LN 3 stated, the prescription label indicated, handle with gloves in addition to having a yellow hazardous medication label. During an interview on 8/31/26 at 9:40 a.m. with the Director of Nursing (DON), the DON stated, nurses should have worn gloves when handling and administering hazardous medications such as finasteride. With hazardous medications there was risk of affecting reproductive system. A review of finasteride's Safety Data Sheet (a document that provides detailed information about the hazards of a chemical substance), dated 2/12/24, indicated, reproductive toxicity.consider double gloves.or other impervious gloves if skin contact is possible. During an interview on 8/31/26 at approximately 1 p.m. with the DON, the DON stated that the facility did not have a specific policy for handling hazardous medications. During a review of the facility's policy and procedure (P&P) titled, Medications Administration-General Guidelines, undated, version 3, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices.personnel authorized to administer medications do so only after they have familiarized themselves with the medication .to administer medications in a safe and effective manner.read medication label three (3) times before pouring. 3. Resident 68 was admitted to the facility in mid 2026 with diagnoses that included type 2 diabetes (a condition where the body does not use insulin properly, causing sugar to build up in the blood) and hypertensive heart disease with heart failure (heart problems caused by long term high blood pressure that makes the heart work harder over time and weakens its ability to pump blood). During an observation on 8/30/26 at 9:11 a.m. in Resident 68's room, three white pills sat loose on the overbed table. Resident 68 stated the nurse gave them to him. This surveyor took a picture of the pills, and they were identified as two medications to treat diabetes and one medication to treat high blood pressure and heart failure. During a concurrent observation and interview on 8/30/26 at 9:17 a.m. with Licensed Nurse (LN 4) in Resident 68's room, LN 4 confirmed the three pills on the overbed table. LN 4 stated medications should not be left at the bedside, and the correct practice was to watch residents take their pills. LN 4 further stated pills left at the bedside could be consumed by another resident and have a bad outcome, as well as result in an inaccurate record of the resident taking the medications. During an interview on 9/2/26 at 11:55 a.m. with the Director of Nursing (DON), the DON stated she expected nurses to ensure medications were taken and not leave them at the bedside. The DON further stated medications left at the bedside could be taken by other residents and, if not taken by the resident, could cause complications of the conditions the medications were prescribed to treat.

Based on observation, interview, and record review, the facility failed to ensure the medication rate did not exceed 5% for 1 of 2 sampled residents (Resident 100), when:1. A licensed nurse administered an incorrect dose of lovenox (medication used as a blood thinner) not according to the Physician's Order.2. A licensed nurse administered a dose of hydrocodone-acetaminophen (combination of two medications used for pain) 5/325 mg (milligram, unit of measure) for a pain level of zero against the Physician's Order.As a result, 2 errors were identified out of 28 opportunities for error during the observation of medication administration; the facility medication error was 7.14%.Findings: 1. During an observation of medication administration on 8/30/26 at 8:40 a.m., Licensed Nurse (LN) 2 was observed preparing and administering Resident 100's morning medications which included lovenox 150 mg in a prefilled syringe.Reconciliation of the observation of medication administration with Resident 100's current Physician's Orders indicated an order for lovenox, dated 10/7/25, inject 0.8 ml (milliliter, unit of measure, subcutaneously (under the skin), discard 0.2 ml from syringe and inject 0.8 ml (120mg).During an interview on 8/30/26 at 12:05 p.m. with LN 2, LN 2 stated, I acknowledged that I gave the wrong dose to the resident. LN 2 further stated according to the Physician's Order and pharmacy label, only 0.8 ml (120 mg) should have been given to the resident instead of the full 1 ml (150 mg) prefilled syringe. LN 2 also stated that a higher dose of lovenox could increase the risk of bleeding.During an interview on 8/31/2026 at 9:29 a.m., the Director of Nursing (DON), the DON acknowledged that the medication error occurred when Resident 100 received an accidental higher dose of lovenox. The DON further stated that the on call nurse practitioner or physician was notified on the day of the incident, but the facility had not yet received any orders related to the error. The DON also stated that the resident was at risk of bleeding and bruising.2. During an observation of medication administration on 8/30/26 at 8:40 a.m., LN 2 was observed preparing and administering Resident 100's morning medication, which consisted of one hydrocodone-acetaminophen 5/325 mg tablet without asking what the resident's pain level was.Reconciliation of the observation of medication administration with Resident 100's current Physician Orders indicated an order for hydrocodone-acetaminophen 5/325 mg, dated 7/28/26, give one tablet by mouth every 6 hours as needed for moderate to severe pain 4-10, a pain scale used to rate how much something hurts from 0 (no pain) to 10 (worst pain imaginable).A Review of Resident 100's vital sign documentation on 8/30/2026 8:59 a.m., indicated Resident 100's pain level was documented as zero (no pain).During an interview on 8/30/26 at 12:15 p.m. with LN 2, LN 2 stated, I forgot to ask the resident what his paint level was this morning. LN 2 explained the wound care team typically wanted the resident to receive it, so a dose was given to him.During an interview on 8/31/2026 at 9:36 a.m., the DON stated that for the resident's as needed pain medication, the nurse was expected to ask about both the pain intensity level and the location. The documented note only indicated that a dose was given prior to wound treatment. The DON added that the nurse should have asked and assessed the resident to determine whether the as needed medication was needed before administering it.During a review of the facility's policy and procedure (P&P) titled, Medications Administration-General Guidelines, undated, version 3, the P&P indicated, Medications are administered as prescribed. During a review of the facility's policy and procedure (P&P) titled, Resident Examination and Assessment, dated 2001, the P&P indicated, the purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan .14. pain: a. description of pain; b. location, duration, severity. Documentation: the following information should be recorded in the resident's medical record.all assessment data obtained during the procedure.

Based on observation, staff interviews, and record review, the facility failed to ensure that pharmaceutical products were stored in accordance with facility policies, procedures, and manufacturers' requirements when staff did not check or monitor the temperature of the central supply medication room on a regular daily basis.This failure had the potential to compromise the integrity of medications, which could result in the administration of ineffective pharmaceutical products and pose a risk to patient safety. Findings:During an inspection of the facility's central supply medication room on 8/30/26 at 8:49 a.m., it was observed that the medication room did not have a temperature monitoring sensor, thermometer, or a temperature log.During an interview on 8/30/26 at 8:49 a.m. with Licensed Nurse (LN) 2, LN 2 acknowledged that the room temperature was not being checked or monitored, and she did not have a thermometer to ensure the room temperature was within the required range.During an interview on 8/31/26 at 9:47 a.m. with the Director of Nursing (DON), the DON stated that the central supply room was considered a medication room and that there was a risk of medication degradation if medications were not kept within the recommended temperature range for storage.During an interview on 8/31/26 at 12:45 p.m. with the Director of Maintenance (DOM), the DOM stated he only checked the central room's chiller temperature (a system that uses cold water to cool down a building) on Mondays and Fridays. He also stated that the nursing staff checked other medication rooms' temperatures.During a review of the facility's policy and procedure (P&P) titled, Medications Storage in the facility, undated, version 3, the P&P indicated, Medications and biologics are stored safely, securely, and properly, following the manufacture's recommendations.Medications requiring storage at room temperature are kept at temperatures ranging 59 (F) [Fahrenheit, unit of measure] to 86 (F). Suitable temperature recording devices include a calibrated continuous recording device or an NBS [National Bureau of Standards] calibrated thermometer with alarms will be used.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of infections for three of 25 sampled residents (Resident 1, Resident 48, and Resident 15) for a census of 121 when: Resident 1's fingernails were long, jagged, untrimmed and had black substances underneath the nail beds;Resident 48's toenails were long, jagged, untrimmed and had fungus-like-colored-appearance; and, Resident 15's wheelchair had spilled liquids marks, food droppings, white-colored-tissue-like-substances stocked in between its corners and wheels had black-sticky substances. These failures had the potential to result in nail discomfort and deformity for Resident 1 and Resident 48 and skin irritations for Resident 15, and increase the spread of infections for the residents. Findings: 1.During an observation on 9/1/26 at 12:31 p.m., in room [ROOM NUMBER], Resident 1's fingernails were long, jagged, untrimmed and had black substances underneath the nail beds. During a concurrent observation and interview on 9/1/26 at 12:31 p.m., in room [ROOM NUMBER], Resident 1 showed his fingernails and stated he wanted it trimmed and cleaned. During a concurrent observation and interview on 9/1/26 at 12:31 p.m. in room [ROOM NUMBER] with Licensed Nurse 4 (LN 4), LN 4 confirmed Resident 1's fingernails were long, jagged, untrimmed and had black substances underneath the nail beds. LN 4 stated Resident 1 could have skin tears when he itched and scratched because of the sharp and jagged fingernails. LN 4 stated Resident 1's fingernails should be trimmed and cleaned for better hygiene and lowered the risk of spreading germs. 2.During an observation on 8/31/26 at 12:10 p.m. and on 9/1/26 at 4:48 p.m., in room [ROOM NUMBER], Resident 48's toenails were long, jagged, untrimmed and had fungus-like-colored-appearance. During a concurrent observation and interview on 9/1/26 at 4:48 p.m., in room [ROOM NUMBER], Resident 48 stated her toenails had not been trimmed for a long time. Resident 48 stated she wanted her toenails trimmed because it gave her discomfort, snagged on her socks and bedsheets which was painful. During a concurrent observation and interview on 9/1/26 at 4:48 p.m. in room [ROOM NUMBER] with LN 5, LN 5 confirmed Resident 48's toenails were long, jagged, untrimmed and had fungus-like-colored-appearance. LN 5 stated toenails should be kept clean to prevent painful infections, ingrown toenails and the build-up of harmful bacteria. LN 5 also stated dirt, dead skin, and sweat easily collect under long toe nails, and the warm and moist environment breeds fungus and bacteria. 3.During an observation on 9/1/26 at 3:50 p.m. in room [ROOM NUMBER], Resident 15 was seated in her wheelchair. Resident 15's wheelchair had spilled liquid marks, food droppings, white-colored-tissue-like-substance stocked in between its joints and corners and wheels had black-sticky substances. During a concurrent observation and interview on 9/1/26 at 3:50 p.m., in room [ROOM NUMBER], Resident 15 stated her wheelchair should be cleaned as it was her own place to sit. Resident 15 also stated she always wheeled her wheelchair. During a concurrent observation and interview on 9/1/26 at 3:50 p.m., in room [ROOM NUMBER] with LN 5, LN 5 confirmed Resident 15's wheelchair had spilled liquids marks, food droppings, white-colored-tissue-like-substance stocked in between its joints and corners and wheels had black-sticky substances. LN 5 stated wheelchairs should be cleaned daily to stop the spread of germs, prevent sticky buildup from food or leaks, and protect the moving parts from damage. LN 5 also stated high-touched spots like push rims and armrests collect dirt and bacteria from hands and public places every day, wiping and cleaning lowered the risk of Resident 15 from getting sick. During an interview on 9/2/26 at 12:03 p.m., with the Director of Nursing (DON), the DON stated her expectations:Resident 1's fingernails should be trimmed and cleaned for better hygiene. Resident 1 could scratched his skin and the long, jagged fingernails could cause skin infections. Resident 48's toenails should be trimmed and fungal-like condition should be treated. Untreated or poorly managed fungal toenail could result in physical pain when walking secondary to bacterial infections. Resident 15's messy wheelchair should be cleaned on a regular basis. Resident 15 deserved dignity and recognition of basic care. Dirty wheelchairs could make resident unhappy. No one wants to use dirty wheelchairs. A review of the facility's Policy and Procedure (P&P) titled, FINGERNAILS/TOENAILS, CARE OF, revised 2/2018, the P&P indicated, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. General Guidelines: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 3. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 5. Watch for and report any changes in the color of the skin around the nail bed, blueness of the nails, any signs of poor circulation, cracking of the skin between the toes, any swelling, bleeding, etc. A review of the facility's Policy and Procedure (P&P) titled, MAINTENANCE SERVICE, revised 12/2009, the P&P indicated, Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation. 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in asafe and operable manner at all times.

