Monrovia Gardens Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized care plan (CP) for one of two sampled residents (Resident 1) that addressed Resident 1's behavior of taking off Resident 1's clothes and lying naked in bed. This deficient practice had the potential to result in unmet individualized needs for Resident 1 and the potential to affect Resident 1's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to assist a resident who was unable to carry out activities of daily living (ADLs) for one of three sampled residents (Resident 1) by failing to ensure: 1. Resident 1's hair was washed. 2. Resident 1 received assistance to effectively communicate with staff. 3. Resident 1 received set-up assistance during mealtime. These deficient practices had the potential to result in a negative impact on Residents 1's quality of life and self-esteem. These deficient practices potentially caused a delay in care and miscommunication. During an observation on 7/7/2026 at 11:46 a.m., in Resident 1's room, Resident 1 was in bed, wearing a bonnet (hat worn to sleep to protect textured, curly, or natural hair). Resident 1 did not have a communication board, writing pad or an iPad at bedside. During an observation on 7/8/2026 at 12: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a diet that met the nutritional needs for one of three sampled residents (Resident 1) by failing to ensure: 1. Resident 1 received meals according to the dietary menu (a structured, planned selection of food items tailored to meet specific nutritional, health, lifestyle, or cultural needs) on 7/7/2026. 2. Resident 1's meal tray had the correct food according to Resident 1's dietary slip. 3. Dietary staff served Resident 1 a meal that offered nutritional value. These deficient practices had the potential to impact Resident 1's nutritional status and placed Resident 1 at risk for undesired weight loss and malnutrition. [...]

Inspectors wroteBased on observation and interview, the facility did not provide a working call light to one of three sampled residents (Resident 1). This deficient practice had the potential to cause a delay in care or the inability to obtain necessary care and services for Resident 1. Based on observation and interview, the facility did not provide a working call light (a communication device used by patients in hospital or nursing facilities to request assistance from nursing staff) to one of three sampled residents (Resident 1). This deficient practice had the potential to cause a delay in care or the inability to obtain necessary care and services for Resident 1. During an observation on 7/7/2026 at 11:46 a.m., in Resident 1's room, Resident 1's call light did not work when Resident 1 pushed the call light button. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor for side effects (unpleasant or adverse reactions) for two of three sampled residents (Residents 1 and 3) who were prescribed opioid medications (a class of drugs that act on the nervous system to relieve pain) while at the facility. These failures resulted in necessary medication and had the potential for Residents 1 and 3 to experience side effects from opioid medications while in the care of the facility. (Cross Reference F552)a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/3/2026 with diagnoses including fracture (broken bone) of sacrum (bone located at the base of the backbone), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and lack of coordination. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) or Resident 1's Responsible Party (RR 1) was informed in advance of the risks and benefits of taking Resident 1's Physician ordered Percocet (a prescription medication combining the opioid [a class of drugs that act on the nervous system to relieve pain] pain reliever oxycodone and the non-opioid pain reliever acetaminophen). This failure resulted in the violation of Resident 1's right to be informed of risks and benefits of Resident 1's treatment for pain and had the potential for Resident 1 to experience negative side effects of taking Percocet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary communication care and services for one of two sampled residents (Resident 1) when Mandarin (a major Chinese language) communication cards (picture or word based cards used to help a resident understand what staff are saying and used to express the resident's needs when speaking is difficult or English is limited) were not available for Resident 1 in Resident 1's room. This deficient practice had the potential to result in Resident 1 being unable to communicate needs effectively and the potential to affect Resident 1's psychosocial (the emotional and social requirements that individuals must have to feel safe, supported, and capable of functioning well in their environment) well-being.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan interventions for one of four sampled residents (Resident 1) who had a weight loss of 24 pounds (lbs.) in one month. This deficient practice placed Resident 1 at risk for continued weight loss and had the potential for Resident 1 to receive inappropriate care and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide podiatry (treatment of the feet and feet disorders) care to one of four sampled residents (Resident 1). This deficient practice resulted in Resident 1 not getting treatment for long and thickened toenails for 112 days (from 11/20/25 to 3/2/26) and placed Resident 1 at risk for ingrown toenails (when the nail grows into the surrounding skin), pain, injury, and infection.

Inspectors wroteBased on interview and record review the facility failed to ensure one of four sampled residents (Resident 2) had the resident's hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) pressure dressing on the right upper arm removed in accordance with the physician order. This deficient practice placed Resident 2 at risk for forming a blood clot in the right upper arm dialysis fistula (a surgically created connection between an artery and a vein, typically in the arm, designed for long-term hemodialysis [dialysis] access) which could result in Resident 2 missing life-saving hemodialysis treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Resident 10, Resident 1, and Resident 51), had information regarding Advance Directives (AD - legal document indicating resident preference on end-of-life treatment decisions) filed in Resident 10, Resident 1, and Resident 51's medical records as indicated in the facility's policy and procedure (P&P) titled, Advance Directives. This deficient practice had the potential to cause confusion among the healthcare providers in the event Resident 10, Resident 1 and Resident 51 required immediate medical care and/treatment and had the potential for the residents to receive inadequate or medically unnecessary care and/or treatment/services regarding life-sustaining treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure necessary care and services were provided for two of two sampled residents (Residents 48 and 51) by failing to:a. Ensure Resident 48's neurology (the branch of medicine that deals with the brain, spinal cord, and nerves) consult (getting expert opinion or advice about a patient's condition) was ordered in a timely manner.b. Ensure Resident 51 did not self-administer Pepto Bismol Ultra (a double-strength medication used to relieve nausea, heartburn, indigestion, upset stomach and diarrhea) brought from home and kept at Resident 51's bedside without a physician's order. This deficient practice resulted in the delay of care for Resident 48 and had the potential to result in unmet physical needs to Resident 48. [...]