Based on interview, record review, and facility document review, the Consultant Pharmacist (CP) did not identify Medication Regimen Review (MRR) irregularities for one of five sampled residents (Resident 5) when the resident was receiving a higher-than-recommended dose of apixaban (a blood thinning medication) despite meeting criteria requiring a reduced dose.This resulted in potential adverse effects, including excessive bleeding for Resident 5.Findings:Resident 5 was an [AGE] year-old dependent on dialysis with limited kidney function admitted to the facility from an acute care hospital.A review of apixaban's Prescribing Information (PI), dated 4/25, the PI indicated, In patients with at least 2 of the following characteristics: age greater than or equal to 80 years.serum creatinine [Serum creatinine is a waste product from your muscles that your kidneys normally filter out. A blood test measures how much of it is in your bloodstream-if levels are high, it usually means your kidneys aren't cleaning your blood as well as they should] greater than or equal to 1.5 mg/dL [milligram/deciliter, unit of measure].the recommended dose is 2.5 mg orally twice daily.A review of Resident 5's Physician's Order, dated 5/12/26, indicated apixaban oral tablet 5 mg (milligram, unit of measure), to give one tablet by mouth two times a day for A-FIB (atrial fibrillation, when the heart beats in an irregular, sometimes fast pattern that can lead to blood pooling and increase the risk of stroke).A review of Resident 5's monthly lab reports indicated Resident 5's serum creatinine was 5.30 mg/dl on 6/22/26, 4.96 mg/dl on 7/27/26, and 4.61 mg/dl on 8/24/26.A review of Resident 5's Medication Administration Record (MAR) for the month of August 2026 indicated that the resident received apixaban 5 mg two times daily.During an interview on 9/2/26 at 10:58 a.m. with the Director of Nursing (DON), the DON stated that she was unable to find any orders from the dialysis physician to change any of the orders and she was unable to find any recommendations from the facility's Consultant pharmacist (CP) regarding the apixaban's dose.During an interview on 9/2/26 at 12:16 p.m. with the facility's CP, the CP stated since the resident was [AGE] years old and had limited kidney function, the dose of apixaban should have been decreased to 2.5 mg twice daily. This recommendation was not included in the July and August monthly medication reviews. During an interview on 9/2/26 at 2:27 p.m. with the facility's Medical Doctor (MD), the MD sated she did not see any notes why the 5 mg twice daily dosing was indicated for the resident. The dose should've been adjusted to 2.5 mg twice daily since the medication was renally cleared. The MD also stated the high dose of apixaban put the resident at high risk for bleeding.A review of a highly reputable peer reviewed cardiology study published in Circulation, a widely recognized cardiovascular journal, dated 2023, provided evidence supporting the need to reduce apixaban dosing in elderly or renally impaired patients. The higher 5 mg twice daily dose was associated with increased risk of major bleeding, while showing no improvement in stroke prevention or mortality compared to the reduced 2.5 mg dose.During a review of the facility's policy and procedure (P&P) titled, Consultant Pharmacist Report, undated, version 3, the P&P indicated, The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy.The consultant pharmacist identifies irregularities through a variety of sources including: Medication Administration Records (MARs); prescribers' orders; progress notes of prescriber,.laboratory and diagnostic test results.

Based on observation, interview, and record review, the facility failed to ensure care and services were provided according to accepted standards of clinical practice for one of 25 sampled residents (Resident 48) for a census of 121, when: The Ace bandage wrap (a stretchable elastic strip used to apply gentle, supportive compression to sprains, strains, and leg swelling) order was without clear treatment indication (It is the clinical justification for using a specific therapy to reach a therapeutic goal); There was no nursing evaluation on the leg swelling; and, There was no nursing evaluation on the continued use of the Ace wrap bandage. These failures had the potential to result in missed complications, worsening patient conditions, increased discomfort and missed to modify an ineffective treatment plan. Findings: During a review of Resident 48's admission Record (AR), the AR indicated she was admitted with diagnoses which included cellulitis (common bacterial infection of the deeper layers of the skin and the tissues beneath it) of right lower limb, obesity, peripheral vascular disease (PAD, slow and progressive circulation disorder) and lymphedema (swelling condition when fluid buildup in the soft tissues, usually in an arm of leg).During a review of Resident 48's Physician's Order (PO) dated 3/16/26, the PO indicated, Ace wraps to bilateral lower extremities. ON [in the morning]. OFF [in the afternoon]. Two times a day. Monitor skin on [Bilateral Lower Extremities] for any changes. Notify [Medical Doctor] [as needed]. During a review of Resident 48's care plan, initiated on 8/23, titled, SKIN: [Resident 48] is at risk for skin breakdown related to obesity, impaired mobility, peripheral vascular disease, and neuropathy. Check skin during daily care provisions, notify physician of abnormal findings, float bilateral heels with pillow while in bed for edema, keep skin clean and dry to the extent possible and minimize skin exposure to moisture.Further review of the record did not show any documented evidence on the following: 1) There was no clear treatment indication for the use of the Ace wraps. 2) There was no nursing evaluation done on the leg swelling; and, 3) There was no nursing evaluation done on the continued use of the Ace wrap bandage such as circulation, effectiveness and skin health. During an observation on 8/30/26 at 10:16 a.m., in room [ROOM NUMBER], Resident 48's BLE were dry, flaky, and swollen. No Ace wraps bandage applied to BLE. The Ace wraps were rolled and placed on her bed. During a concurrent observation and interview on 9/1/26 at 2:56 p.m., in room [ROOM NUMBER], Resident 48 stated she did not know what the Ace wrap bandage was all about, sometimes nurses wrapped it too tight and sometimes too loose. Resident 48 stated if the wrap was too tight she removed it because the [Velcro, fastening device made of two strips of fabric] was digging and hurting her skin. Resident 48 stated her legs were still swollen. During a concurrent interview and record review on 9/1/26 at 2:58 p.m. with Licensed Nurse 5 (LN 5), Resident 48's clinical record was reviewed. LN 5 confirmed the following: 1) the Ace wrap order was without indication, 2) There was no nursing evaluation done on the bilateral leg swelling, and, 3) There was no nursing evaluation done on the continued use of the Ace wrap. LN 5 stated any treatment order should have an indication to prove the benefits outweigh the risks. LN 5 also stated there should be an evaluation outcome and notification report to alert the doctor if the Ace wrap treatment was working or not. LN 5 stated clear indication was important for patient safety and nursing assessment and evaluation outcome report were necessary for team feedback, to track, adjust safe, effective, and personalized patient care. During a concurrent interview and record review on 9/2/26 at 12:08 p.m., with the Director of Nursing (DON), Resident 48's clinical record was reviewed. The DON confirmed the Ace wrap treatment order was without any clear indication. The DON stated any treatment order should have a clear indication for patient safety and to prevent harmful or unnecessary interventions, that the expected benefits of a treatment outweigh its risks. The DON also stated nursing evaluation for the use of the Ace wrap and the leg swelling should be done for patient safety and coordinated care. Without coordinated care, Resident 48's comfort level could be affected and skin issues could worsen. During a review of the facility's Policy and Procedure (P&P), titled, PRESSURE ULCER/SKIN BREAKDOWN, CLINICAL PROTOCOL, revised 4/26, the P&P indicated, Monitoring: b. Current approaches should be reviewed for whether they remain pertinent to the resident's/patient's medical conditions, . and the impact of specific treatment .