Inspectors wroteBased on interview and record review, the facility failed to properly store discontinued controlled medications (DCM, drugs strictly regulated by government law due to their high potential for abuse, addiction or dependence) for two of two sampled residents (Resident 87 and Resident 89) as indicated in the facility's policy and procedures (P&P) titled, Controlled Substance, and Controlled Medication Storage. This deficient practice had the potential to result in diversion (illegally taking prescription drugs from their intended use, taking the drug from the healthcare setting for personal abuse) or medication errors involving Resident 87 and 89's DCMs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in one of one kitchen (Kitchen 1) when the following was observed: 1. A large bag of round brown frozen meat was observed unlabeled and undated in the facility's walk-in freezer. 2. A brown green build up was observed on two of the four corners of the dishwasher.3. The water collection area of the dishwasher had brown, tan gunk buildup in the water and the gunk rimmed the waterline.4. The stove top was observed with an accumulation of layered sticky to touch grease spots and food particles.5. The area behind the stove was dusty, sticky to touch, and colored layer of buildup. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 31), was treated with dignity when on 12/16/2025, Licensed Vocational Nurse 3 (LVN 3) failed to knock on Resident 31's door prior to entering Resident 31's room. This deficient practice resulted in Resident 31 feeling bothered and had the potential to result in Resident 31 feeling invaded to Resident 31's privacy and feeling humiliated, embarrassed, and ashamed.

Inspectors wroteBased on interview and record review, the facility failed to do a background check for one of three sampled certified nursing assistant (CNA 2). This failure had the potential to risk the residents' personal safety, mistreatment and misappropriation of personal funds.

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive care plan (CP), for one of one sampled residents (Resident 4), that addressed diabetes mellitus (a chronic [persistent or long-lasting] disease characterized by high blood sugar levels due to insufficient insulin [a hormone which regulates the amount of sugar in the blood] production) and anticoagulant (a medication that helps prevent blood clots) use. This failure had the potential to result in unmet individualized medical needs for Resident 4 and the potential to affect the resident's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to revise one of one sampled resident's (Resident 8's) fall risk care plan after Resident 8 had a fall on 11/26/2025. This failure placed Resident 8 at risk for future and recurrent falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one of one sampled resident (Resident 60) with their chosen individual activity when their television was not working. This failure had the potential to affect the resident's psychosocial well-being, mental health and self-satisfaction.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) measures for one of two sampled residents (Resident 9) were provided as ordered by the physician when Resident 9's low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure injuries) was set to static (not moving, changing, or active) and Resident 9's heel protectors were not on. These failures had the potential to worsen and prevent the healing for Resident 9's pressure ulcer/injury and had the potential for Resident 9 to develop further skin injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure a post-fall review (assessment done by the facility to identify underlying medical conditions, environmental factors, and other fall risk factors to create/revise interventions to prevent falls) for one of one sampled resident (Resident 8) was completed after Resident 8 fell on [DATE]. This failure had the potential to place Resident 8 at an increased risk of further falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 7) who received enteral feeding (liquid form of nutrients given to people who cannot eat or drink by mouth safely) through a gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach, can be used to give nutrition and/or drugs) had a properly labeled enteral feeding bag. This failure had the potential to result in Resident 7 receiving an expired or inappropriate amount of enteral feeding/nutrition and experiencing nausea, vomiting, abdominal bloating, or other complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 23), received proper respiratory (relating to breathing) care when, on 12/16/2025 and 12/18/2025, Resident 23 did not receive 4 liters per minute (L/min, unit of measurement) of oxygen (02, a colorless, odorless, tasteless gas essential for living) therapy as indicated in the physician's order dated 11/30/2025. This deficient practice had the potential to result in desaturation (a drop in the oxygen level in the blood), respiratory distress, and a physical decline to Resident 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection (the invasion and growth of germs in the body) prevention and control practices for 1 of 5 sampled residents (Residents 10) by failing to ensure Resident 10's restroom which was in full view of Resident 10 remained clean and orderly. This failure could potentially result in health hazards such as cross contamination (bacteria or microorganisms are unintentionally transferred from one surface/object to another and can result in a harmful effect) and compromise Resident 10's physical well-being.

Inspectors wroteBased on interview and record review, the facility failed to implement the antibiotic stewardship program (promotes the appropriate use of antibiotics [ABX, a medicine that inhibits growth of infection]) for one of three sampled residents (Resident 31). Resident 31s' physician (Medical Doctor [MD] 1) was not informed Resident 31 did not meet Loebs (a tool used to help prescribers decide if to start the use of ABX aiming to reduce unnecessary use of ABX) or the McGreer's criteria (infection surveillance checklist used to determine the appropriate ABX) for ABX use. This deficient practice had the potential to result in unnecessary ABX treatment and lead to ABX resistance (germs, mostly bacteria, that have become strong enough to resist many common ABX, making infections harder to cure) to Resident 31.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported to the California Department of Public Health (CDPH) within two hours of being notified, for 1 of 1 sampled resident (Resident 1), when Resident 1 had right eye discoloration on 10/10/25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the dignity of one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 left Resident 1 in soiled diapers following an episode of stool incontinence (lack of voluntary control over urination or defecation). This failure resulted in Resident 1 feeling frustrated and helpless and had the potential for Resident 1 to experience a decline in health and wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 2 and Resident 4), received activities of daily living care according to the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, by failing to: 1. Ensure Resident 4 was not left soiled with urine and/or feces on 8/29/2025. 2. Ensure Resident 2's hair was regularly brushed and groomed. As a result of these failures, Residents 2's and Resident 4's needs were unmet. Resident 4 was left soiled in Resident 4's brief (disposable under garment used for those who have a loss of continence [ability to hold the bladder and bowels]) with urine and feces. Resident 2's hair was matted (hair that is closely tangled into a dense mass). Resident 2 experienced pain and itching in Resident 2's head. [...]

Inspectors wroteBased on observation, interview, and record review, the facility to ensure one of four sampled residents (Resident 4) received timely response to Resident 4's requests and needs in accordance with the facility's policy and procedure (P&P) titled, Answering the Call Light, by failing to ensure: On 8/29/2025, Resident 4's call light was fully connected to the wall and was within reach of Resident 4. This failure caused Resident 4 to not be able to get assistance from staff when Resident 4 needed to be changed. Resident 4 was left soiled in Resident 4's briefs (disposable under garment used for those who have a loss of continence [ability to hold the bladder and bowels]) with urine and/or feces.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) was given a therapeutic diet (a medically-prescribed meal plan tailored to manage or treat a specific health condition, often by modifying nutrient intake, texture, or food types) according to the facility's policy and procedure (P&P) titled, Therapeutic Diets, by failing to ensure Resident 3, who was prescribed a minced and moist diet (a dietary modification designed for individuals with moderate to severe difficulty swallowing [dysphagia] that adds moisture and small pieces of food aid in swallowing), did not receive toasted bread on Resident 3's lunch tray on 9/2/2025. This failure resulted in Resident 3 being served food that was not minced and moist. This failure had the potential for Resident 3 to be unable to swallow the bread and lead to choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure swamp coolers (evaporative cooler, a device that cools air by using water evaporation) used in resident's rooms and in the facility were maintained in a safe and operable manner for two of three sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to result in electrical resident care equipment not in safe operating conditions and affecting residents' wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility to ensure one of five sampled residents (Resident 1) was provided timely responses to requests and needs according to the facility's policy and procedure (P&P) titled, Answering the Call Light, by failing to ensure:On [DATE], [DATE] and [DATE], Resident 1's call light was fully connected to the wall and was within reach of Resident 1. This failure caused Resident 5 to not be able to get assistance from staff when Resident 1 needed to be changed. Resident 1 was left soiled in Resident 1's briefs (disposable under garment used for those who have a loss of continence [ability to hold the bladder and bowels]) with urine, feces, and/or blood. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) received activities of daily living care according to the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, by failing to: Ensure Resident 1 was not left soiled of urine, feces, and/or menstruation fluid on 7/12/2025, 8/1/2025, and 8/5/2025. As a result of these failures, Resident 1 was left soiled in Resident 1's brief (disposable under garment used for those who have a loss of continence [ability to hold the bladder and bowels]) with urine, feces, and/or blood. Cross Reference: F558Findings: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its past plan of correction regarding providing means of communication for one of five sampled residents (Resident 1). This deficient practice had the potential for facility staff to inappropriately communicate with residents that could lead to a delay in care, needs being unmet, or neglect. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure one of three sampled residents (Resident 3) who was unable to speak would have a communication board to assist her to communicate with the facility staff as indicated in the care plan. This deficient practice had the potential for the resident's inability to express her needsFindings: During a review of Resident 3's nursing care plan dated 10/14/2024, the care plan indicated Resident 3 had communication problem. The care plan goal was for Resident 3 to maintain current level of communication by (how, with what assistance i.e. making sounds, using appropriate gestures, responding to yes/no questions, using communication board, writing messages). The care plan interventions were to ensure availability and functioning of adaptive communication equipment message board, telephone. [...]

Inspectors wroteBased on interview, and record review, the facility failed to follow the facility's Use of Restraints policy and procedure (P&P) to ensure one of two sampled residents (Resident 1) freedom from physical restraint (any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: Is attached or adjacent to the resident's body; Cannot be removed easily by the resident; and Restricts the resident's freedom of movement or normal access to his/her body) not required to treat the resident's medical symptoms (an indication or characteristic of a physical or psychological condition) by using a gown to confine Resident 1 on Resident 1's wheelchair to prevent resident's falling on 6/26/205. This deficient practice violated Resident 1's right and had the potential to result in impairing Resident 1's physical and psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician-ordered diagnostic test (MRI) was scheduled and completed for one of three residents (Resident 3 ) reviewed for follow-up medical care. This failure resulted in a delay in diagnostic testing for Resident 3 and had the potential to result in delayed diagnosis and treatment for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was plugged in and functioning for one of two sampled residents (Resident 1). This deficient practice had the potential to result in unmet needs for Resident 1.