Based on observation, interview, and record review, the facility failed to ensure Resident 100 was free from significant medication errors when a licensed nurse administered an incorrect dose of lovenox (medication used as a blood thinner) not according to the Physician's Order.This failure resulted in Resident 100 being at risk for bleeding.Findings:According to the Institute for Safe Medication Practices (ISMP)-a nonprofit organization dedicated to preventing medication errors, dated 2018, high alert medications are drugs that can cause serious harm or death if used incorrectly. Lovenox is classified as a high alert medication by ISMP. Dosing or administration mistakes can lead to severe bleeding or other dangerous outcomes.A review of the lovenox's Prescribing Information, dated 2025, indicated that accidental overdosage following administration of lovenox may lead to hemorrhagic complications (bleeding problems inside the body that can be dangerous). During an observation of medication administration on 8/30/26 at 8:40 a.m., Licensed Nurse (LN) 2 was observed preparing and administering Resident 100's morning medications which included lovenox 150 mg in a prefilled syringe.Reconciliation of the observation of medication administration with Resident 100's current Physician's Orders indicated an order for lovenox, dated 10/7/25, inject 0.8 ml (milliliter, unit of measure, subcutaneously (under the skin), discard 0.2 ml from syringe and inject 0.8 ml (120mg).During an interview on 8/30/26 at 12:05 p.m. with LN 2, LN 2 stated, I acknowledged that I gave the wrong dose to the resident. LN 2 further stated according to the Physician's Order and pharmacy label, only 0.8 ml (120 mg) should have been given to the resident instead of the full 1 ml (150 mg) prefilled syringe. LN 2 also stated that a higher dose of lovenox could increase the risk of bleeding.During an interview on 8/31/2026 at 9:29 a.m., the Director of Nursing (DON), the DON acknowledged that the medication error occurred when Resident 100 received an accidental higher dose of lovenox. The DON further stated that the on call nurse practitioner or physician was notified on the day of the incident, but the facility had not yet received any orders related to the error. The DON also stated that the resident was at risk of bleeding and bruising.During a review of the facility's policy and procedure (P&P) titled, Medications Administration-General Guidelines, undated, version 3, the P&P indicated, Medications are administered as prescribed.

Based on interview and record review, the facility failed to ensure a Resident was free from unnecessary drugs when one of five sampled residents (Resident 5) was on a higher than required dose of apixaban (a blood thinner medication) resulting in excessive dosing for its indication in accordance with the manufacturer's requirements.This facility failure resulted in Resident 5 being at high risk for unwanted adverse effects, such as excessive bleeding.Findings: Resident 5 was an [AGE] year-old dependent on dialysis with limited kidney function admitted to the facility from an acute care hospital.A review of Resident 5's Physician's Order, dated 5/12/26, indicated apixaban oral tablet 5 mg, to give one tablet by mouth two times a day for A-FIB (atrial fibrillation, when the heart beats in an irregular, sometimes fast pattern that can lead to blood pooling and increase the risk of stroke).A review of apixaban's Prescribing Information (PI), dated 4/25, the PI indicated, in patients with at least 2 of the following characteristics: age greater than or equal to 80 years.serum creatinine [Serum creatinine is a waste product from your muscles that kidneys normally filter out. A blood test measures how much of it is in bloodstream-if levels are high, it means kidneys are not cleaning blood as well as they should] greater than or equal to 1.5 mg/dL [milligram/deciliter, unit of measure].the recommended dose is 2.5 mg (milligram, unit of measure), orally twice daily.A review of Resident 5's monthly lab reports indicated Resident 5's serum creatinine was 5.30 mg/dl on 6/22/26, 4.96 mg/dl on 7/27/26, and 4.61 mg/dl on 8/24/26.A review of Resident 5's Medication Administration Record (MAR) for the month of August 2026 indicated that the resident received apixaban 5 mg two times daily.During an interview on 9/2/26 at 10:58 a.m. with the Director of Nursing (DON), the DON stated that she was unable to find any notes from the dialysis physician to change any of the orders and she was unable to find any recommendations from the facility's Consultant pharmacist (CP) regarding the apixaban's dose.During an interview on 9/2/26 at 12:16 p.m. with the facility's CP, the CP stated since the resident was [AGE] years old and had limited kidney function the dose of apixaban should have been decreased to 2.5 mg twice daily. This recommendation was not included in the July and August monthly medication reviews. During an interview on 9/2/26 at 2:27 p.m. with the facility's Medical Doctor (MD), the MD stated she did not see any notes why the 5 mg twice daily dosing was indicated for the resident and the dose should've been adjusted to 2.5 mg twice daily since the medication was renally cleared. The MD also stated the high dose of apixaban put the resident at high risk for bleeding.During a review of the facility's policy and procedure (P&P) titled, Medications Administration-General Guidelines, undated, version 3, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices.if a dose seems excessive considering the resident's age and condition.the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary contacts the prescriber for clarification.

Based on observation, interview, and record review, the facility failed to ensure timely podiatry service was provided for one of twenty five sampled residents (Resident 48) for a census of 121 to meet the resident's toenail care needs. This failure resulted in Resident 48's toenails with long, jagged, snagged on her socks and sheets and not attaining her practicable physical, mental and psychosocial well-being. Findings: During a review of Resident 48's admission Record (AR), the AR indicated she was admitted with diagnoses which included diabetes mellitus (DM, high blood sugar levels), obesity, peripheral vascular disease (PAD, slow and progressive circulation disorder) and lymphedema (swelling condition when fluid buildup in the soft tissues, usually in an arm of leg).During a review of Resident 48's Physician's Order (PO) dated 1/28/26, the PO indicated, PODIATRY EVERY OTHER MONTH PRN TOENAIL CARE. AUTH#: 32611921448 EFFECTIVE 01/21/26 EXPIRES 01/21/27. During a review of Resident 48's undated quarterly assessment (QA), the QA indicated Resident 48 requested for podiatry services. Further review of the records did not show any documented evidence a podiatry service was provided to Resident 48 after it was authorized. During an observation on 9/1/26 at 2:41 p.m., in room [ROOM NUMBER], Resident 48 toenails were long, jagged and had a fungal-infested-colored-like-appearance. During a concurrent observation and interview on 9/1/26 at 2:41 p.m., Resident 48 stated she was mad and frustrated due to her toenails not being done and she asked why it was taking too long just to cut her toenails. Resident 48 also stated cutting her toenails could have been done earlier, it was ridiculous, it was not right, and her toenails cut out her socks and got caught in her blanket. Resident 48 also stated she was just miserable.During a concurrent interview and record review on 9/1/26 at 2:52 p.m., with the Social Services Director (SSD), Resident 48's clinical record was reviewed. The SSD confirmed Resident 48's podiatry service was not done. SSD stated it should have been done timely, but it was not. During a concurrent observation and interview on 9/1/2026 at 4:48 p.m., with Licensed Nurse 5 (LN 5), LN 5 stated toenails should be kept clean to prevent painful infections, ingrown nails and the build-up of harmful bacteria. LN 5 also stated dirt, dead skin, and sweat easily collect under long toenails, and the warm and moist environment breed fungus and bacteria. During an interview on 9/2/26 at 12:08 p.m., with the Director of Nursing (DON), the DON stated her expectation that routine and preventive care on issues like long and fungal-like-infested-toenails can escalate quickly without proper hygiene and maintenance. The DON stated routine podiatry visits keep minor skin and nail problems under control. A review of the facility's Policy and Procedure (P&P) titled, FOOT CARE, revised 10/2022, the P&P indicated, Policy Statement: Residents receive appropriate care and treatment in order to maintain mobility and foot health. Policy Interpretation and Implementation: 1. Residents are provided with foot care and treatment in accordance with professional standards of practice. 2. Overall foot care includes the care and treatment of medical conditions to prevent foot complications from these conditions (e.g., diabetes, peripheral vascular disease, immobility, etc.). A review of the facility's Policy and Procedure (P&P) titled, SOCIAL SERVICES, revised 9/2021, the P&P indicated, Social Services Policy Statement: Our facility provides medically-related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. Policy Interpretation and Implementation1. The director of social services is a qualified social worker and is responsible for: f. meeting or assisting with the medically-related social service needs of residents. 2. Medically-related social services are provided to maintain or improve each resident's ability to control everyday physical needs (e.g., appropriate adaptive equipment for eating, ambulation, etc.); and mental and psychosocial needs (e.g., sense of identity, coping abilities, and sense of meaningfulness or purpose).