Inspectors wroteBased on interview and record review the facility failed to ensure the facility's Policy and Procedure (P&P) titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program included screening of potential employees, previous employers, and/or current employers. The facility failed to maintain documentation indicating screening of 3 of 6 sampled employees (Certified Nursing Assistant [CNA] 1, CNA 2 and CNA 3). This deficient practice had the potential to result in hiring of employees that were involved in resident abuse incidents and the potential to jeopardize the safety of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 7 and CNA 8 provided incontinent (loss of bladder control, varying from a slight loss of urine after sneezing, coughing, or laughing to complete inability to control urination) care to one of two sampled residents (Resident 1). This deficient practice had the potential to result in a rash or skin irritation to Resident 1.

Inspectors wroteBased on observations, interview, and record review, the facility failed to follow its infection control measure for three of three sampled residents (Residents 6, 7, and 8) by failing to ensure: 1. Certified Nurse Assistant (CNA) 2 used proper hand hygiene after handling Resident 8 ' s dirty food tray. 2. CNA 2 used proper hand hygiene before handling Resident 6 and 7 ' s food tray to CNA 1. 3. CNA 1 used proper personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) in a SARS-CoV-2 (COVID-19) exposed room 4. CNA 1 used proper hand hygiene before tray-set up and in-between Resident 6 and 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan (a plan that outlines resident-specific interventions used to guide a resident ' s care for a given area of concern), with measurable objections for one of three sampled residents (Resident 6) to ensure Resident 6 was monitored and interventions were identified for her non-compliance to wear Resident 6's facemask during a SARS-Co2-V (COVID-19) outbreak in the facility. This failure had the potential to result in Resident 6 not receiving the necessary care and interventions for non-compliance that could lead to a decline in the resident ' s physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nurse staffing for one of two night shifts (11 pm to 7 am shift) staffing reviewed to provide incontinent (unable to control excretion of urine or the contents of the bowels) care to one of 15 sampled residents (Resident 3) on 3/26/2025, in accordance with the facility's Policy and Procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, and the facility's Facility Assessment (a guide used by the facility to evaluate what resources are necessary to care for the facility's residents). This failure had the potential to delay the provision of care and services for Resident 3 and other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to protect resident's rights to privacy and confidentiality of protected health information (PHI, any information in the medical record that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment) for one of 15 sampled residents (Resident 8) when the Social Services Director (SSD) emailed Resident 8 ' s Face Sheet (admission Record) and podiatry (medical care and treatment of the feet) care needs to an unauthorized recipient. This deficient practice had the potential to compromise Resident 8's privacy and confidentiality.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) who required assistance with activities of daily living (ADLs- tasks of everyday life such as bathing, dressing, and toileting) was provided care when staff did not change Resident 1 ' s incontinence (involuntary loss of urine or feces) brief (diaper) promptly. This failure resulted in Resident 1 to not receive assistance with ADL as needed and had the potential to result in skin breakdown and affect Resident 1 ' s well-being.

Inspectors wroteBased on interview and record review, the facility failed to manage pain for one of seven sampled residents (Resident 2) as indicated in Resident 2's care plan and the facility's policy and procedure (P&P) titled, Pain Assessment and Management, by failing to: 1. Ensure licensed nurses (LNs) assessed and documented Resident 2's pain level before and after administration of oxycodone (medication used to treat moderate to severe pain) for pain management. 2. Ensure LNs assessed and documented Resident 2's abdominal pain level and characteristic and administered pain medication as needed and ordered by the physician on 1/13/2025 and 1/14/2025. These deficient practices had the potential for Resident 2 to experience unrelieved/uncontrolled pain that could result in physical, mental, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to honor 1 of 15 sampled residents' (Resident 1's) food preferences when the dietary services department did not provide Resident 1's requested meal for dinner on 3/26/25. This failure resulted in Resident 1's food choices not being honored and had the potential for unmet nutritional needs to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 15 sampled residents (Resident 1) was provided with water according to Resident 1's need and preference when Resident 1's water pitcher was not filled during the morning of 3/27/25. This deficient practice had the potential for Resident 1 to not receive proper hydration.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide restorative nursing services (RNS- specialized nursing interventions provided by a restorative nursing assistant [RNA] focused on helping to maintain or regain functional abilities to achieve the highest level of well-being, often after rehabilitation or to prevent decline) for one of three sampled residents (Resident 2), according to the facility's policy and procedure (P&P) titled, Restorative Nursing Services, by failing to: 1. Ensure Restorative Nurse Assistant (RNA) 5 completely followed Resident 2's physician orders (PO) for range of motion (ROM- exercises and/or movements designed to improve the flexibility and mobility of joints) when RNA 5 provided RNS to Resident 5 on 2/25/2025, 2/26/2025 and other unspecified days in 2/2025. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate documentation of restorative nursing services (RNS- specialized nursing interventions provided by a restorative nursing assistant [RNA] focused on helping to maintain or regain functional abilities to achieve the highest level of well-being, often after rehabilitation or to prevent decline) provided to one of three sampled residents (Resident 2), according to the facility's policy and procedure (P&P) titled, Charting and Documentation, by failing to: 1. Ensure RNA 5 did not initial Resident 2's Restorative Nursing Flow Sheet (RNFS) when RNA 5 did not provide Resident 2 with range of motion (ROM- exercises and/or movements designed to improve the flexibility and mobility of joints) as ordered by the physician on 2/25/2025, 2/26/2025 and other unspecified days in 2/2025. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three sampled residents' (Resident 2's) property from loss, according to the facility's policy and procedure (P&P) titled, Personal Property, when facility staff did not inventory Resident 2's durable medical equipment (DME- reusable medical devices, equipment, or supplies prescribed by a healthcare provider to assist with the treatment, monitoring, or management of a medical condition or disability) of a right hand resting splint (RHRS) in Resident 2's Resident Clothing and Possession (RCP) form on 1/21/2025, and the RHRS was not lost in the facility. These failures had the potential for Resident 2 to develop further loss of function and contracture (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) of the right hand.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan (CP - document created that outlines the type of care a patient needs) for one of seven sampled residents (Resident 4) for a rash discovered on admission. This failure had the potential to result in unmet individualized needs for Resident 4 and to lead to a break in continuity of care for an existing condition.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of three sampled residents (Resident 12) as indicated in the facility's policies and procedures (P&P) titled, Falls and Fall Risk, Managing, Safety and Supervision of Residents, and Care Plans, Comprehensive Person-Centered, by failing to: 1. Ensure Certified Nursing Assistant (CNA) 4 and/or Licensed Vocational Nurse (LVN) 6 provided supervision/monitoring (the act of watching a person) to Resident 12, who was assessed as being high risk for falls and had a history of multiple falls when CNA 4 and LVN 6 failed to prevent Resident 1 from being inside the facility's conference room with the door closed, unsupervised, on 12/28/2024. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 4 of 18 sampled residents (Residents 3, 8, 17, and 18) who required assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting, a person performs daily) were provided assistance with ADLs when: 1. Resident 3's, Resident 8's, and Resident 18's wet and/or dirty incontinence briefs (diapers) were not changed promptly. 2. Resident 17's hair was not washed and combed as scheduled. These failures resulted in Resident 3, Resident 8, Resident 17, and Resident 18 to not receive assistance with ADLs as needed and had the potential to affect Resident 3's, Resident 8's, Resident 17's, and Resident 18's well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient Certified Nursing Assistants (CNAs) provided care and services to four of 18 sampled residents (Residents 3, 8, 17, and 18) in accordance with the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, and the facility's Facility Assessment Tool (a guide used by the facility to evaluate what resources are necessary to care for the facility's residents), on 12/16/2024, 12/22/2024, 12/23/2024, 12/26/2024, 12/28/2024, 1/4/2025, and 1/7/2025. This failure resulted in residents having to wait for up to an hour for call lights (device used by a resident to signal their need for assistance from staff) to be answered and for residents to be changed and cleaned promptly. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a communication device was provided to 1 of 18 sampled residents (Resident 17) when Resident 17, who was not able to speak, went out to a medical appointment on 1/21/2025. This failure had the potential for Resident 17 to not be able to communicate during a medical appointment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan for 2 of 18 sampled residents (Residents 12 and 17) by failing to: 1. Ensure Certified Nursing Assistant (CNA) 4, Licensed Vocational Nurse (LVN) 6, and all nurses (any CNAs, LVNs, and Registered Nurses [RNs]) in the nursing station provided frequent visual checks and kept Resident 12 at the nursing station for monitoring. 2. Ensure LVN 9 administered medications to Resident 17 accompanied by another staff. These failures had the potential for Resident 12 and Resident 17 to not receive the care and services needed to address Resident 12's fall risk and Resident 17's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to coordinate with an outside care provider to provide necessary care and services for 1 of 18 sampled residents (Resident 17) when the facility did not obtain an after visit care record or after visit summary (AVS- document which details everything that happened during an appointment, the treatment plan, and any new medications, tests, and instructions from the care provider) from Resident 17's neurologist's (a medical doctor who diagnoses, treats and manages disorders of the nervous system [brain, spinal cord and nerves]) office after Resident 17's appointment on 11/12/2024. This failure had the potential for Resident 17 to not receive the necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure certified nursing assistants (CNAs) turned and cared for 2 of 18 sampled residents (Resident 7 and Resident 8) according to the CNAs training when: 1. CNAs (unable to identify) did not use a draw sheet (lift sheet- small sheet used to reposition patients in bed) to turn Resident 7 and Resident 8 in bed. 2. CNAs (unable to identify) roughly and hurriedly turned Resident 8 to Resident 8's side while changing Resident 8 in bed. These failures resulted in Resident 7 and Resident 8 to have pain during care provision and had the potential to affect Resident 7's and Resident 8's well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient nursing staff was available to answer call lights timely and provide care and nursing related services to 2 of 3 sampled residents. This deficient practice resulted in the failure to answer Resident 1's and Resident 2's call lights timely, and Resident 3 to feel nursing service provided was too rushed.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents' (Resident 1) right to be treated with dignity and respect when Registered Nurse (RN) 1 instructed Resident 1, in the presence of Resident 1's visitor, that Resident 1 needed to provide a urine sample (a collection of urine that can be used for a variety of tests). This failure resulted in Resident 1 feeling embarrassed and disrespected.