Based on observation, interview, and record review, the facility failed to ensure residents were assisted with activities of daily living (ADL, basic self-care tasks) to maintain personal hygiene for three of 25 sampled residents (Resident 112, Resident 130 and Resident 66) when they did not receive their scheduled showers.These failures increased the risk of skin-related infections and had the potential to diminish the residents' sense of dignity. Findings: 1.Resident 112 was admitted to the facility in mid 2026 with diagnoses that included a left below the knee amputation, a condition where the body does not use insulin properly causing sugar buildup in the blood, and muscle weakness. During a review of Resident 112's Minimum Data Set (MDS, federally mandated resident assessment tool) dated 7/27/26, the MDS showed a Brief Interview for Mental Status (BIMS—an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident) score of 14/15, which indicated intact cognition. During an interview on 8/30/26 at 11:51 a.m. with Resident 112 in her room, Resident 112 stated she did not receive her scheduled shower yesterday (Saturday, 8/29/26). Resident 112 stated she was not offered any type of bed bath, and it was important to her to feel clean. During a review of the Shower Schedule, undated, the schedule indicated Resident 112 was scheduled to have a shower on Wednesday and Saturday. During a review of Resident 112's POC [point of care] Response History, dated 9/2/26, the POC indicated no shower was provided on Saturday (8/29/26). There was no documented refusal of a shower. 2. Resident 130 was admitted mid 2026 with diagnoses that included a left leg fracture and difficulty walking. During a review of Resident 130's MDS dated [DATE], the MDS showed a BIMS score of 14/15, which indicated intact cognition. During an interview on 8/30/26 at 8:40 a.m. with Resident 130 in his room, Resident 130 stated he had only one shower since his admission, and the guy did not show up to give his scheduled shower on Thursday, 8/27/26. Resident 130 stated his last shower was six days ago, and it was impeding my ability to feel like a human. During a review of the Shower Schedule, undated, the schedule indicated Resident 130 was scheduled to have a shower on Monday and Thursday. During a review of Resident 130's POC [point of care] Response History, dated 9/2/26, the POC indicated no shower was provided on Thursday (8/27/26). There was no documented refusal of a shower. The last documented shower was Monday, 8/24/26. During a concurrent interview and record review on 8/30/26 at 12:51 p.m. with Licensed Nurse (LN 4) of Resident 112 and Resident 130's POC and shower schedule, LN 4 confirmed the shower schedule and the documentation showing showers were not given. LN 4 stated he would expect staff to give showers as scheduled and stated showers were a good opportunity to check the skin to ensure there were no skin infections. LN 4 further stated showers were good for the resident's self esteem. During a concurrent interview and record review on 9/2/26 at 11:50 a.m. with the Director of Nursing (DON) of Resident 112 and Resident 130's POC, the DON confirmed both residents did not receive showers as ordered. The DON stated she would expect staff to give residents showers, and associated risks for not showering could include skin issues and psychosocial issues. During a review of the facility's policy and procedures (P&P) titled Activities of Daily Living [ADL], Supporting, dated 4/25, the P&P indicated, Residents are provided with care, treatment, and services as appropriate to maintain their ability to carry out activities of daily living [ADL]. Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. 3. A review of Resident 66's admission Record (AR) indicated Resident 66 was admitted to the facility in July 2026 with diagnoses which included a lumbar compression fracture (a crushed bone in the lower back) and physical decline due to generalized muscle weakness. During a review of Resident 66's Activities of Daily Living (ADL) care plan, dated 6/15/26 indicated, [Resident 66] has actual ADL/mobility decline. During a concurrent observation and interview on 8/31/26 at 10:14 a.m. in Resident 66's room, Resident 66 was observed in bed under the covers with messy, uncombed hair and a stale odor. Resident 66 stated, I don't feel clean. I don't remember when my last shower was. During a review of the facility's Shower Schedules, undated, the schedule indicated Resident 66 was scheduled to receive a shower every Monday and Thursday. During a review of Resident 66's POC, for August 2026, the POC indicated Resident 66 did not receive showers on 8/6/26, 8/13/26 or 8/31/26. The shower scheduled for 8/13/26 indicated Resident 66 refused a shower that was offered at 10:21 p.m. During an interview on 8/31/26 at 4:12 p.m. with LN 7, LN 7 stated when a resident refuses a shower the Certified Nursing Assistant (CNA) is expected to notify the LN and attempt to determine the reason for the refusal. LN 7 stated a resident might refuse a shower when it is offered too early or too late in the day and the CNA should offer a shower at a different time. LN 7 confirmed resident refusals should be documented in the resident's medical record the reason if identified, interventions offered, actions taken and the outcome. LN 7 stated, Sometimes it just takes another person, at another time to ask the resident if they would like a shower, it's the perfect time for a skin check. LN 7 further indicated ADL care encouraged and maintained a resident's mobility, hygiene and dignity. During a concurrent interview and record review on 9/2/26 at 11:03 a.m. with the DSD, Resident 66's POC was reviewed. The DSD confirmed Resident 66 did not receive showers as scheduled. The DSD stated additional information should be documented when a resident refused a shower and acknowledged Resident 66 might not have wanted a shower at 10:21 p.m. The DSD indicated showers are important for residents' overall health, hygiene, and dignity. The DSD acknowledged that when showers are not provided, or a resident is not well groomed, they have an increased risk for skin breakdown, foul odors and loss of dignity.

Based on observation, interview, and record review, the facility failed to provide one of 25 sampled residents (Resident 15) the necessary care and services to maintain the resident's abilities to perform activities of daily living for a census of 121 when the hearing aid device (HAD) was not applied as indicated. This failure had the potential to result in Resident 15's confusion, agitation, increased social isolation and diminished quality of life.Findings: During a review of Resident 15's admission Record (AR), the AR indicated she had diagnoses which included dementia (decline in mental ability severe enough to interfere with daily life) and Alzheimer's (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks). During a review of Resident 15's Physician's Order (PO) dated 2/17/25, the PO indicated, Consult-Audiology with follow-up and treatment as indicated. During a review of Resident 15's Activities of Daily Living (ADL) care plan titled, At risk for altered ADLs [related to] decline in functional ADL activity [related to] Alzheimer's . During a review of Resident 15's August 2026 Medication Administration Record (MAR, an official log used to track every medicine/ treatment given to a patient), the MAR indicated, hearing aids one time a day apply [in the morning] and remove at [hour of sleep] and put in narcotic box and remove per schedule. During an observation on 8/31/26 at 10:19 a.m., and at 2:51 p.m., Resident 15 was not wearing her HAD and appeared confused, agitated by the different voices she heard around. Resident 15 asked the staff three times, what did you say? During a concurrent observation and interview on 8/31/26 at 2:51 p.m., in room [ROOM NUMBER], with Certified Nurse Assistant 6 (CNA 6), CNA 6 confirmed Resident 15 was hard of hearing (HOH) and was not wearing her HAD. CNA 6 stated at times Resident 15 got agitated because she could not understand what was going on. During a concurrent observation and interview on 9/1/26 at 3:50 p.m., with Licensed Nurse 5 (LN 5), LN 5 confirmed the HAD was to be on in the morning and off at hour of sleep, but this time was not applied but kept inside the black box inside the medication cart. LN 5 stated Resident 15 should use her HAD for her quality of life, to hear clearly and communicate properly without staff having to speak in a louder voice near her ear. LN 5 stated Resident 15 got agitated at times when people were talking but could not understand and could not hear. During a concurrent observation and interview on 9/1/2026 at 3:57 p.m., in room [ROOM NUMBER], with CNA 2, CNA 2 confirmed Resident 15 was not wearing her HAD and she never saw she had use it. CNA 2 stated she had to adjust her voice, louder or go nearer to the resident's ear so she could hear. During a concurrent interview and record review on 9/1/26 at 4:18 p.m., with the Social Services Director (SSD), Resident 15's clinical record was reviewed. SSD confirmed per audiologist, the use of the HAD was valid and needed. During a concurrent interview and record review on 9/2/26 at 12:08 p.m., with the Director of Nursing (DON), Resident 15's clinical record was reviewed. The DON stated she expected the staff to offer and apply the HAD. The DON stated if Resident 15 could not hear she could feel isolated. The DON confirmed the HAD was ordered on 4/2025 and that there was no documented evidence in the nurses notes that it was offered or that Resident 15 had refused or threw it away when applied. During a review of the facility's Policy and Procedure (P&P) titled, Hearing Impaired Resident, Care of, undated, the P&P indicated, Policy Statement: Staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents and visitors. Policy Interpretation and Implementation: 3. Staff will assist residents with care and maintenance of hearing devices.

Based on interview and record review, the facility failed to protect the rights for one of 25 sampled residents (Resident 3) when the facility disregarded Resident 3's right for autonomy (when healthcare providers, caregivers, or facility staff make decisions for a resident without their consent, input, or consideration of their preferences) to designate his own representative.This failure resulted in Resident 3's psychological distress, functional decline and loss of dignity.Findings: A review of Resident 3's admission Record (AR) indicated Resident 3 was readmitted to the facility in March 2026 with diagnoses which included dementia (a decline in memory, thinking and social abilities) and cerebrovascular disease (conditions that affect blood flow to the brain).During a review of Resident 3's Case Management (CM) progress note, dated 4/28/26 at 3:54 p.m. by Licensed Nurse (LN) 6, LN 6 indicated it was made clear to [RR] and [RR's daughter] that they will be kept informed of Resident 3's care and condition, but [FM] will be the decision maker.During an interview on 8/30/26 at 11:10 a.m. with Resident 3 and RR, in Resident 3's room, Resident 3 stated, They're [facility] violating my rights, [facility staff] say I'm unable to make my own decisions and [facility staff] won't even let me be involved in making my own decisions. Resident 3 became choked up and stated, I want [RR] to make decisions, and I want to go home with [RR] and watch tv [television]. [RR] knows what I want. RR stated the facility disregarded Resident 3's ability to make his own choices and refuses to acknowledge her as Resident 3's representative even after she provided the facility with a copy of Resident 3's VA [Veterans Affairs] Advanced Directive and Durable Power of Attorney for Health Care and Living Will (AD/DPOA) which named her as Resident 3's Power of Attorney (POA, a legal document that names a trusted person to make decisions or act on another's behalf). RR stated the facility notified her that a complaint had been filed against her ability to care for Resident 3, and the facility decided to remove her from any involvement in Resident 3's care. RR stated, The facility has appointed Family Member (FM) as the decision maker without Resident 3's consent and they claim [FM] holds the POA, but I haven't seen any documentation of this. RR indicated the facility has and allowed FM to make decisions that are misaligned with Resident 3's wishes which have negatively affected Resident 3's quality of life and functional status.During a concurrent interview and record review on 8/30/26 at 3:20 p.m. with the Administrator (Admin), the Admin presented a copy of Resident 3's AD/DPOA dated 6/26/26, which named RR as the POA.During a telephone interview on 9/1/26 at 9:23 a.m. with an APS Representative (APSR) the APSR stated APS does not have jurisdiction over residents in a skilled nursing facility and confirmed APS does not have the authority to remove or revoke a person's identified representative or POA. During a concurrent interview and record review on 9/2/26 at 12:14 p.m. with LN 6, Resident 3's medical record and AD/DPOA were reviewed. LN 6 acknowledged RR was identified as Resident 3's POA and stated the facility removed RR as Resident 3's representative after a complaint had been filed against RR with Adult Protective Services (APS).During an interview on 9/2/26 at 1:43 p.m. with the Hospital Liaison (HL), the HL confirmed when residents were admitted to the facility the resident should be asked who they wanted as their identified representative. The HL stated, FM verbally told me he would be the one who will make the decisions for [Resident 3's] health. HL confirmed FM did not provide documentation that identified him as Resident 3's representative or POA.During an interview on 9/2/26 at 3:09 p.m. with the Admin, the Admin acknowledged FM held no legal authority to make decisions for Resident 3.A review of the facility's policy and procedure (P&P) titled, Advance Directives revised September 2022, the P&P indicated, The resident has the right to formulate an advance directive. Advance directives are honored in accordance with state law and facility policy. Determining Existence of Advance Directive 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 3. Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative. 4. Written information includes a description of the facility's policies to implement advance directives and applicable state law. If the Resident Does not have an Advance Directive 1. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives.A review of the facility's P&P titled, Resident Rights revised August 2009, 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: a. Be informed about what rights and responsibilities he or she has. c. Choose a physician and treatment and participate in decisions and care planning; 2. Residents are entitled to exercise their rights and privileges to the fullest extent possible. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