Inspectors wroteBased on interview and record review, the facility failed to monitor blood sugar levels for one of three sampled residents (Resident 4) who was diabetic (diabetes, also known as diabetes mellitus, is a chronic condition that affects how the body uses glucose [sugar] for energy). This failure had the potential for Resident 4's blood sugar levels to be too high or too low which could lead to illness and/or death.

Inspectors wroteBased on interview and record review, the facility failed to immediately remove Certified Nurse Assistant 1 (CNA 1) from performing resident care duties in accordance with the facility's policy and procedure for one of three sampled residents (Resident 1), who alleged CNA 1 was rough while changing Resident 1 while the facility's investigation was in progress. This deficient practice had the potential to result in the potential for Resident 1 to be subjected to further abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to accommodate to the needs of two of two sampled residents (Resident 36 and Resident 26) when: a. The facility failed to ensure a toilet paper dispenser was installed in the restroom for Resident 36. b. The facility failed to ensure Resident 26 had footrests when transported via the wheelchair. This deficient practice led to pain in Resident 36's shoulder when reaching for toilet paper and resulted in Resident 26 feeling uncomfortable during transport.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 14 and 40) and/ or their representatives were informed of their right to formulate an advanced directive as indicated in the facility's policy and procedure (P&P) titled, Advanced Directives. This deficient practice infringed on the resident's and/or the representatives' right to be fully informed of the option to formulate an advance directive and had the potential to cause conflict with the residents' wishes regarding health care decision making.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of three sampled residents (Residents 34, 48 and Resident 79) received appropriate care, treatment, and services to meet each resident's physical, mental, and psychosocial needs when the facility failed to: a. Initiate 72-hour monitoring when Resident 79 experienced a change of condition (COC, a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) and when Resident 79 was found with bruising and a scab on Resident 79's left eye and left eyebrow. b. Follow physician's order for Resident 34's doxazosin (medication used to treat high blood pressure and used to treat an enlarged prostate). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure facility provided care and services to prevent pressure ulcers for two of four sampled residents (Resident 47 and Resident 79.) As a result, Resident 47 developed a recurrent Associated Skin Damage (MASD, an erosion or inflammation of the skin caused by long-term exposure to moisture and irritants such as urine or stool) and Resident 79 developed a skin rash on the scrotum and buttocks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure incontinent (having no or no voluntary control over urination or defecation [discharge of feces from the body]) care was provided for two of two sampled residents (Resident 47 and Resident 79). This deficient practice resulted in Resident 47 and Resident 79 to develop Moisture Associated Skin Damage (MASD, an erosion or inflammation of the skin caused by long-term exposure to moisture and irritants such as urine or stool), this failure had the potential to result in physical declines to Residents 47 and 79.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was sufficient nursing aides to provide care and respond to each resident's basic needs for two of two sampled residents (Residents 29 and 51). This failure resulted in Residents 29, 51 felt frustrated and the residents not receiving the care or receiving delayed care and treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food were stored, prepared, and distributed under sanitary conditions for all the residents in the facility by failing to: C. Ensure food past it's use-by date was not stored in one of two freezers observed in the kitchen. D. Check the quaternary sanitizing solution (ammonium solution used for sanitizing surfaces) with the quaternary test strip according to the manufacturer's instructions for one of two Kitchen Aides observed. These deficient practices placed the residents at risk for an outbreak of foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wrotec. During a review of Resident 71's AR, the AR indicated the facility admitted Resident 71 on 3/26/2024, and re-admitted on [DATE], with diagnoses that included pneumonia (an infection of the lungs that may be caused by bacteria, viruses, or fungi), quadriplegia (a condition that causes partial or total paralysis [the loss of the ability to move some or all of the body] of all four limbs and the torso), neuralgia (a sharp, burning, or stabbing pain that occurs in a nerve pathway and is caused by nerve damage or irritation), and neuritis (inflammation of a nerve or nerves). During a review of Resident 71's MDS, dated [DATE], indicated Resident 71 was dependent (helper does all of the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and dependent with mobility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 34) was treated with dignity by failing to provide privacy while accessing Resident 34's G-tube (gastrostomy tube, a tube inserted through the belly to bring nutrition and/or medications directly to the stomach) during medication administration. This deficient practice resulted in exposure of Resident 34's portion of the abdomen (belly) and had the potential to result in Resident 34's value as human being not respected.

Inspectors wroteBased on interview and record review, the facility staff failed to promptly notify the physician that a resident had broken bottom dentures which caused difficulty with eating for one of one sampled resident (Resident 73). This deficient practice resulted in a delay in the provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure bed hold (holding or reserving a resident's bed during periods of absence) notification was provided to one of one sampled resident (Resident 83) or the resident's representative when Resident 83 was transferred to the General Acute Care Hospital (GACH) on 9/7/2024. This deficient practice had the potential to result in Resident 83 or the resident's representative to not be aware of the option to return to the facility following hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an accurate assessment was conducted for one of one sampled resident (Resident 40). Resident 40 did not have physical restraints as indicated on Resident 40's Minimum Data Set (MDS - a federally mandated resident assessment tool). This deficient practice led to an inaccurate assessment of Resident 40's status during the observation period captured on the MDS and had the potential to result in incorrect care and services provided to Resident 40.

Inspectors wroteBased on interview and record review, the facility failed to implement the intervention to monitor and document peripheral edema (swelling caused by fluid trapped in the body such as the hands, legs and feet) for one of one sampled resident (Resident 14) as indicated in Resident 14's care plan (CP - document developed that describes the supports, services and interventions for a person's care) titled, At risk for fluid/ electrolyte (type of mineral found in fluids and body) imbalance, at risk for peripheral edema. This deficient practice had the potential to lead to Resident 14 developing shortness of breath and fluid overload (when the body has too much fluid).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 27) was provided with appropriate treatment and services in accordance with the physician's orders and as outlined in the resident's plan of care (CP [provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan]) to maintain, restore or improve the functional ability for Resident 27. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to honor the food preferences of one of one sampled resident (Resident 69) and ensure Boost (nutritional supplement shake) was given to Resident 69 on 10/29/2024. This deficient practice led to Resident 69's decreased appetite and potentially contributed to significant weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to promptly provide dental services for one out of one sampled resident (Resident 73). This deficient practice had the potential to result in the inability to effectively chew foods, weight loss, lack of energy and loss of muscle mass for Resident 73.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 68), was honored, and served her food preferences during tray-line observation of the kitchen. This deficient practice had the potential to negatively impact Resident 68's nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 27) call light (a device used by a resident to signal the need for assistance) system was within reach in accordance with Resident 27's care plan (CP, provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan]) and the facility's policy and procedure (P&P) titled, Call Lights. This failure had the potential to result in Resident 27 to not have Resident 27's needs met in a timely manner and/or Resident 27 to experience harm if Resident 27 was unable to alert staff during an emergency.

Inspectors wroteBased on interview and record review, the facility failed to protect one of one resident (Resident 1) from physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm), when Resident 2 hit Resident 1 in the face with a closed fist on 6/5/2024. This failure had the potential to result in serious mental and physical injury and a physical and psychosocial decline to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a change in condition (COC- a change in the resident's health or functioning that requires further assessment and intervention) for one of four sampled residents (Resident 1) as indicated in the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, by failing to: Ensure Resident 1's assigned Licensed Vocational Nurses notified Resident 1's Primary Physician (PP/Medical Doctor [MD] 1) promptly (punctually [with little or no delay]) when Resident 1 was assessed not taking in foods or liquids from 5/11/2024 at 5 pm to 5/13/2024 at 7:30 am. This failure resulted in a delay in providing the necessary care and treatment for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure they had a certified Infection Preventionist (IP- a nurse who helped prevent and identify the spread of infectious disease in the healthcare environment) on staff from 4/24/2024 to 5/7/2024. This failure had the potential for lack of oversight of the facility's infection control practices during a COVID-19 (minor to severe respiratory illness caused by a virus and spread from person to person) outbreak at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received restorative nursing services ([RNS], person-centered nursing care provided by a restorative nursing assistant [RNA] designed to improve or maintain the functional ability of residents to achieve their highest level of well-being possible) as ordered by the physician. This deficient practice had the potential for Resident 1 to experience decreased functional mobility and decline in Activities of Daily Living ([ADL] fundamental skills required to independently care for oneself, such as eating, bathing, and mobility).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (minor to severe respiratory illness caused by a virus and spread from person to person) in accordance with the facility's policy and procedure by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 wore proper personal protective equipment ([PPE] protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) while in a suspected COVID-19 room. 2. Ensure CNA 1 removed used gloves after leaving a resident's room (Resident 1). These deficient practices had the potential to cause the spread of COVID-19 infection to other residents and staff members in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services for two of five sampled residents (Resident 282 and Resident 16) by failing to: a. Ensure Resident 282's discontinued medication was removed from one of two medication carts observed (Medication Cart 1). b. Ensure physician ordered medication Calcium 500 milligram (mg, unit of measurement- supplement used to prevent or treat low blood calcium) was not expired for Resident 16. This failure had the potential to lead to medication administration errors and/or drug diversion (transfer of a resident's prescribed medication to another individual).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in one of one kitchen (Kitchen 1). On 10/16/23, a bag of frozen chicken was unlabeled and undated. This failure had the potential to result in foodborne illnesses to all residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when: a. The water temperature for two of two laundry room washing machines were 71 degrees Fahrenheit (F, unit of measurement). b. Personal Protective Equipment (PPE, protective clothing or equipment, designed to protect the wearer from injury or the spread of infection or illness) was not use while providing care for two of two sampled residents (Resident 29 and Resident 31). These failures had the potential to result in the spread of infections throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of one sampled resident's (Resident 235) right of self-determination (make choices and manage one's own life) and treat Resident 235 with respect and dignity. Certified Nursing Assistant (CNA) 1 cut Resident 235's hair without Resident 235's consent. This failure resulted in Resident 235 to feel angry and sad.