Based on interview and record review the facility failed to follow reporting and response requirements after an allegation of financial abuse was reported for one of three sampled residents (Resident 1) when:Report of investigation was not received by the State agency (California Department of Public Health-CDPH) within the 5-day as required by the regulations andResident 1's psychosocial (mental, social interactions and emotional well-being) status was not assessed following allegations of financial abuse.These failures resulted in CDPH being unaware of the outcome of the facility's abuse investigation and potential risk for psychosocial harm to Resident 1.1.A review of the facility report dated 7/1/26, indicated, the facility reported to CDPH an allegation of financial abuse with Resident 1 as the victim, and an outside agent as the alleged perpetrator. During an interview on 7/9/26, at 10:04 a.m., with Administrator (ADM), ADM stated he did not send the 5-day report to CDPH regarding the financial abuse allegation reported to CDPH on 7/1/26.A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated 2022 indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.Follow-Up Report 1. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report.2. During an interview on 7/9/26, at 10:14 a.m., with Social Services Director (SSD), SSD stated, the procedure of the facility after an abuse allegation is made, is the social services staff will follow up with the resident involved in the abuse allegation for 72 hours to monitor their psychosocial wellbeing in order to see how they are doing and document the visit in the progress notes. SSD stated, for Resident 1's abuse allegation the follow up visits were not completed.During an observation and interview on 7/8/26, at 10:18 a.m., with Resident 1, Resident 1 stated he did not wish to speak about the incident. During the interview Resident 1 was observed to be preoccupied.A review of Resident 1's Progress notes dated 7/1/26 to 7/9/26 indicated no progress notes were charted for any psychosocial or follow up visits related to the abuse allegation reported on 7/1/26.During an interview on 7/9/26, at 1:08 p.m., with Medical Records Director (MRD), MRD stated it is the facility practice to conduct psychosocial visits.

Based on interviews and records reviews the facility failed to ensure a prompt resolution was provided for one out of three sampled residents (Resident 1), when Resident 1's Family Member (FM) filed a grievance for Resident 1's lost prescription glasses. This failure resulted in Resident 1's inability to see clearly.Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in [DATE] with diagnoses which included vascular dementia (a cognitive decline caused by restricted or blocked blood flow to the brain) and combined forms of age-related cataracts (multiple types of cataracts affecting both eyes due to the natural aging process).During a review of Resident 1's Inventory of Personal Effects, dated [DATE], the inventory indicated Resident 1 had a pair of glasses.'A review of the Theft and Loss Log Year 2025 indicated Resident 1's eyeglasses were reported as lost/missing on [DATE].A review of the Theft and Loss Record, dated [DATE] by Licensed Nurse (LN) 1, LN 1 reported Resident 1's prescription eyeglasses with pink frames and eyeglass case were missing. A review of Resident 1's Progress Notes, Social Service Note indicated the following:1. [DATE] at 12:17 p.m.: the Social Services Assistant (SSA) indicated the morning LN reported Resident 1's eyeglasses were missing and were unable to be found.2. [DATE] at 12:30 p.m.: Family Member (FM) provided the facility with a copy of Resident 1's eye glass prescription, dated [DATE], which indicated the prescription was valid for two years. 3. Late entry on [DATE] at 1:53 p.m.: Interdisciplinary Team Meeting (IDT, a collaborative group of medical professionals from diverse specialties who work together to address a resident's complex needs) indicated, Resident 1 likes to do her word puzzles .Resident 1 wears eyeglasses.During a telephone interview on [DATE] at 12:37 p.m. with the FM, the FM indicated the facility has still not provided a resolution for Resident 1's prescription glasses that have been lost for over five months. The FM stated a copy of Resident 1's current glasses prescription, which expired in [DATE], was provided to the facility in [DATE]. The FM stated, I gave the facility a copy of [Resident 1's] current prescription, she [Resident 1] didn't need another eye exam. The facility should replace the glasses as requested, period. That facility has literally wasted months attempting to get authorization from [Resident 1's] insurance to cover the cost so they don't have to spend any money. The FM stated the receipt of purchase for the prescription glasses was provided to the facility and included the location where the glasses were purchased. The FM stated, Those eyeglasses should have been replaced months ago.During a telephone interview on [DATE] at 11:52 a.m. with the Long Term Care Ombudsman (LTCO), the LTCO stated he was aware that Resident 1's prescription eyeglasses and case were reported as missing/lost in [DATE]. The LTCO stated, The time it's taken for the facility to replace or reimburse the cost of [Resident 1's] glasses is inappropriate, especially since [FM] provided the facility with a current prescription months ago. The LTCO indicated the facility is expected to provide the resident or family member with prompt resolutions to grievances/complaints filed. The LTCO stated an expected and appropriate time frame for resolution is approximately one month. The facility should either replace or reimburse the cost of the lost item with something comparable, only after approval from the resident or family member. The LTCO stated, I didn't realize they [facility] still haven't replaced them [prescription eyeglasses and case] yet.During an interview on [DATE] at 1:14 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated when residents were admitted to the facility an inventory was taken of the resident's personal items and documented on the resident's inventory sheet. CNA 1 stated when items were reported as lost or missing the first thing to do was to search the resident's room and laundry room. CNA 1 indicated if the items were not found during the search the LN was notified and if a resident or family member continued to report additional items as lost/missing the complaint was elevated to the Social Services (SS) office. CNA 1 indicated only the items identified on a resident's inventory record would be investigated and reimbursed or replaced by the facility.During an interview on [DATE] at 1:42 p.m. with LN 1, LN 1 stated when items listed on the resident's inventory record were determined as lost or missing the items were reported directly to the SS office on a handwritten note. LN 1 further stated the resident or family member may file a grievance for lost items on a grievance form which was kept at the nursing station.During an interview on [DATE] at 2:11 p.m. with the Social Services Director (SSD) the SSD indicated staff, residents and family members were instructed to complete a grievance form when items were lost or missing. The SSD stated the SS office was responsible for the grievance/complaint process, which included an internal investigation and documented actions taken or proposed by the SS staff for the resolution of the filed grievance/complaint. The SSD indicated that the final report was submitted to the Admin and provided the determination and approval for resolution. The SSD indicated when the Admin approved the replacement or reimbursement for a lost/missing item from the resident's inventory the Admin will identify the approved actions to be taken to resolve the grievance/complaint, signed and dated the grievance/complaint form and returned the form to the SS office to carry out the steps identified as the approved resolution. The SSD confirmed Resident 1's glasses had still not been replaced or reimbursed since [DATE], and stated, No, these three to four months it has taken just to get [Resident 1's] glasses replaced is not appropriate. We [SSD and SSA] can only do so much, we must notify the Administrator who then makes the final decision about the outcome.During a concurrent interview and record review on [DATE] at 2:31 p.m. with the SSD and the SSA, Resident 1's grievance forms and inventory of personal effects were reviewed. The SSA and SSD confirmed Resident 1's grievance for her missing/lost prescription eyeglasses and case, filed in [DATE], still had not been resolved. The SSA and SSD reiterated, Whatever we do, it has to be approved by the Administrator. The SSA and SSD were unaware that a written summary of the investigation needed to be provided to the person who filed the grievance or complaint, and stated, We didn't know we had to do that. The SSD acknowledged the lack of timely resolutions for grievances/complaints, and stated, When residents or family members continue to file grievances or complaints that the facility doesn't resolve in a timely manner can cause residents and family members to really lose trust in our facility and processes.During an interview on [DATE] at 3:33 p.m. with the Director of Nursing (DON), the DON acknowledged the facility's responsibility to ensure the safety and security of a resident's personal belongings. The DON stated, The prompt investigation and resolution for grievances and complaints ensures the trust between the facility and residents or family members. It's all about communication and keeping the resident and family updated.A review of the facility's Filing Grievances/Complaints P&P indicated, The Administrator has delegated the responsibility of grievance and/or complaint investigation to [blank]. Upon receipt of a grievance and/or complaint [blank] will investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. The Administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken. The resident, or person filing the grievance and/or complaint on behalf of the resident will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. The Administrator, or his or her designee, will make such reports orally within [blank] working days of the filing of the grievance or complaint with the facility. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office.A review of the facility's P&P titled Personal Property revised [DATE], the P&P indicated, Residents are permitted to retain and use personal possessions, including furniture and clothing. Resident belongings are treated with respect by facility staff, regardless of perceived value.The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary. The facility promptly investigates any complaints of misappropriation or mistreatment of resident property.A review of the facility's P&P titled, Grievances/Complaints - Staff Responsibility revised [DATE], the P&P indicated, Staff members are encouraged to guide residents about where and how to file a grievance and/or complaint. Staff members will inform the resident or the person acting on the resident's behalf that he or she may file a grievance or complaint with the Administrator or other agencies as noted.