Inspectors wroteBased on interview and record review, the facility failed to submit a new Level I Screening (identifies if an individual has a suspected mental illness or an intellectual/developmental disability) for one of four sampled residents (Resident 29) for Preadmission Screening and Resident Review (PASRR). This failure had the potential to result in Resident 29 to not receive special services for treatment of mental illnesses.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement an individualized care plan (CP) for one of one sampled resident (Resident 30) by failing to: A. Implement Resident 30's CP related to rehab services to reflect the current individualized plan of care for physical therapy (PT) services. B. Develop and/or implement Resident 30's CP related to the monitoring of Resident 30's hemoglobin (red protein in red blood cells that transport oxygen to the body's tissues) and occult bleeding (refers to the positive lab test from a stool sample to determine blood loss not visible to the resident or physician). C. Develop and/or implement Resident 30's CP related to Resident 30's eye specialist consultations to reflect all interventions, including the follow-up appointments and ophthalmologist's recommendations. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise a Care Plan (CP), for one of one sampled resident (Resident 68), to reflect the Registered Dietitian's (RD) recommendation to increase daily Boost (high calorie nutritional support for weight loss or maintenance) consumption as indicated in the facility's Policy and Procedure (P&P), titled, Care Plans, Comprehensive Person-Centered, This failure had the potential to result in a physical decline and additional weight loss to Resident 68.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to administer eye drops in accordance with the professional standards of practice for one of six residents selected for medication pass observation (Resident 41). This failure had the potential to cause adverse effects to Resident 41 related to the systemic absorption (process of medication movement from the site of medication administration to the body) or lower-than-prescribed dose administered to Resident 41.

Inspectors wroteBased on interviews and record review, the facility failed to ensure follow-up appointments with the eye specialist/s were arranged to address the eye problems of one of one sampled resident (Resident 30). This failure had the potential to cause further vision disturbances or loss of vision of Resident 30 due to a delay in proper eye health services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess for removal of an indwelling catheter (urinary catheter, a tube left in the bladder to drain urine) for one of two sampled residents (Resident 11) according to the facilities policy and procedure (P&P) when they failed to: 1. Assess and document Resident 11's ongoing need for a urinary catheter. 2. Use a standardized tool for documenting clinical indications for the need of Resident 11's urinary catheter. This failure had the potential to result in a urinary tract infection (UTI, an infection of any part of the urinary system, kidneys, bladder or urethra) for Resident 11.

Inspectors wroteBased on interview and record review, the facility failed to implement Registered Dietitian's recommendations to prevent weight loss for one of three sampled residents (Resident 68) by failing to provide Resident 68 Boost (nutritional drink) with high protein nourishment four times a day. This failure resulted in Resident 68 experiencing weight loss and had the potential to result in significant weight loss.

Inspectors wroteBased on interview and record review, the facility failed to follow pharmacy recommendations, for one of one sampled resident (Resident 31), to evaluate for discontinuation for the use of megestrol acetate (megace, appetite stimulant) as indicated in the facility's Policy and Procedure (P&P), titled Medication Regimen Review (Monthly Report [MRR]). This failure had the potential to result in administration of unnecessary medication to Resident 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was less than 5 percents (%) for two of two sampled residents (Residents 16 & 41) during the medication pass observation by failing to: 1. Ensure Licensed Vocational Nurse 4 (LVN 4) verified the medication expiration date prior to the administration of Calcium (dietary supplement and antacid) to Resident 16 in accordance with the facility's policy and procedures (P&P). 2. Ensure LVN 3 administered Resident 41's eye drops in accordance with the professional standards of practice. As a results, the medication error rates during the medication pass observation was at 5.56% due to two medication errors in a total of 36 opportunities observed. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the timely collection of a lab sample as ordered by the physician for one of one sampled resident (Resident 30), who was being monitored for occult bleeding (OB, bleeding not visible to the resident or the physician but would test positive on the fecal occult blood test [lab test to check stool samples for hidden or occult blood]). This failure had the potential to cause a decline in Resident 30's physical and/or psychological well-being due to the delay in services provided.

Inspectors wroteBased on interviews and record review, the facility failed to ensure nursing staff notify the resident's physician (PHYS 1) regarding critical lab value/results (blood test result) for one of one sampled resident (Resident 24). This failure resulted in Resident 24 receiving a delay in care. Resident 24 was transferred to General Acute Care Hospital 1 (GACH 1) for a higher level of care one day after Licensed Vocational Nurse 2 (LVN 2) received the critical lab results from the Premier Lab Solutions (PLS).

Inspectors wroteBased on interviews and record review, the facility failed to provide physical therapy (PT) as ordered by the physician for one of two sampled residents (Resident 30). This failure had the potential to negatively affect Resident 30's physical well-being due to a decline in mobility and/or psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility's governing body (individuals such as the facility owner, chief executive officer, or other individuals who are legally responsible to establish and implement policies regarding the management and operations of the facility) failed to ensure, for one of one sampled resident (Resident 71), policies regarding wheelchair alarms ( fall prevention alarm, devises designed to alert a care giver or staff member that a patient attempts to exit the wheelchair) and bed alarms were created and implemented. This failure had the potential to cause emotional or physical harm to Resident 71.

Inspectors wroteBased on interview and record review, the facility failed to report 2 of 2 sampled resident's (Resident 1 ' s and Resident 2 ' s) allegation of abuse to the local Ombudsman (an official appointed to investigate individuals ' complaints against facility administration), to the Police, and to the State Survey Agency within two hours by failing to: 1. Report Resident 1 ' s alleged physical abuse on 9/15/2023 by CNA 1 and 2. Report Resident 2's alleged verbal abuse on 10/1/2023 by LVN 1. This failure had the potential to place Resident 1, Resident 2, and other residents of the facility at risks for physical and verbal abuse by Certified Nursing Assistant (CNA 1) and Licensed Vocational Nurse (LVN 1) after being identified as perpetrators of the alleged abuses on 9/15/2023 and 10/1/2023.