Based on observation, interviews, and record review, the facility failed to ensure that physician ordered wound care was provided as prescribed for one of three sampled residents (Resident 1). This failure resulted in Resident 1 missed wound care for one day.Findings:Resident 1 was admitted in March 2025 with diagnoses including diabetes mellitus (difficulty in blood sugar control and poor wound healing), bullous pemphigoid (autoimmune skin disease causing large blisters), diabetic ulcer (open sore in people with diabetes), bipolar disorder (extreme mood swings) and obsessive compulsive disorder (general pattern of concern with orderliness, perfectionism, and control). Resident 1 had a history to refused wound care from other nurses unless it was provided by Treatment Nurse (TN) 2. A review of Resident 1's Order Summary Report (OSR) dated 3/7/25 indicated, Resident has capacity to make her decisionsA review of Resident 1's Discontinued Order Summary indicated, Order date: 12/3/25 Start date: 12/5/25 Discontinued date: 12/19/2025 for the following treatment order:1. Tx [Treatment] Order : Right lower legs chronic diabetic wounds: Cleanse wounds with n/s [normal saline], pat dry. Apply zinc oxide to open areas ,Cover with ABD pads [abdominal pad, a large, highly absorbent bandage], secure with roll gauze and ACE wrap [a stretchy, reusable bandage to provide compression and support] wrap. Change 3x a week and PRN [pro re nata means as needed] soiling. Notify Md [Medical Doctor] for any worsening or s/s [signs/symptoms] of infection. every (sic) day shift every Mon, Wed, Fri for treatment and moitoring (sic) for 14 Days2. Tx order: left dorsal foot/ toes- Cleanse wounds with n/s, pat dry. Apply zinc oxide, Apply Super absorbent pad. Gauze between the toes, secure with roll gauze and ACE wrap. Change 3x a week and PRN soiling. NOtify (sic) MD for any changes. every day shift every Mon, Wed, Fri for 14 Days.3. Tx order: Left lower legs- Cleanse wounds with n/s, pat dry. Apply zinc oxide, Apply Super absorbent pad. Gauze between the toes, secure with roll gauze and ACE wrap. Change 3x a week and PRN soiling. NOtify (sic) MD for any changes. every day shift every Mon, Wed, Fri for 14 Days4. Tx order: right dorsal foot/ toes- Cleanse wounds with n/s, pat dry. Apply zinc oxide, Apply Super absorbent pad. Gauze between the toes, secure with roll gauze and ACE wrap. Change 3x a week and PRN soiling. NOtify (sic) MD for any changes. every day shift every Mon, Wed, Fri for 14 DaysA review of Resident 1's Treatment Administration Record (TAR) for the above prescribed wound care orders included a blank space on 12/12/25 which indicated that the wound care treatment was not executed. During an interview with Licensed Nurse (LN) 1 on 12/23/25 at 10:21 a.m., LN 1 stated that Resident 1 often refused wound care if the treatment nurse was not TN 2. LN 1 stated she did not remember the exact date when Resident 1 missed a wound care treatment. LN 1 explained that she learned about the missed treatment when TN 2 told her that Resident 1 had missed wound care the previous week. LN 1 also indicated this was the only missed wound care treatment she knew about. During an interview with Resident 1 on 12/23/25 at 11:13 a.m., Resident 1 stated she was not sure if there had been a miscommunication, but no one came to provide her wound care treatment last week. During a concurrent interview and record review with the Director of Nursing (DON) on 12/23/25 at 1:30 p.m., the DON stated that a blank space in the TAR for 12/12/25 meant the treatment was missed. The DON stated that on 12/12/25, one treatment nurse called off work, so the Charge Nurse gave the wound care instead. The DON further stated that treatment nurses usually document if Resident 1 refused wound care however there was no documentation on 12/12/25 that the resident refused. A review of the facility's policy and procedure (P&P) titled Dressings, Dry/Clean revised September 2013 indicated, 1. Notify the supervisor if the resident refuses the dressing change. 2. Report other information in accordance with facility policy and professional standards of practice.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for one of three sample residents (Resident 1) when Resident 2 and Resident 1 had a physical altercation. This failure resulted in Resident 1 sustaining a fall with an abrasion to forehead and broken nails.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted in October 2025 with diagnosis including complete paraplegia (loss of movement and/or sensation, to some degree, of the legs).During a review of Resident 1's Minimum Data Set (MDS) (a federally mandated resident assessment tool), dated 10/14/25, indicated Resident 1 had no memory impairment. During a review of Resident 1's Nurse's notes, dated 11/29/25, indicated Resident 1 .noted with altercation with a male resident (Resident 2), noted pt (patient) lying down on the floor and holding the left leg of the male resident, near the patio door on hallway 300. Noted with small abrasion ,superficial wound to right side forehead. Right hand 1st and 2nd finger with partial broken nail.Right hand 2nd and 3rd finger partial broken nails with nail bed exposed.During a review of Resident 2's AR, the AR indicated Resident 2 was admitted in August 2025 with unspecified dementia (a progressive state of decline in mental abilities) and Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). During a review of Resident 2's MDS, dated [DATE], MDS indicated Resident 2 had severe memory impairment.During a concurrent observation and interview, on 12/16/25 at 2:11 p.m. in Resident 1's room, Resident 1 stated she felt overwhelmed and it was a lot that the incident occurred. Resident 1 observed to have broken nails on right hand. Resident 1 further stated she sustained a headache, and her artificial nails came off post altercation. During a concurrent interview and record review on 12/16/25 at 3:45 p.m. with Social Services Director (SSD), Resident 2's Nurses notes, dated 10/21/25, indicated Resident 2 had a history of resident to resident altercation. The Nurse's notes indicated Resident to Resident altercation seen by the staff. per eye witnesses, (Resident 2) grabbed/punch resident B. SSD confirmed that a post Social Services follow up was done on 10/22/25 and acknowledged that Resident 2 needed a secured/dementia facility that can manage his behaviors not here at the current facility.During an interview on 12/16/25 at 4:15 p.m. with Administrator (ADM) and Director of Nursing (DON) in ADM office, the ADM and DON confirmed that there was a physical altercation between Resident 1 and Resident 2. The ADM further stated that facility staff responded well post altercation.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revision date of April 2021, the P&P indicated, .Residents have the right to be free from abuse.This includes but is not limited to freedom from.physical abuse.During a review of the facility's P&P titled, Resident Rights, undated, P&P indicated The resident has the right to be free from verbal, sexual, physical, mental abuse.

Based on interview and record review, the facility failed to ensure resident rights were respected and honored for one of three sampled residents (Resident 1) when Licensed Nurse (LN) 1 did not initiate interventions to allow Resident 1 to go safely out on pass with a family member.This failure had resulted in Resident 1 not able to go out and have dinner on thanksgiving weekend with her family, and had the potential to negatively impact residents' psychosocial well-being.Findings:During a review of Resident 1's clinical record, Resident 1 was admitted to the facility in late 2024 with multiple diagnoses which included major depressive order and general anxiety. Resident 1's clinical record indicated Resident 1 had no memory impairment.Resident 1 submitted a complaint via email to California Department of Public Health on 11/30/25 at 4:29 a.m., which indicated Resident 1 had planned on going out with her son to celebrate thanksgiving dinner but was denied by the facility. During a review of Resident 1's Nurse's note dated 11/29/2025 at 1:59 p.m., indicated, Noted resident's son. bringing a wheelchair in the facility.he planned on taking resident out to eat Thanksgiving dinner. Resident did not have an LOA (Leave of absence) order, no progress notes regarding LOA for today, confirmed with.Nurse. (Son) was educated that there needs to be an LOA order from the doctor in advance in order to leave the facility, or else it will be considered AMA (against medical advice) if the resident leaves. Resident was also educated of this information and started yelling at this RN Supervisor stating, YOU CAN'T KEEP ME HERE. IF I WANT TO LEAVE I'M GOING TO BUT YOU CAN'T TELL ME I CAN'T COME BACK I WAS NEVER TOLD THAT I NEED A DOCTOR'S NOTE FOR AN LOA, I WANT THIS IN WRITING!During an interview on 12/10/25 at 1:51 p.m., LN 1 confirmed that Resident 1 did not go out to Thanksgiving dinner. LN 1 stated no further intervention was made and no attempt was made to call a doctor because I was told not to call the doctor on weekends because it is not favorable [to the doctor] . LN 1 acknowledged that she did not follow through to get an LOA order and other interventions so that Resident 1 can go to Thanksgiving dinner with son safely. During a review of Resident 1's care plan, dated 9/15/25, indicated, .Psychosocial- Well-being:.is at risk for psychosocial well-being concerns. Will minimize risk for decline in mood and behavior/psychosocial well-being. The care plan further indicated, Social Isolation: Resident is at risk for social isolation due to prefers to stay in room. Will be active on her own. Educate on the importance of social interaction. Encourage socialization.During an interview on 12/10/25 at 4 p.m., the Director of Nursing (DON) acknowledged that LN 1 should have attempted to call the doctor [to get an LOA order]. The DON further confirmed that Resident 1 was not included in facility preparation to get LOA orders from the doctor prior to the holiday weekend.During a review of facility's policy and procedure titled, Resident Rights-Quality of Life, revised March 2017, indicated The resident has a right to a dignified existence, self determination.and access to, persons and services inside and outside of the Facility.The resident has the right to exercise his or her rights as Resident of the Facility.The resident has the right to be free of interference, coercion.or reprisal from exercising his or her rights.The Resident has a right to be fully informed in advance about care and treatment that may affect the Resident's well being.No facility policy and procedure was provided for obtaining a Leave of Absence or Out on Pass doctor orders for the residents when requested.

Based on observations, interviews, and record review, the facility failed to ensure that one of five sampled residents (Resident 1's) right to send and receive mail was protected when it withheld Resident 1's mail for a period of seven months.This failure had the potential to cause emotional distress such as social isolation, missed important matters, and distrust in care for Resident 1.Findings:Resident 1 was admitted to the facility in March of 2025 with diagnoses that included depression.During an interview on 9/22/25 at 12:51 p.m. with Resident 1, Resident 1 indicated that she had been waiting for important letters from her insurance and law enforcement that were of significance to her and caused her to worry. During a concurrent interview and record review on 9/22/25 at 3:59 p.m., with the Activities Director (AD), Resident 1's Order Details, dated 3/7/25, was reviewed. The Order Details indicated, Resident has capacity to make her decisions. The AD indicated that Resident 1's mail was being withheld by activities staff since March of 2025, since they believed Resident 1 did not have capacity to make her own decisions.During an interview on 9/23/25 at 10:47 a.m. with the Director of Nursing (DON), the DON indicated residents at the facility have the right to receive mail and that she expected staff to give the mail directly to the residents when appropriate.During a review of the facility's policy and procedure (P&P) titled, Mail and Electronic Communication, revised 5/17, the P&P indicated, Residents are allowed to communicate privately with individuals of their choice and may send and receive personal mail, email and other electronic forms of communication confidentially.Mail and packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries).

Based on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for one of five sampled residents (Resident 1) when Resident 1 was not administered glipizide (a medication used to control high blood sugar levels in adults with type 2 diabetes) as prescribed by the physician.This failure had the potential to cause Resident 1 to experience uncontrolled blood sugar levels, which could result in complications such as vision impairment and/or nerve issues related to poor blood sugar control.Findings:Resident 1 was admitted to the facility in March of 2025 with diagnoses that included type two diabetes (a chronic condition that causes a person to have persistently high blood sugar levels).A review of Resident 1's Order Details, dated 3/7/25, indicated, glipiZIDE Oral Tablet 2.5 MG [milligrams, a unit of measurement] Give 1 tablet by mouth one time a day for DMII [type two diabetes] TAKE 30 MINUTES BEFORE MEALS AND HOLD IF BLOOD GLUCOSE IS LESS THAN 100During an observation on 9/23/25 at 8:21 a.m., during a medication administration for Resident 1, Licensed Nurse 1 (LN 1) administered Resident 1's glipizide after Resident 1 had finished her breakfast.During an interview on 9/23/25 at 9:10 a.m., with LN 1, LN 1 confirmed she did not administer the glipizide per physician orders. LN 1 indicated that it is important to give as ordered to prevent hypoglycemia (low levels of sugar in the blood).During an interview on 9/23/25 at 10:47 with the Director of Nursing, the DON indicated that she expected nursing staff to administer medications as ordered by the physician.During a review of the facility's policy and procedure (P&P) titled, Medication Administration-General Guidelines, dated 3/18, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices.Medications are administered in accordance with written orders of the attending physician.

Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of care for one of five sampled residents (Resident 1), when Resident 1's pain was not assessed and managed, and Resident 1's Responsibility Party (RP) did not receive communication regarding Resident 1's change in condition from the physician. These failures resulted in a delay in determining that Resident 1's cause of pain was due to a fracture of the right leg. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in November 2024 with multiple diagnoses including fracture of lower end of right femur (thighbone), nondisplaced intertrochanteric fracture of right femur (hip fracture), diabetes (too much glucose in the blood), dementia (loss of memory and other thinking abilities), and failure to thrive (inability to sustain weight due to poor nutrition).A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 5/14/25, indicated Resident had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 3 out of 15 that indicated Resident 1 was severely cognitively impaired. A review of Resident 1's MDS, Functional Abilities, dated 5/14/25, indicated Resident 1 was dependent for bed mobility and transfers.A review of Resident 1's Medication Administration Record (MAR), for 7/1/25 to 7/31/25 indicated order Tylenol Tablet 325MG [milligrams] (Acetaminophen) Give 2 tablets by mouth every 6 hours as needed for Pain . start date 12/12/24, indicated Resident 1 was only offered the medication on 7/30/25. Pain level on 7/30/25 indicated NA (Not applicable). A review of Resident 1's MAR, for 7/1/25 to 7/31/25, indicated order Pain Monitor For Presence Of Pain Every Shift Using Scale 0-10 . start date 12/22/24, indicated Resident 1 had pain level of 0 that indicated No Pain from 7/1/25 to 7/31/25. A review of Resident 1's SBAR [Situation, Background, Appearance, Review] Communication Form, dated 7/30/25 at 11:00 a.m., indicated . CNA [Certified Nursing Assistant] reported to nurse that resident has pain in right lower leg with turning or getting out of bed. Assessed resident. VS [Vital Signs] WNL [Within Normal Limits], pain observed on right lower leg with touching. Bruising noted on lower right leg. Tylenol offered for pain, took half the dose and refused to take more .Notified MD [Medical Doctor], received order for STAT [immediate] x-ray .A review of Resident 1's SBAR Communication Form, dated 7/30/25 at 4:00 p.m., indicated .Resident was noted with a pain upon movement while in bed during day shift. Pain is localized to RLE Right Lower Extremity] Resident yells out pain and verbalizes don't move that leg when assessment to the leg is done. X-ray was order to r/o [rule out] Fx [fracture] . A review of Resident 1's Physician Progress Note, dated 7/3/25, indicated . [Resident 1's RP] left a message for me to call her. I called her this morning . A review of Resident 1's Progress Note, dated 7/28/25, indicated .I received transferred call from [RP], who began expressing concerns during the conversation. She intended to go over about the missing brace and pt. [patient] having pain .A review of Resident 1's Progress Note, dated 7/29/25, indicated .An email from [RP] was received today addressing a list of issues but initial concern was related to missing brace and associated pain, brought to the attention of the office team for follow up. I also communicated this with the nurse on duty and the CNA [Certified Nursing Assistant] and relay the information. According to the nurse on duty nothing was brought to her attention before .A review of Resident 1's Progress Note, dated 7/30/25 at 10:15 a.m., indicated .approximately 10:15am writer was walking down hallway and notice resident not up in w/c [wheelchair] today. Writer asked CNA why she wasn't up and that when CNA reported to me she has pain in her leg. Writer assessed and observed RLE with some swelling, no redness, slight discoloration observed to the lower part of the shin and tender to the touch .Resident's assigned charge nurse was informed .A review of Resident 1's Progress Note, dated 7/30/25 at 11:58 a.m., indicated .CNA reported to nurse that resident has pain in right leg with turning or getting resident out of bed. Assessed resident .pain observed on right lower leg above ankle with touching. Tylenol offered for pain, resident took half of dose and refused to take more . Notified MD, received order for STAT x-ray. Will carry out orders and continue to monitor .A review of Resident 1's Progress Note, dated 7/30/25 at 3:23 p.m. indicated .Resident expressed pain when touching right lower leg .A review of Resident 1's Progress Note, dated 7/30/25 at 4:40 p.m., indicated .Approximately 1520 [3:20 p.m.] hours with a follow up visit with resident to check on the pain management and effectiveness and the RLE skin integrity, the resident observed again with facial grimacing once the shin area was touched lightly .MD called, informed of the persistent tenderness to touch, requested for a routine pain management order and order to transfer to the ER [Emergency Room] for further evaluation, MD in agreement . A review of Resident 1's Progress Note, dated 7/30/25 at 4:42 p.m., indicated .MD acknowledged speaking to the resident's [RP] . A review of Resident 1's Progress Note, dated 7/30/25 at 4:50 p.m., .MD gave order .to send resident out to ER for assessment of RLE pain after X-ray was done .A review of Resident 1's Care Plan [Resident 1] has intense pain upon touching right leg, initiated 7/30/25, .Interventions .MD notified .Obtain x-ray .Transfer to ER for Eval [Evaluation] . A review of Resident 1's Care Plan Pain: [Resident 1] is At risk of pain or discomfort due to medical diagnosis of Dementia, initiated 11/22/24, .Interventions .Notify physician if resident experiences unmanageable or intolerable pain .A review of Resident 1's Radiology Report, for x-ray done at the facility, with report date 7/30/25 at 5:59 p.m., indicated .Tibia and Fibula [lower leg bones] .Right .Results .Impacted fracture deformity [ends of bone driven into each other] of the distal femur supracondylar region [thighbone just above the knee] with moderate anterior angulation [curvature angled forward]. Comminuted fracture deformity [bone breaks in three or more pieces] of the distal tibia shaft and possible the calcaneus [heel]. Conclusion: Multiple right lower extremity fractures . Handwritten note on report indicated sent to acute. During a telephone interview on 8/8/25 at 8:42 a.m. with Resident 1's Responsible Party (RP), RP stated Resident 1 had pain in her right leg beginning 7/16/25. The RP stated Resident 1 was not getting anything for pain management. RP stated she asked for MD to contact her regarding Resident 1's pain. The RP stated MD never contacted her. The RP stated on 7/28/25, Resident 1's private caregiver reported to her that Resident 1 still had pain in right leg. The RP requested MD call her. The RP stated the MD did not contact her. The RP stated on 7/30/25 Resident 1 was still in pain and she requested again to speak w/ MD. RP stated facility obtained x-ray that showed comminuted spiral fracture of the tibia. The RP stated Resident 1 is capable of reporting pain and was supposed to get Tylenol as needed for pain. During an interview on 8/8/25 at 11:51 a.m. with the Administrator (ADM), the ADM stated Resident 1 first reported pain on 7/30/25. The ADM stated Resident 1 received Tylenol on 7/30/25, but spit it out. During a joint interview on 8/8/25 at 12:12 p.m. with the ADM and the Director of Nursing (DON), the DON stated Resident 1's MAR did not indicate she had any pain. The DON stated the Assistant Director of Nursing (ADON) found out Resident 1 was having pain on 7/30/25 when she talked with the CNA who was not able to put Resident 1 in the wheelchair due to pain and then notified the nurse. The DON stated they use a communication binder to notify MD that family would like call back. The DON stated that MD spoke with family on 7/3/25 and not again until 7/30/25. The DON stated the MD had been on vacation one week in July. Requested documentation from communication binder that MD had been notified of family request for a return call. The ADM stated unable to provide. During an interview on 8/8/25 at 2:24 p.m. with CNA 1, CNA 1 stated approximately two weeks ago, Resident 1 was not responding to her as she usually does. CNA 1 asked another CNA to assist with turning her and Resident 1 would not respond. CNA 1 reported to the nurse who said do not get her up. CNA 1 stated she did not get Resident 1 up the next day. CNA 1 stated the next time she worked with Resident 1, between 7/22/25 and 7/24/25, she asked Resident 1 what was happening because she was not talking. CNA 1 stated Resident 1 responded and said pain. CNA 1 stated she notified nurse who said do not get her out of bed. CNA 1 stated on 7/30/25 she notified the ADON that Resident 1 had pain and moaned when touched. During an interview on 8/8/25 at 2:39 p.m. with Licensed Nurse (LN) 1, LN 1 stated on 7/30/25 she was notified by a CNA that Resident 1 had pain in her right leg. LN 1 stated she assessed Resident 1's pain and observed some discoloration present. LN 1 stated she offered Tylenol, but Resident 1 would not take it. LN 1 stated she was not aware if Resident 1 had any pain prior to 7/30/25.During a concurrent interview and record review on 8/8/25 at 2:52 p.m. with the Case Management Assistant (CMA), reviewed the Progress Note dated 7/28/25 that indicated Resident 1 had pain. The CMA stated she notified the nurse on duty to let her know. The CMA stated she had checked with the CNA and nurse who were not aware she was having pain. The CMA stated she did not know if the nurse then assessed Resident 1 for pain. During an interview on 8/8/25 at 3:32 p.m. with CNA 2, CNA 2 stated if resident complains of pain, she notifies the nurse. CNA 2 stated if a resident has pain she expects the nurse to assess pain and give pain medication. During a telephone interview on 8/14/25 at 9:11 a.m. with Resident 1's Caregiver (CG), the CG stated Resident 1 showed evidence of having pain several times starting the first or second week in July. The CG stated Resident 1 would yell out but when asked would say she was okay. The CG stated she notified the nurse on 7/23/25 that Resident 1 was having pain. CG stated the nurse came in and tried to give Resident 1 Tylenol but she would not take it. CG stated she did not see the nurse do anything else to assess or relieve pain. The CG stated the facility staff stopped getting Resident 1 out of bed on 7/23/25 because her leg was hurting. During a concurrent telephone interview and record review on 8/14/25 with the DON, reviewed Resident 1's CG report of pain to the nurse on 7/23/25. The DON stated she cannot prove that Resident 1's pain was assessed on 7/23/25 as there was no documentation in the progress notes. The DON stated she asked staff if Resident 1 had any complaints of pain or if they noticed anything to indicate pain prior to 7/30/25 and staff did not report anything prior to 7/30/25. Reviewed that Resident 1 was offered Tylenol on 7/23/25 but not indicated in the MAR or in a progress note. The DON stated if Resident 1 was offered Tylenol and refused it should be documented in a progress note. The DON stated the assessment should be documented, especially if offered medication and refused. The DON stated the pain scale in the MAR indicated Resident 1 did not have pain, even on 7/30/25 when she was sent to the hospital due to pain. Reviewed progress notes for 7/23/25, 7/28/25, and 7/29/25. Reviewed with the DON that CNA reported to the nurse that Resident 1 had pain between 7/22/25 and 7/24/25. The DON acknowledged that there are no progress notes that indicate Resident 1 was assessed for pain for 7/22/25 to 7/24/25. The DON stated her expectation if resident has pain, the nurse is to evaluate pain, where it is, what kind of pain it is, if repositioning helps and if medication may be given. A review of the facility's Policy and Procedure (P&P) titled Pain-Clinical Protocol, revised 4/25, indicated .The provider and staff will identify individuals who have pain or who are at risk for having pain .The nursing staff will assess each individual for pain .when there is onset of new pain .The provider will help identify causes of pain, for example, by examining the resident directly, reviewing the resident's history, and via discussion with the resident and staff .The provider will help identify the extent to which underlying causes of pain can be addressed or reversed . he provider will perform or order appropriate tests as needed to help clarify sources of pain. For example, an x-ray may help to identify the cause of joint pain .The provider will order appropriate non-pharmacologic and medication interventions to address the individual's pain .A review of the facility's P&P titled Resident Rights, revised 2/21, indicated .Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to .communication with and access to people and services, both inside and outside the facility .be informed of, and participate in, his or her care planning and treatment .choose an attending physician and participate in decision-making regarding his or her care .

Based on interviews and record review, the facility failed to protect two of three sampled residents' (Resident 1 and Resident 2) right to be free from physical abuse when they were attacked by Resident 3. This failure resulted in Resident 1 to sustain a laceration (cut) to the left side of the head, a blunt head trauma injury, and chest wall contusion (bruising). Resident 2 sustained a laceration to the back of his head and multiple skin tears. Findings: During a review of Resident 1's face sheet, Resident 1 was admitted to the facility on [DATE] with diagnoses that included cellulitis (skin infection) of left lower limb and congestive heart failure (CHF-heart can't pump enough blood). Resident 1 was his own responsible party. During a review of Resident 1's Admission Minimum Data Set (MDS-an assessment tool), dated 6/24/24, the MDS described Resident 1 as able to make himself understood and able to understand others. Resident 1's Brief Interview for Mental Status (BIMS-a screening that aids in detecting cognitive impairment-mental capacity) score was 15 which indicated he was cognitively intact. The MDS described Resident 1 as having no signs or symptoms of delirium (Serious disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings) or behavioral symptoms. During a review of Resident 1's Progress Notes, dated 7/10/24 at 4 a.m. indicated, Resident was lying on the courtyard ground with blood dripping from his head, verbalized he was hit with a walker several times to his head and kicked by another resident after attempting to break up a resident to resident altercation, police arrived at 0415 (4:15 a.m.), CSI (Crime Scene Investigation) arrived at 0515 (5:15 a.m.), first aide (sic) applied with a pressure dressing placed, laceration to L (left) side of head 1 cm x 0.2 cm (unit of measurement), bleeding subsided, emergency services notified and sent to [name of hospital] ER (emergency room ) for further evaluation. Review of Resident 1's Progress Note dated 7/10/2024 at 11:33 a.m. indicated, Resident return from E.R transfer following physical altercation with another resident with Dx (diagnosis): Fall, Scalp laceration, Blunt head trauma injury, Chest wall contusion. No new order. During an interview on 7/12/24 at 10 a.m. with Resident 1, Resident 1 stated the incident occurred around 4 a.m. and was not sure how the event started. He stated he woke up and went out to have a cigarette and proceeded to wheel himself out to the smoking area (facility's inner courtyard). Resident 1 stated he heard screaming/yelling and realized his friend (Resident 2) was being attacked, with a walker, by another resident. Resident 1 identified the other resident was Resident 3. Resident 1 stated he went over to help his friend when Resident 3 started attacking him with the walker. Resident 1 stated he tried to put up his left arm to protect himself. He stated he was bleeding from his head, and sustained bruising on the left side of his rib area and got multiple cuts on his left forearm. Resident 1 confirmed he was sent to the ER, after being interviewed by police. During a review of Resident 2's face sheet, Resident 2 was admitted to the facility on [DATE] with diagnoses that included aortic aneurysm (bulge in wall of aorta the body's main artery) and chronic obstructive pulmonary disease (COPD-lung disease that makes it difficult to breathe). Resident 2 was his own responsible party. During a review of Resident 2's Admission MDS dated [DATE] described Resident 2 as able to make himself understood and able to understand others. Resident 2's BIMS score was 12 which indicated he was cognitively intact. The MDS described Resident 2 as having no signs or symptoms of delirium or behavioral symptoms. During a review of Resident 2's Change in Condition Evaluation, dated 7/10/24 at 4:30 a.m., indicated Resident 2 was outside when Resident 3 Started to make physical contact with this resident (Resident 2) resulting in several open areas. The Change in Condition Evaluation indicated Resident 2 sustained Multiple skin tears on both forearms, unable to pull skin back over open areas, and back of scalp . During a review of Resident 2's Skin & Wound Evaluation, dated 7/10/24 at 7:05 p.m. indicated, Noted new skin issue injury to his back of his head 0.6cm x 2cm x 0.2cm to his back of his head laceration as noted . During a review of Resident 2's Skin & Wound Evaluation, dated 7/10/24 at 7:16 p.m. indicated, .left outer forearm skin tear measurement was 6 cm x 5.6 cm . During a review of Resident 2's Skin & Wound Evaluation, dated 7/10/24 at 7:24 p.m. indicated, . right outer forearm skin tear measurements was 4.6 cm x 3.5 cm . During a review of Resident 2's Skin & Wound Evaluation, dated 7/10/24 at 7:25 p.m. indicated, .right inner forearm skin tear x 2 the upper inner arm measurements was 12 cm 6.5 cm (sic) . lower fore arm (sic) measurements was 1.4 cm x 1 cm . During a review of Resident 3's face sheet, Resident 3 was admitted to the facility on [DATE] with diagnoses that included Schizophrenia (serious mental health condition that affects how a person thins, feel and behaves). Resident 3 was his own responsible party. Review of Resident 3's Admission MDS, dated [DATE], the MDS described Resident 3 as able to make himself understood and able to understand others. Resident 3's BIMS score was 15 which indicated he was cognitively intact. The MDS described Resident 3 has having no delirium or behavioral symptoms. Review of Resident 3's Progress Notes, dated 7/10/24 at 8:57 a.m. indicated, Resident to resident altercation resulting in resident being taken in police custody, arrested due to multiple residents with multiple injuries sustained. Resident 3 was unable to be observed or interviewed because he was discharged (incarcerated) from the facility on 7/10/24. During a review of the facility's Five-Day Follow Up Report, undated and written by the Administrator regarding, Altercation between residents on 07.10.2024, indicated, On 07.10.2024 it was reported by both victims and one witness, [CNA 1], that at roughly 4:00am [Resident 3] approached [Resident 2] in the courtyard of [NAME] Oaks Care Center from behind and forcibly hit him with his walker on the head. [Resident 3] continued to beat him and forced him to the ground. At this time, [CNA 1] was next to [Resident 2]. She began to yell for help, separated herself from the situation and called 911 / emergency services. Shortly after, [Resident 1] was seen approaching and attempted to stop [Resident 3]. [Resident 3] then began to beat [Resident 1] with the same walker and forced him to the ground. [CNA 1] reports that nurses and CNAs then reported promptly as did emergency services. [Resident 3] was reported to have asked emergency services to be taken to the emergency room .Conclusion -After investigation, the incident is found to be substantiated. The residents involved in the incident have no reported psychosocial issues. During a review of CNA 1's statement dated 7/10/24 indicated, At approximately 4:05 AM as I was using the restroom by the courtyard door. I heard shouting coming from the courtyard and outside the restroom door. As I run out, I see [Resident 2] on his hands and knees in distress with blood running down his arms and head. And when I look out the courtyard door I see [Resident 1] on the floor with [Resident 3] standing over him kicking him in the face and head. I proceeded to tell [Resident 3] to please step away from him [Resident 1]. He complied and that's when everyone else came to assist. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, revised December 2016 indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse .Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents .