Every finding on record at Blue Oak Post-Acute

Based on interviews and record review, the facility's Social Services Department failed to ensure the discharge planning process was documented for one resident (Resident 1) of five sampled residents when the facility planned to discharge Resident 1 from the facility to a shelter without having documented: that the shelter could meet Resident 1's medical needs, Resident 1's involvement in the discharge process, and without preparing Resident 1 to transfer to the new facility.This failure decreased the facility's potential to ensure Resident 1 had a safe discharge and prevent Resident 1's readmission to the hospital. Cross Reference F628Findings:A record review of Resident 1's admission record indicated admission to the facility on 6/2/21 with a diagnosis of Type II Diabetes Mellitus (DM- a medical condition characterized by poor blood sugar control and poor wound healing) and had a history of Traumatic Brain Injury (damage caused to the brain by a forceful bump, blow, or jolt).A review of Resident 1's comprehensive nursing care plan, dated 2/16/22, indicated Resident 1 wished to remain in the facility for long term care due to the inability to care for self or in home care settings. No revisions or additions were noted on this care plan to support a transition to a lower level of care nor a pending discharge.A review of Resident 1's Interdisciplinary Team's (a group of people with different areas of expertise collaborating towards a common goal) Care Conference note, dated 6/4/26, indicated Resident 1 had no change in his discharge plans; however, the Social Services Department (a group of people who evaluate a resident's safety, coordinates care, and provides people resources to obtain basic life needs like food, housing, and medical care) indicated applications for a place Resident 1 could transfer or discharge to were waiting for approval. Resident 1 was not listed as an attendee at this meeting. No evidence of additional documentation regarding Resident 1's discharge could be located in Resident 1's medical record. A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 6/8/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation and judgment status of a resident) score of 15 which indicated intact cognition (the mental process of acquiring knowledge, and understanding through thought, experience and the senses). A further review of Resident 1's MDS indicated Resident 1 required a walker or wheelchair for mobility, needed supervision for toileting and tub/shower transfers and moderate/partial assistance (the helper completed less than half of task by either lifting, holding or supporting the trunk or limbs) for showering or bathing.During an interview on 7/29/26 at 8:48 a.m. in Resident 1's room, Resident 1 stated someone from the Social Services Department came into his room during the week of 7/20/26 and told him he was being discharged to a shelter in the Upper Northern California area. Resident 1 stated he was initially surprised to learn he was being discharged in two days. Resident 1 stated he had not requested a discharge and became fearful about being sent to a facility that did not provide 24 hour nursing care, explaining that nurses have administered his insulin twice a day. Resident 1 stated he was afraid he would fall, become ill, require hospitalization, or die if he was discharged to a setting that was unable to meet his medical needs. Most recently, Resident 1 stated he was told that because the facility was no longer a long term care facility and he had no skilled nursing needs, a discharge to a lower level of care was appropriate. Resident 1 further stated he had not received any education on how to manage his diabetes through insulin administration and diet, both skills he would need to safely prepare himself to live in a lower level of care. Resident 1 denied having received a written notice of discharge prior to being informed he was being discharged . Resident 1 stated he spoke with someone from the shelter and was told the shelter could only provide a bed, a room, a shower, laundry services, and transportation to and from medical appointments. The shelter would not be able to provide assistance with insulin administration or assistance to shower or bathe.During an interview at the nurse's station on 7/29/26 at 9:13 a.m., Licensed Nurse 1 (LN 1) stated if Resident 1 were to be discharged , he would need medication education which included safe insulin injections, how to recognize the signs and symptoms of hyperglycemia (very high blood sugar levels) and hypoglycemia (very low blood sugar levels), and how to treat both of them. LN 1 stated a diabetic diet was a very important aspect of DM care, so a dietitian would likely need to be involved in part of the DM training as well. LN 1 stated the amount of resident education would require a minimum of one week of introduction, constant reinforcement, and persistent return demonstration to determine competency and safety with all medications and needles.During an interview on 7/29/26 at 12:49 p.m. in the Social Services Director's (SSD) office, the SSD stated that after the change in ownership, the facility's focus shifted to the care of short term residents. As a result, she began working on transitioning long term, stable residents whenever possible. The SSD explained there was no formal discharge meeting; instead, information about long term residents was gathered during various other meetings to help her team understand potential discharge needs. The SSD acknowledged she did not document discharge planning processes or progress in the resident's medical record and instead tracked information on an internal document stored on her computer. The SSD further stated that the Social Services team informally met outside of structured care planning processes, and these discussions were not incorporated into, or documented in, residents' medical records or comprehensive care plans. This included any progress on individual discharge plans for residents. The SSD stated the shelter in Upper Northern California had an opening for Resident 1. Resident 1 had a phone interview with administration at that building on 7/21/26 and was accepted. Discharge to the shelter was planned for 7/23/26.During an interview in the Training Room on 7/29/26 at 1:29 p.m., the Assistant Director of Nursing (ADON) stated DM education required 48-72 hours at a minimum due to the complexity of the disease and the multiple important topics needing reinforcement and return demonstration of self-administration of insulin. The ADON stated time was needed to ensure the education stays with the resident. It is important for them to be safe at home.A review of the facility's job duties for the position of Social Worker, revised July 2024, indicated the social worker would Participate in the development of a resident centered care plan for each resident. Involve the resident/family in planning individualized objectives and goals for the resident.Ensure the discharge needs of each resident are identified and result in the development of a discharge plan for each resident.A review of the facility's policy titled Discharge Planning and Transitions of Care, dated 1/14/26 indicated, The facility shall implement coordinated discharge planning and transitions of care processes to ensure safe, appropriate and person-centered transitions that meet each resident's medical, psychosocial and functional needs in accordance with federal and state regulations.Discharge planning shall be a collaborative, interdisciplinary process that includes the resident and/or the resident's representative. The interdisciplinary team shall assess each resident's potential discharge needs, including medical, functional, psychosocial and environmental considerations. Social Services shall assess psychosocial factors, support systems, preferences, and available community resources. Discharge planning information shall be incorporated into the resident's comprehensive care plan. Residents.shall be informed of discharge options and actively involved in discharge planning decisions.Education shall be provided in a manner the resident can understand.Planned discharges shall be conducted in accordance with resident's rights, notice requirements, and facility policy. Social Services shall assist the residents and families in understanding the discharge processes and available appeal rights when applicable. All planned discharges shall be documented in the medical record. All discharge planning assessments, resident communications, referrals, coordination activities and transitions of care shall be documented accurately, timely and in accordance with facility documentation standards.

Based on interview and record review, the facility's Social Services Department failed to provide the Ombudsman (an independent official who mediates disputes between residents and the facility) and one resident (Resident 1) of five sampled residents with the required written discharge notice when the Social Services Department informed Resident 1 that he was going to be discharged with two days notice.This failure led to Resident 1 experiencing fear from not understanding the reason for his discharge, not knowing where he was being discharged to, and the prevention of the Ombudsman from performing mandated oversight of Resident 1's right to be informed of his rights regarding the discharge process. Cross Reference F627Findings:During a phone interview on 7/28/26 at 10:01 a.m., the Ombudsman (OM) stated she did not receive a notice of discharge nor was contacted for any discharge planning for Resident 1. The OM stated she became aware of the attempted discharge after receiving a phone call from Resident 1's family member. The OM further stated the Administrator (ADM) and the Social Services Director (SSD) both stated they were unaware of the need to notify the OM's office during the discharge process.During an interview on 7/29/26 at 8:48 a.m. in Resident 1's room, Resident 1 stated someone from the Social Services Department came into his room during the week of 7/20/26 and told him he was being discharged to a shelter in the Upper Northern California area. Resident 1 stated he was initially surprised to learn he was being discharged in two days. Resident 1 denied receiving a written notice of discharge prior to being informed he was being discharged . During a review of Resident 1's electronic medical record, no evidence was found showing the facility issued a written discharge notice or any other required discharge documentation to Resident 1 or the Ombudsman.During an interview on 7/29/26 at 12:49 p.m. in the SSD's office, the SSD stated she was unaware written notices must be provided to both the resident and the Ombudsman at least 30 days prior to a discharge. The SSD admitted she had never issued written discharge notices and had not documented any discharge planning progress in the resident's medical record. The SSD stated discharge information was tracked informally on a spreadsheet stored on her personal computer and Social Services discussions regarding discharge occurred informally outside of structured care planning processes. These discussions were not incorporated into residents' care plans or records.During an interview on 7/29/26 at 2:55 p.m., the ADM acknowledged the SSD had not completed necessary tasks and documentation as per facility policy regarding discharge processes. A review of the facility's policy titled Discharge Planning and Transitions of Care dated 1/14/26, indicated, The purpose of the Social Services Manual is to establish standardized policies and procedures that ensure residents receive.support consistent with applicable federal.regulations.It is the responsibility of representatives of the social services department to ensure appropriate discharge planning and transitions of care processes remain in place.Planned discharges shall be conducted in accordance with resident's rights, notice requirements, and facility policy. Social Services shall assist the residents and families in understanding the discharge processes and available appeal rights when applicable. All planned discharges shall be documented in the medical record. All discharge planning assessments, resident communications, referrals, coordination activities and transitions of care shall be documented accurately, timely and in accordance with facility documentation standards.

Based on observation, interview, and record review, the facility failed to implement the care plan of one of five sampled residents (Resident 1) when the care plan for a toileting program was not carried out and Resident 1's noncompliance with the toileting program did not have a care plan. This failure had the potential to impede Resident 1's ability to regain her continence and delay her readiness for discharge home. During a phone interview on 6/8/26 at 2:54 p.m., Family Member (FM) stated she had spoken with five staff members regarding Resident 1's every-two-hour toileting program including two social services staff, the Director of Nursing, an occupational therapist, and one of Resident 1's nurses. FM stated the nurse had told FM that Resident 1 had been refusing to go to the toilet every two hours per the program. FM stated she told the nurse that they can call her any time, day or night, if Resident 1 refuses, and she (FM) will tell Resident 1 that if she complies with the toileting program she will get closer to going home to her cat. FM stated that Resident 1 really wants to see her cat, and if she says that to her, she can get Resident 1 to comply. FM stated she has not gotten one phone call to tell her Resident 1 was refusing to go to the toilet and that they needed her to encourage Resident 1 to comply. FM stated Resident 1 had been continent prior to falling and breaking her arm. FM stated she needed Resident 1 to regain her continence before she came home, and also because using incontinence briefs was causing Resident 1 to develop urinary tract infections. Review of Resident 1's face sheet indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses including a fracture of the left humerus (a break in the bone of the upper arm), schizophrenia, and dementia. Review of Resident 1's care plan revealed a focus area [Bowel and Bladder] Incontinence Program [related to] frequently incontinent, dated 3/25/26. Review of the focus area's interventions included prompted toileting program every two hours and at bedtime, dated 5/11/26. Further review of the care plan revealed there was no focus area regarding noncompliance or refusal of care. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 4/3/26, indicated Resident 1 had moderate cognitive impairment, no rejection of care, was able to walk 10 feet using a walker with supervision, and needed substantial assistance with toileting. Review of Resident 1's SLUMS (St. Louis University Mental Status) examination (a test for approximating global cognitive functioning), dated 3/31/26, indicated severe dementia. During an observation and concurrent interview on 6/9/26 at 10:40 a.m., Resident 1 was lying in bed. When queried, Resident 1 stated staff did not help her to the bathroom. Resident 1 stated, I don't get up, so that's a stupid question. During an interview on 6/9/26 at 2:32 p.m., Certified Nursing Assistant A (CNA A) stated that when a resident was on an every-two-hour toileting program, it showed in her tasks for that resident. CNA A stated she charted in the resident's record every time she helped the resident to the toilet. CNA A verified she did not chart once per shift that she took the resident to the toilet every two hours. During a record review and concurrent interview on 6/9/26 at 4:08 p.m., Director of Staff Development (DSD) reviewed the CNA's documentation for Resident 1 of the task titled, Prompted toileting program [every two hours] and at bedtime dated 5/12/26 through 6/9/26. DSD verified the CNAs had documented toileting Resident 1 four times per day between 5/12/26 and 6/4/26 and three documented refusals between 5/12/26 and 6/9/26. DSD stated, We could do better. DSD stated it was his expectation that the CNAs chart every time they took the resident to the toilet so they could document that the order to toilet the resident every two hours was followed. DSD stated that the goal of the toileting program was to regain continence and success would be if the resident was not incontinent in her brief and voided in the toilet. DSD verified that if the resident was non-compliant with the toileting program, the family should be involved to encourage the resident to be compliant. DSD stated the family knew the resident best so we should always try to involve the family. During an interview on 6/10/26 at 9:42 a.m., CNA B stated Resident 1 was on her regular resident assignment. CNA B stated Resident 1 was on an every-two-hour toileting schedule but she refused most of the time. CNA B stated that if Resident 1 refused to get up to the toilet there was nothing she could do except to tell the nurse that Resident 1 refused. CNA B stated Resident 1 was compliant with the toileting schedule all day long on Saturday (6/6/26) and stayed dry all day. During an interview on 6/10/26 at 10:27 a.m., Licensed Nurse C (LN C) stated Resident 1 was on her regular resident assignment. LN C stated they tried their best to get Resident 1 to comply with the toileting program but Resident 1 could be very defensive and often refused to get up to the toilet. LN C verified that if Resident 1 was refusing to comply with the toileting program, a care plan for noncompliance should be developed. LN C stated developing the care plan was the responsibility of us nurses or the DSD, and verified it should be developed with input from Resident 1's family. LN C stated the potential outcome to the resident if she did not comply with toileting every two hours was Resident 1 could develop a urinary tract infection. During an interview on 6/10/26 at 10:44 p.m., Assistant Director of Nursing (ADON) stated one of the reasons it was important to involve family in the development of the resident's care plan was to set the resident up for success after their discharge. During an interview on 6/10/26 at 11:29 a.m., ADON verified it was her expectation that if Resident 1 was regularly refusing to comply with her toileting program, Resident 1 should have a care plan to address the noncompliance so that her caregivers could see what interventions worked and did not work to encourage compliance. ADON also stated that the CNAs should be documenting Resident 1's refusal to go to the toilet when prompted. Review of facility policy and procedure Care Plans, Comprehensive Person-Centered, dated 12/5/25, indicated, The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: . receive the services and/or items included in the plan of care .

Based on interview and record review, the facility Social Services Director (SSD) failed to make a medical appointment for one of five sampled patients (Resident 1) when Resident 1 was admitted to the facility with a physician order for a neurosurgery appointment that was never carried out for eleven weeks. This failure potentially prolonged a spinal condition that caused Resident 1 to have difficulty walking, and may have been surgically corrected had Resident 1 been able to see the neurosurgeon.During a phone interview on 6/8/26 at 2:54 p.m., Family Member (FM) stated Resident 1 had an MRI (magnetic resonance imaging, a noninvasive medical imaging test that produces highly detailed, 3D cross-sectional images of the inside of the body) of her back that showed a narrowing in her spinal cord that is causing Trendelenburg gait (an abnormal walking pattern where the pelvis drops on the unsupported side when lifting one leg to step) and that Resident 1 needed a neurology consult. FM stated she had been asking about the status of this consult since Resident 1 had been admitted but no appointment had been made yet. FM stated she was concerned Resident 1 may not be able to make enough progress in physical therapy to be able to come home if the issue with Resident 1's spinal cord was not addressed. Review of Resident 1's face sheet indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses including a fracture of the left humerus (a break in the bone of the upper arm), spinal stenosis of the lumbar region (a significant narrowing of the spinal canal in the lower back, causing intense compression of the nerves that control your legs), difficulty in walking, falling, and weakness. Review of Resident 1's document Hospitalist Discharge summary, dated [DATE], indicated Resident 1's discharge diagnoses included weakness and severe lumbar stenosis with the comment to follow up with neurosurgery as outpatient. Review of Resident 1's document Skilled/Intermediate Facility Instructions/Orders, dated 3/25/26, indicated, Discharge Instructions: . Please obtain a referral for a neurosurgeon within 2 weeks for lumbar spinal stenosis - [patient] can followup at [hospital system named] with one of our surgeons - [three surgeons named]. Review of Resident 1's facility history and physical note dated 3/25/26 indicated, She also [sic] significant weakness, MRI showed severe lumbar stenosis . outpatient followed [sic] up recommended by neurosurgery. During a record review and concurrent interview on 6/9/26 at 2:57 p.m., when queried, Social Services Director (SSD) stated she had no documentation that a neurosurgery appointment had been made for Resident 1 because they had not yet found a provider to send Resident 1 to. SSD reviewed Resident 1's History and Physical dated 3/25/26 and verified that it indicated Resident 1 had severe lumbar stenosis with a recommendation for follow up with neurosurgery. SSD reviewed Resident 1's document Skilled/Intermediate Facility Instructions/Orders, dated 3/25/26, and stated she had never seen that order before to obtain a referral for a neurosurgeon within two weeks with the names of three potential neurosurgeons for Resident 1 to see. SSD verified the date on the discharge instructions was 3/25/26. SSD stated it was her responsibility to review the discharge orders for patients being admitted to the facility from the hospital and to let the scheduler know about any appointments that need to be made. SSD stated the potential outcome to a resident if she did not get her follow up appointments was her health could deteriorate. SSD also stated that the sooner the appointment was made, the better, because these specialties were impacted and getting seen could take three to four months. SSD stated getting all the paperwork in place to make an appointment with a specialist took about five to seven days to complete. During an interview on 6/10/26 at 10:44 a.m., Assistant Director of Nursing stated that the potential outcome to Resident 1 not having this appointment with neurosurgery could affect whether it is safe for her to go home or not and could delay her discharge plan. During an interview on 6/10/26 at 11:29 a.m., Administrator verified SSD reported directly to her. Administrator stated it was her expectation that SSD began the process for making the follow up appointments for newly admitted residents as soon as possible. Review of facility job description Director of Social Services, last revised 7/2024, indicated under Duties and Responsibilities, Plan, develop, organize, implement, evaluate and direct the social service programs of the facility.

Based on interview and record review, the facility failed to ensure one resident in a census of 123 (Resident 2) received quality nursing care that was resident-centered and in accordance with her goals of care, as indicated in her Nursing Care Plan (a document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes) when she experienced a Change of Condition (sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains; without intervention, the deviation could lead to clinically significant complications up to and including death) at approximately 8 a.m. on [DATE], but her responsible party (RP; individual with decision-making authority regarding the patient's care) was not notified until approximately 11 a.m.This failure caused an approximate 3-hour timespan between identification of Resident 2's medical emergency to notification of her RP, preventing him from consulting family and making timely treatment decisions for her. This in turn delayed Resident 2's transfer to the hospital and treatment of her urinary tract infection (infection in any part of the urinary system) and sepsis (life-threatening medical emergency caused the body's overwhelming response to an infection); she ultimately succumbed to her sepsis and died on [DATE]. Findings:A review of Resident 2's face sheet (front page of the medical record that contains a summary of basic information about the resident) indicated she was eighty-seven years old and admitted to the facility on [DATE] with diagnoses of unspecified dementia (progressive state of decline in mental abilities), hemiplegia (total or nearly complete paralysis on one side of the body), and Hemiparesis (weakness or paralysis on one side of the body, affecting daily activities and mobility) following a cerebral infarction (stroke).Review of Resident 2's nursing care plan, dated [DATE], with target date [DATE], indicated, It is very important for [Resident 2] . to have her son [name] involved in discussions about her care. The care plan goal indicated, [Resident 2] daily preferences will be respected daily over the next review date.Review of Resident 2's nursing care plan, dated [DATE], with target date [DATE], indicated, [Resident 2] has impaired cognitive function/dementia or impaired thought processes r/t [related to] Dementia .A review of Resident 2's physician orders, dated [DATE], indicated that Resident 2 did not have the capacity to make her own health care decision. The order further indicated, . The Surrogate decision maker [responsible party/RP] is: [son's name] .A review of Resident 2's POLST (Physician Orders for Life-sustaining Treatment; a medical order that specifies a seriously ill patient's treatment preferences in emergencies) indicated, Do not attempt Resuscitation/DNR. (DNR is a medical order that instructs healthcare providers not to perform cardiopulmonary resuscitation - CPR: chest compressions, rescue breathing, and defibrillation to restart the heart] if a person's heart stops beating or they stop breathing). The POLST indicated potential medical interventions were, Comfort-focused treatment, with a goal of maximizing comfort. The POLST was signed by Resident 2's RP on [DATE].Review of Resident 2's medical record revealed a document titled, Change of Condition Assessment, dated [DATE] at 11 a.m., that indicated, 1. Triggering Event/Change. a. Mental Status Change. b.Family Reported Concern. 2. Describe. Unstable vital signs [clinical measurements of heart rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions] . The document indicated Resident 2's vital signs on [DATE] at 11 a.m. were: . Blood pressure [BP]: 77/43 [normal BP is 120/80] . Pulse (heartrate): 109. Irregular [arrhythmia; heartrate is too fast, too slow or has an unsteady, erratic rhythm] . O2 [oxygen] sats [saturation] 81% [oxygen saturation levels - percent of oxygen in a person's blood; normal range is approximately 95% - 100%] on Room Air [oxygen level without supplemental administration of oxygen; breathing regular air] . The document indicated Resident 2's mental status at the time was, .d. Unresponsive [unconscious and does not react to external stimuli like voice, touch, or pain] . The document indicated, 10. Describe Change of Condition in Detail: Resident has unstable vital signs, out of regular limits. is sweating profusely and is lethargic [profound tiredness, sluggishness, and reduced alertness, often characterized by severe fatigue and diminished mental capacity] and unresponsive to verbal commands.Review of Resident 2's medical record revealed Licensed Nurse A (LN A) documented a nurse progress note (documentation of a resident's clinical status, response to treatment, and care updates), dated [DATE] at 11 a.m., that indicated, This morning around 0800 [8 a.m.] CNA [certified nurse assistant] reported to this nurse that resident [Resident 2] had a low blood pressure [BP]. This nurse checked vital signs, all were stable [within normal limits] except for BP(72/40). Resident was repositioned and encouraged to drink fluids and eat breakfast. After breakfast vital signs were reassessed. BP continued to be low and oxygen was now low as well. Vital signs: BP 77/43, HR [heartrate] 103. o2 [oxygen]: 81% . MD was notified for an order for supplemental oxygen. Resident was placed on 2L [oxygen rate of 2 liters per minute] of oxygen via nasal cannula [flexible tube with two prongs that fit into the nostrils]. Son. arrived for a visit. This nurse and son discussed residents' vital signs, and son made phone call to other family members. It was decided to send [Resident 2] to [local hospital name] . Paramedics arrived around 1100 (a.m.) and transferred resident.Review of Resident 2's ambulance trip sheet (formal record of a patient's encounter during an ambulance transport), dated [DATE], indicated an EMT (Emergency Medical Technician) and paramedic arrived on-scene and made contact with Resident 2 at 11:16 a.m. The document indicated Resident 2 was unable to answer questions, her skin was warm and diaphoretic (sweaty), her temperature was 103.1 F (Fahrenheit; normal is 98.6 F) and her oxygen saturation was 90% on 2 Liters of oxygen; at 11:18 a.m., her blood pressure was 94/29 and her heartrate was 159 (normal is 80 - 100). The EMT and paramedic documented Resident 2's RP and family stated Resident 2 was never supposed to be comfort care (as indicated on the POLST); the trip sheet indicated they requested she remain DNR with full treatment; they wanted all possible treatment for Resident 2 except CPR.Review of Resident 16's hospital History and Physical Examination (comprehensive clinical evaluation of a patient's health history and physical examination), dated [DATE], indicated she arrived in the Emergency Department (ED), she had a low BP, temperature of 105 F and normal oxygen level while receiving supplemental oxygen. The physician's assessment indicated Resident 2 presented (came to the ED) with altered mental status (change in awareness, cognition, or behavior ) and septic shock (a life-threatening condition characterized by dangerously low blood pressure and organ dysfunction due to a severe infection) due to a urinary tract infection; she was admitted to the Intensive Care Unit (unit in hospitals that provides round-the-clock monitoring and treatment for people with serious illnesses).Review of Resident 16's hospital Discharge Death Summary (documentation in a patient's medical record when a patient dies during or after a hospital stay), signed on [DATE], indicated Resident 2 died on [DATE] at 9:07 p.m. Her Cause of Death was identified as septic shock. due to urinary tract infection .During a confidential telephone interview on [DATE] at 3:10 p.m., Confidential Family Members B (CFM B) stated they visited Resident 2 regularly and she had been fine during a visit the week prior to [DATE]. CFM B stated they arrived for a visit on [DATE] around 11:30 a.m. but Resident 2 was not responsive and they could not wake her up. CFM B stated they spoke to the nurse (LN A) and she told them Resident 2's vital signs were low and her oxygen level was 81%. CFM B stated they then called a family member; they decided to call 911 (medical emergency service) and transfer Resident 2 to the hospital. CFM B stated paramedics (emergency responders) arrived and took Resident 2 to the hospital, where she later died.During the same confidential interview on [DATE] at 3:10 p.m., CFM B stated the facility had not notified them that Resident 2's vital signs were not okay and her oxygen was low. They stated, how did she get that bad without a call? CFM B stated they were Resident 2's decision maker (responsible party) and she was not on Hospice (comfort-focused end of life care). CFM B stated they were not sure exactly what her POLST indicated, but they wanted her to be No CPR (no chest compressions), to receive treatment if necessary, and to be comfortable. CFM B stated Resident 2 had had a UTI (urinary tract infection) in the past while at the facility and had received treatment (and recovered). During a concurrent interview and medical record review on [DATE] at 1:50 p.m., LN A reviewed Resident 2's medical record. LN A stated before breakfast on [DATE], a CNA reported to her that Resident 2 had, low vital signs. LN A stated she double-checked the vital signs and her BP was low. She stated she encouraged fluids (encourage consumption of beverages) and instructed the CNA to try and feed her breakfast. LN A stated after breakfast at approximately 8:30 a.m., Resident 2 was still not well; her blood pressure was low, her heartrate was elevated and her oxygen saturation was decreased to 81%. She stated she checked Resident 2's POLST, called the physician, and gave Resident 2 supplemental oxygen (oxygen delivered via plastic tubing placed at the base of the nostrils) per the physician's orders. She stated Resident 2's family member (the RP) arrived after the supplemental oxygen was started. LN A stated she discussed the POLST with the RP after he arrived and the RP called another family member; after the call, the RP told her to send Resident to the hospital. She stated she called 911 at 11 a.m. LN A stated she had not called the RP prior to his arrival; she stated she told him about Resident 2's deteriorating condition after he arrived at the facility, not earlier in the morning when it was identified.During a follow-up confidential telephone interview on [DATE] at 2:22 p.m., CFM B stated they were not sure how long Resident 2's BP and oxygen were low the morning of [DATE]. CFM B stated he was not aware her blood pressure and oxygen levels were low at approximately 8 a.m. CFM B stated had they known about Resident 2's condition earlier, they, would have come in right away. CFM B stated staff should have called him; they stated staff sometimes called another family member with updated/information about Resident 2, but that family member had not been called, either. During a concurrent interview and record review on [DATE] at 3:40 p.m., the Director of Nursing (DON) reviewed Resident 2's electronic medical record. The DON confirmed Resident 2's blood pressure had been low at 77/43 and her oxygen was low at 81%. When asked if staff should have notified the RP as soon as possible when her unstable vital signs were identified at approximately 8 a.m., the DON stated, yes. The DON stated it was her expectation that family be notified when a Resident experienced a Change of Condition.Review of facility policy titled, Resident Rights, subtitled Procedure/Guidelines, dated [DATE], indicated, II. Resident Rights. c. Participation in care: i. Be fully informed about their health status and treatment options. ii. Participate in . treatment choices.Review of facility policy titled, Resident Participation - Assessment/Care Plans, subtitled, Policy interpretation and Implementation, revised 11/2025, indicated, 3. The resident's/representative's right to participate in the . implementation of the plan of care includes the right to: . f. participate in the type. of care. h. be informed. of changes to the plan of care. i. request changes to. care of treatment offered or proposed.Review of facility policy titled, Acute Condition Changes - Clinical Protocol, subtitled, Assessment and Recognition, revised 3/2018, indicated, 1. The physician will help identify individuals with a significant risk for having acute changes of condition. for example, and individual with. unstable vital signs (blood pressure, heartrate) . Under subtitle, Treatment/Management, the policy indicated, 2. The physician and staff will identify relevant resident/patient wishes.

F600 The facility failed to ensure residents were free from physical abuse, including resident to resident abuse, when it did not implement effective preventative resident abuse nursing care planned interventions to prevent three resident to resident altercations for three of five sampled residents (Residents 2, 3, and 5). As a result, Resident 2 sustained head trauma to the right side and back of his head, with pain, swelling and redness; Resident 3 sustained abrasion with bleeding to his right ear, and Resident 5 sustained skin injury resulting in redness on his jaw. These failures resulted in abuse, pain, physical injuries and increased risk of psychosocial harm.A review of Resident 1's admission Record indicated he was admitted to the facility in 2017 and readmitted on [DATE] with severe mental illness disorder (a psychiatric condition characterized by significant disturbances in thinking, mood, behavior, or perception that profoundly affect a person's ability to function in daily life).A review of Resident 2's admission Record indicated he was admitted to the facility on [DATE] with a primary diagnosis of severe mental illness.A review of Resident 3's admission Record indicated he was admitted on [DATE] with a primary diagnosis of severe mental illness.During an interview with Licensed Nurse 1 (LN1) on 4/15/26 at 10:50 a.m., she stated that during the 5 p.m. medication pass on 3/20/26, Resident 1 suddenly began punching Resident 2's head and face with a closed fist. LN1 stated she was not surprised due to Resident 1's known history of aggression toward peers prior to his current admission.A review of Resident 2's nursing care plan on the focus area for skin integrity, dated 3/20/26, documented that he sustained slight swelling and redness to the back right side of his head after being hit by another resident. The goal stated the redness and swelling would decrease.During an interview with Resident 2 on 4/16/26 at 2:09 p.m., he recalled the incident and pointed to the area where he was struck, and relayed he felt pain on his head, at the time of the incident. When asked if he felt safe, he stated he wanted to be discharged .During an interview with unlicensed staff member 1 (US1) on 4/16/26 at 2:45 p.m., US1 stated that on 3/22/26 at approximately 2:45 p.m., he heard commotion on the patio and found Resident 1 kicking Resident 3 while Resident 3 was on the ground. Other staff who witnessed the entire event reported to him and the charge nurse that Resident 1 attacked Resident 3 without provocation, initially striking him on the head and then kicking him in the torso until staff intervened.A progress note dated 3/22/26 at 4:44 p.m. by Licensed Staff 2 (LS2) documented a head to toe assessment of Resident 3 after the assault on the patio. LS2 documented an abrasion with bleeding on the right ear, which was cleaned with normal saline. LS2 reported the injury to the physician and wound care nurse.A review of Resident 4's admission Record indicated an original admission in 2017 and a readmission on [DATE] for severe mental illness.A review of Resident 5's admission Record indicated he was admitted on [DATE] with a diagnosis of severe mental illness.A review of Resident 4's nursing care plan documented that on 3/26/26, Resident 4 struck Resident 5 on the chin and that Resident 4 had a known history of physical aggression.A review of Resident 4's, change in condition, assessment by Licensed Nurse (LN2) indicated that on 3/26/26 at 6 a.m., Resident 4 hit Resident 5 after becoming upset about not being able to shower first.A review of a report of alleged abuse document SOC-341 (a California form used by mandated reporters and others to officially document and report suspected abuse, neglect, or exploitation of elders and dependent adults to the appropriate authorities) dated 3/26/26, provided to the California Department of Public Health by the Administrator (ADM), indicated LN3 witnessed the 3/26/26 incident in which Resident 4 struck Resident 5 on the chin.A review of Resident 5's Medication Administration Record indicated he was administered pain medication, acetaminophen (an over-the-counter medication used to treat pain) at 6:44 a.m. on 3/26/26.A review of a 5-day-follow-up document dated 4/1/26 provided to the California Department of Public Health by the Administrator stated Resident 5 expressed frustration after being assaulted by Resident 4 and both residents were placed on monitoring every 15 minutes for safety checks.A review of Resident 5's nursing care plan for abuse and skin injury he sustained during the incident occurring on 3/26/26, indicated Resident 5 experienced abuse when struck on the chin, placing him at risk for emotional distress and psychosocial decline. A care plan focus area dated 3/26/26 was added, with a listed goal for the redness of the chin injury to heal by the review date.During an interview and concurrent record review of Resident 4's nursing care plan, with the Assistant Director of Nursing (ADON) on 4/16/26 at 3:02 p.m., the ADON acknowledged Resident 4's nursing care planned goal, created on 4/14/26, pertaining to the 3/26/26 focus area for the resident to resident altercation, in which Resident 4 exhibited abusive behavior towards Resident 5 indicated, The resident will not have emotional distress related to the allegation minimized and the entry was created late, 19 days after the abusive incident occurred back on 3/26/26. The ADON stated nursing care plans must be updated with appropriate resident specific interventions during changes in condition timely, to protect all residents' safety. The ADON acknowledged that delayed or backdated documentation can place residents at risk for harm because staff may be unaware of current needs or events.During an interview with the Director of Nursing (DON) on 4/16/26 at 4 p.m., the DON stated the purpose of the nursing care plan is to provide individualized care and acknowledged the risk of harm to the resident for failure to implement effective interventions specific to the resident's individualized care plan.During an interview on 4/16/26, at 4:40 p.m., the Administrator (ADM), who served as the abuse coordinator, acknowledged residents' right to be free from abuse and neglect, and that all documentation concerning incidents of alleged abuse are required to be made timely, including in the medical record of the residents involved.A review of the facility policy titled, Abuse Reporting and Prevention, dated 2018, indicated, Assessment and Recognition. 4. The physician and staff will help identify risk factors for abuse within the facility; for example, significant numbers of residents/patients with unmanaged problematic behaviors. that might affect resident care. Cause Identification 1. The staff, with the physicians input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes. Treatment/Management 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect.A review of the facility policy titled, Resident Rights, dated 2025, indicated, II. Resident Rights. a. Dignity, Respect and Freedom. iii. Be free from abuse, neglect.

Based on observation, interviews and record reviews, the facility failed to fully implement one out of four sampled residents (Resident 3) fall care plan (CP, a detailed, written document that outlines a resident's individual needs, goals, and how their care will be managed) when Resident 3's bed was not in the lowest position as indicated on his fall CP.This failure put Resident 3 at increased risk for falls and fall related injuries.Findings:A review of Resident 3's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date to the facility on 3/4/26 with diagnoses of difficulty walking and muscle weakness.A review of Resident 3's Fall CP, dated 3/31/26, indicated Resident 3 had an unwitnessed fall and one of the interventions indicated his bed was to be put in the lowest position.During a concurrent observation and interview on 4/2/26 at 3:38 p.m., sitter D and Licensed Nurse (LN) E were present in Resident 3's room. LN E confirmed Resident 3's bed was expected to be in the lowest position. Sitter D confirmed Resident 3's bed was not in the lowest position.During an interview on 4/2/26 at 3:40 p.m., sitter D stated it was important Resident 3's bed was put in the lowest position to ensure Resident 3 did not hurt himself in case he fell. Sitter D acknowledged she forgot to put Resident 3's bed in the lowest position earlier.During an interview on 4/2/26 at 3:42 p.m., LN E stated Resident 3's fall CP indicated his bed should be placed in lowest position because he was at high risk for falls. LN E stated Resident 3 already had multiple falls and added, placing the bed in lowest position decreased the risk of Resident 3 sustaining an injury when he falls. LN E stated staff should follow care plan interventions and explained not following a care plan intervention put the resident at risk for injuries.During a concurrent interview and record review with the Director of Nursing (DON) on 4/2/26 at 4:08 p.m., Resident 3's Fall CP, dated 3/31/26, was reviewed. The DON verified Resident 3's Fall CP indicated Resident 3 had an unwitnessed fall and one of the interventions indicated bed in lowest position. The DON stated fall CP interventions were put in place for a reason and must be followed. The DON stated she expected Resident 3's bed to be in the lowest position, unless staff were performing care with him. The DON confirmed Resident 3 was a high fall risk, had poor safety awareness, and placing the bed in its lowest position decreases Resident 3's risk for injury in case he falls.A review of the facility's policy and procedure (P&P) titled Falls and Fall Risk, Managing, revised 3/2018, the P&P indicated .in conjunction with the attending physician, staff will identify and implement relevant interventions (.as applicable) to try to minimize serious consequences of falling.

Based on observations, interviews and record reviews, the facility failed to ensure their call light system (communication devices/system that allows residents to instantly alert nursing staff, aiding in safety, fall prevention, and resident-centered care) allowed residents to be able to directly communicate with staff when they needed assistance for two out of three sampled residents (Residents 1 and 2) when:1. Resident 1's call light volume was too low to be heard, and2. the light outside Resident 2's room, by their door, failed to illuminate upon call light use.These failures put the residents at risk for delayed provision of care and unmet needs.Findings:A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date to the facility in 9/2025 with diagnoses of Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and Malaise (general, vague feeling of being unwell, uncomfortable, or lacking energy).A review of Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 3/12/26, indicated Resident 1's score was 15 representing no memory issues. A review of Resident 2's face sheet indicated an admission date to the facility in 11/2025 with diagnoses of difficulty walking and muscle weakness.A review of Resident 2's BIMS, dated 3/3/26, indicated Resident 2's score was 12, representing having moderate cognitive impairment (may need extra assistance with daily activities).During a concurrent observation and interview on 4/2/26 at 9:57 a.m., in Resident 1's room, Resident 1 pressed her pendant type of call ight button to alert staff she was requesting assistance. After waiting for about 21 minutes, Resident 1 stated see, I told you no one will come.During an observation on 4/2/26 at 10:05 a.m., outside Resident 1's room in hallway 1, there was no alert noise that could be heard in the hallway indicating Resident 1 had pressed her call light. However, there was a faint audible beep that could be heard at Nursing station 1 that indicated Resident 1 had pressed the call light. Licensed Nurse A (LN A) was seen in hallway 1 but did not respond to Resident 1's call light alert.During an interview on 4/2/26 10:18 a.m., the Director of Staff Development (DSD) verified when Resident 1 pressed the call light, the beep was faint and if there were no staff near or at nursing station 1, staff would not be alerted Resident 1 pressed her call light. The DSD stated it was important that the facility had an effective call light system to ensure resident needs were met.During a concurrent observation and interview on 4/2/26 10:21 a.m., outside Resident 2's room in hallway 1, Resident 2 had pressed her call light but the light above Resident 2's door, that is supposed to illuminate when the call light is pressed, was not illuminated. Resident 2 stated staff did not answer her call light last night nor this morning. Resident 2 stated she waited and waited but no staff came. During an interview on 4/2/26 at 10:35 a.m., the DSD verified when Resident 2 pressed her call light, the light above Resident 2's door, that is supposed to illuminate when the call light is pressed, was not illuminated which indicated Resident 2's call light was not working. The DSD stated it was important that call light was effective and in good working conditions to allow residents to request assistance if they needed it and to prevent accidents and injuries.During a concurrent observation and interview on 4/2/26 at 10:34 a.m., the Maintenance Director (MD) verified Resident 1's call light had a faint beep that could only be heard at nursing station 1 and was a risk for Resident 1's safety as staff would not be able to hear Resident 1's call for assistance once they were away at nursing station 1. MD also verified Resident 2's call light was broken. MD stated it was important that call lights were effective and in good working conditions for residents' safety.During an interview on 4/2/26 at 10:49 a.m., LN A confirmed Resident 1's call light when pressed emitted a faint beep at nursing station 1. LN A stated not hearing Resident 1's call light earlier when in hallway 1 and Resident 1's call light was alerting faintly at nursing station 1. LN A stated there was a big chance no one would come to answer Resident 1's call for assistance because staff could not hear it. LN A stated staff have been aware that Resident 1's call light was not audible if away from nursing station 1. LN A verified she did not report this issue to the supervisor or MD. LN A stated it was important to have an effective and working call light because residents used it to call staff when they needed assistance. LN A stated if call lights were ineffective or were broken, then there would be no way for residents to call for assistance which was a safety risk.During an interview on 4/2/26 at 4:08 p.m., the Director of Nursing (DON) stated call light must be effective and in good working condition as call lights allow residents to notify staff of their immediate needs, which is very important for emergency situations.A review of the facility's policy and procedure (P&P) titled Call lights: Accessibility and Timely Response, undated, the P&P indicated .the purpose of this policy is to assure the facility is adequately equipped with a call light to allow residents to call for assistance.staff will report problems with a call light or call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions.

Based on interview and record review, the facility failed to provide the State Survey Agency (California Department of Public Health [CDPH]) written investigation reports (an investigation conducted by the facility following the allegations of abuse) of two facility reported abuse allegations within five calendar days, for four of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4).This failure decreased the facility's potential to ensure relevant interventions were in place and implemented to prevent further abuse and psychosocial (a combined influence of psychological [the mental and emotional state of a person] factors and the surrounding social environment on physical, emotional, and/or mental wellness) harm for Resident 1, Resident 2, Resident 3, and Resident 4.A review of a facility document dated 12/18/25, and received by CPDH on 12/18/25, indicated an allegation of suspected dependent adult/elder abuse had been made related to a resident-to-resident altercation between Resident 1 and suspected abuser [left blank .Resident 2]. A review of a facility document dated 12/23/25, and received by CPDH on 12/23/25, indicated an allegation of suspected dependent adult/elder abuse had been made related to a resident-to-resident altercation between Resident 3 and Resident 4.During an interview on 1/05/26 at 1:20 p.m., the Administrator (ADM) stated her first day as ADM at the facility was 1/01/2026. The ADM stated she could not locate the facility files [which generally include the facility's five-day investigation report] for either abuse allegation.During an interview on 1/05/26 at 2:05 p.m., the ADM confirmed she could not locate the facility's five-day investigation reports or provide evidence that they were sent to CDPH.During an interview on 1/05/26 at 4:20 p.m., the ADM stated it was their policy to submit the five-day investigation reports to CPDH within five days of the reported abuse allegations.During an interview on 1/07/26 at 12:12 p.m., with the Director of Nursing (DON), she stated she did not know if the facility's investigation reports for both abuse allegations were completed. The DON stated the purpose of the facility's investigation reports was to ensure the facility investigated what happened and what interventions were implemented to provide resident safety. The DON further stated it was a regulatory requirement to provide the five-day investigation report to CDPH.A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised 11/2023, indicated, All allegations are thoroughly investigated.The administrator initiates investigations.Within five business days of the incident, the administrator will provide a follow-up investigation report.

Based on observation, interview, and record review, the facility failed to ensure resident care met professional standards of practice for two of six sampled residents (Resident 1 and Resident 2) when:1: A skin assessment was not completed following the report of bruising/discoloration sustained to Resident 1's right arm after an abuse allegation, and;2: The facility did not conduct 72-hour monitoring every shift (morning [AM], evening [PM] and night shift [NOC]) following Resident 2's change of condition (COC).These failures resulted in inaccurate documentation and monitoring of Resident 1's injuries and decreased the facility's potential to ensure that consistent monitoring and safety measures were provided to Resident 2.1: A review of Resident 1's admission record indicated she was admitted to the facility in July 2025 with medical diagnosis which included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the left side, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 10/25, indicated her Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 13, which indicated her cognition was intact (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact).A review of Resident 1's order summary report dated as of 11/01/25 indicated no orders for blood thinning medications (medications that are known to increase the risk of bruising and bleeding).A review of Resident 1's Situation, Background, Assessment and Recommendation (SBAR, a communication technique used in healthcare to facilitate clear and concise information) - COC progress note dated 12/18/25 at 7:46 a.m., indicated, [Resident 1] Reported alleged physical abuse with skin discoloration on RFA (right forearm).Skin discoloration on RFA was present. No swelling and denies pain.A review of Resident 1's progress notes, type Skin/Wound Note, dated 12/21/25 at 4:38 p.m., indicated, Continue to monitor for discoloration or bruises on right forearm. The skin is intact.During an observation and concurrent interview on 1/05/26 at 2:09 p.m., Resident 1 stated she had bruises on her right arm. Resident 1 further stated a man came into her room and grabbed her right arm. Resident 1 removed one of her shirts to expose both arms. Resident 1 had a bruise on the lateral (situated at or on the side) aspect of her right upper arm below the deltoid (a large muscle forming the contour of the shoulder). The bruise was oblong with purple discoloration lining the outskirts and yellow discoloration inside. The bruise measured approximately 2.5 inches (in.- a unit of measurement) in length and 2 in. wide. Resident 1 had another bruise on the lateral aspect of her right lower arm below the elbow. The bruise was purple and measured approximately 2 in. by 2 in. No other bruises or discoloration was observed on Resident 1's right arm.During an interview and concurrent record review on 1/07/26 at 12:12 p.m. with the Director of Nursing (DON), she confirmed Resident 1's SBAR report indicated skin discoloration to RFA. The DON stated she expected a more detailed skin-wound assessment given the findings following an allegation of abuse. The DON further stated Resident 1 is missing a skin integrity assessment and excepted it to be completed at the time of the SBAR. The DON stated the skin integrity assessment is an extra tool used to describe the wound in detail based on discoloration, size, location, and so forth. The DON verified a skin/wound note for Resident 1 was completed on 12/21/25, and she expected it to be completed on 12/18/25, when the bruising was first reported.A review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, revision dated 2/2021, indicated, .the nurse will make detailed observations and gather relevant and pertinent information.A review of the facility's document, Charge Nurse- Job Descriptions, dated 2003, indicated, [The licensed nurse is to] Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures.2: A review of Resident 2's admission record indicated he was admitted to the facility in December 2016 with medical diagnosis which included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), vascular dementia with behavioral disturbances (when damaged blood vessels reduce blood flow and oxygen to the brain, impairing thinking, memory, and function) and major depressive disorder. A review of Resident 2's MDS dated 11/25, indicated his BIMS score was 13, which indicated his cognition was intact.A review of Resident 2's SBAR - COC progress note dated 12/17/25 at 6:19 p.m., indicated, Resident [Resident 2] observed with increased agitation, physically aggressive behaviors, wandering around other station and walked to other resident's room.Placed on 72-hr (hour) monitoring.A review of Resident 2's care plan dated 12/18/25, indicated, The resident [Resident 2] is exhibiting adverse behavior resulting in: impaired physical well-being, impaired safety, aggressive behavior toward staff and other resident.72-hr monitoring initiated.A review of Resident 2's progress notes showed no evidence that 72-hr monitoring was completed by nursing staff every shift on 12/18/25. There also was no evidence that 72-hr monitoring was completed AM, PM, and NOC shift on 12/19/25, and NOC shift on 12/20/25.During an interview on 1/05/26 at 2:54 p.m. with Licensed Nurse 1 (LN 1), she stated 72-hr monitoring is expected to be completed every shift on both residents for safety purposes following abuse allegations. During an interview and concurrent record review on 1/07/26 at 12:12 p.m., the DON stated her expectation for 72-hr monitoring is that it was completed every shift by licensed nursing staff. The DON further stated she expected nine nurse progress notes total through the 72-hr monitoring period. The DON verified 72-hr monitoring notes were completed on 12/20/25 at 9:05 a.m. and 9:07 p.m. only. The DON confirmed monitoring was only completed two out of the nine expected times. The DON stated, It [72-hr monitoring] should have been more consistent. The DON further stated the importance of 72-hr monitoring is to ensure Resident 2 and other residents were safe. A review of the facility's P&P titled, Charting and Documentation, revision dated 7/2017, indicated, All services provided to the resident.shall be documented in the resident's medical record.A review of the facility's document, Charge Nurse- Job Descriptions, dated 2003, indicated, Ensure that personnel providing direct care to residents are providing such care in accordance with the resident's care plan. Ensure that nurses' notes reflect that the care plan is being followed.

Based on interviews and record review, the facility failed to protect the residents' right to be free of physical abuse by another resident for two of eight sampled residents (Resident 2 and Resident 3) when:1. Resident 2 was struck several times in the back of his head by Resident 1; and2. Resident 3 was struck in the head by Resident 4.These failures resulted in Resident 3 having mild facial pain and fear and had the potential to result in serious bodily harm to the residents.Findings:1. A review of Resident 1's admission record indicated he was last admitted to the facility in 3/2025 with the diagnosis of schizophrenia (a mental illness that makes it hard to tell what's real, as people with this illness may hear voices, see things that aren't there, or have unusual beliefs. It also affects thinking and emotions).A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/19/25, indicated Resident 1 had no memory impairment.A review of Resident 1's progress note, dated 12/12/25 indicated, Resident 1 stated Resident 2 was making weird noises and he hit Resident 2.A review of Resident 2's admission record indicated he was last admitted to the facility in 8/2023 with the diagnosis of schizophrenia.A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had no memory impairment.A review of Resident 2's progress note, dated 12/12/25, indicated Resident 2 reported he was sitting on his bed when Resident 1 approached and began hitting him on the back of the head. Resident 2 denied pain on back of head or neck and no visible marks or bruising noted on head or neck.During an interview on 12/22/25 at 1:44 p.m. with the Case Manager (CM) 1, the CM 1 stated she had spoken with Resident 1 and Resident 1 admitted to hitting Resident 2 on the back of the head.During an interview on 12/22/25 at 3:10 p.m. with the Program Director (PD), the PD acknowledged Resident 2 was hit by Resident 1 on the back of the head and agreed what occurred on 12/12/25 to Resident 2 was physical abuse. Furthermore, the PD stated it was the facility's responsibility to protect the residents from such abuse.2. A review of Resident 3's admission record indicated she was last admitted to the facility in 10/2025 with the diagnosis of schizophrenia.A review of Resident 3's MDS, dated [DATE], indicated Resident 3 had no memory impairment.A review of Resident 3's progress note, dated 12/13/25 and written by the PD, indicated Resident 3 reported she had been lying in bed when Resident 4 approached her and hit her in the head with her hand several times. The note further indicated Resident 3 had complained of mild pain to the right temple area.A review of Resident 4's admission record indicated she was last admitted to the facility in 12/2025 with the diagnosis of schizoaffective disorder (a mental illness blending symptoms of schizophrenia with those of a mood disorder).A review of Resident 4's progress note, dated 12/13/25 and written by the PD, indicated Resident 4 had hit Resident 3 several times in the head, unprovoked.During an interview on 12/22/25 at 12:53 p.m. with Resident 3, Resident 3 stated Resident 4 had hit her on the right side of her face. Resident 3 stated that it hurt and she had been fearful of Resident 4. During an interview on 12/22/25 at 3:10 p.m. with the PD, the PD acknowledged Resident 3 had been hit by Resident 4 and agreed this was physical abuse. The PD confirmed it was the facility's responsibility to protect the residents from such abuse.A review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/21, the P&P stipulated, Residents have the right to be free from abuse.This includes but is not limited to physical abuse.

Based on interview and record review, the facility failed to protect one of five sampled resident's ( Resident 1) right to be free from psychological abuse by a Certified Nursing Assistant ( CNA 1) and Unlicensed Staff 1, when Resident 1 was forced to unclog her room's toilet , which contained urine and feces, with her own gloved hands while the door to room was purposely left open.This failure made Resident 1 feel embarrassed, humiliated and victimized and negatively impacted her psychological well-being.A review of Resident 1's admission record indicated she was admitted in 05/25, with the diagnosis of Paranoid Schizophrenia (a serious mental health condition where a person has a hard time telling the difference between what is real and what is not).A review of Resident 1's Minimum Data Set (MDS- a Federally Mandated assessment tool), dated 11/28/25, indicated Resident 1 had no memory impairment, no symptoms of depression, no hallucinations and no behavioral symptoms.A review of an SBAR (SBAR-Situation, Background, Assessment, Recommendation) note, dated 11/19 at 4:16 pm, indicated Resident 1 reported to the Case Manager and Program Director feelings of emotional distress after an interaction with staff. It further indicated Resident 1 had no prior incidents and reported feeling embarrassed and humiliated by the interaction.During an interview on 12/10/25 at 11:45 am, with Resident 1, Resident 1 recalled the incident in detail. Resident 1 stated that CNA A came to the dining room and asked Resident 1 to come with CNA A to her room where Unlicensed Staff C was waiting with a bag. CNA A proceeded to instruct Resident 1 to remove the contents of the toilet, which contained urine and feces, with gloved hands because it was not fair to Unlicensed Staff C. Resident 1 stated she was shocked and did not know what to do, so she complied. Resident 1 asked CNA A to please close the door and CNA A refused. Resident 1 stated, I felt extremely embarrassed, humiliated and victimized. I felt [CNA 1] was intentionally trying to humiliate and control me.During an interview on 12/10/25 at 3:36 pm, with the Director of the Behavioral Health Program (DBH), the DBH stated she was shocked by the accusation and CNA A's behavior was inappropriate and wrong and would not be tolerated, and CNA A and Unlicensed Staff B were both terminated due to the incident. The DBH stated the incident would make the resident feel fearful, concerned about retaliation, and humiliated.A review of the facility's 5-day summary report, dated 11/25/25, indicated CNA A admitted to her actions and stated she was trying to teach Resident 1 a lesson. The report further indicated Unlicensed Staff C confirmed the incident to be true. A review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/2021, stipulated, residents have the right to be free from abuse, including verbal abuse and mental abuse and the facility has a commitment to prevent resident abuse by anyone.

Based on interview and record review, the facility failed to ensure an abuse allegation was properly investigated when the facility did not interview other residents as part of its investigation.This failure prevented the facility from identifying other residents who could have been affected. Findings:A review of the facility document titled, 5- day summary report, dated 11/25/25, indicated Resident 1 was the only resident interviewed related to the abuse allegation.During an interview on 12/10/25 at 3:36 p.m., with the Director of Behavioral Health (DBH), the DBH stated she had not interviewed other residents during the investigation, and everything that had been done during the investigation was documented on the 5-day summary report.During an interview on 12/11/25 at 3:30 p.m., with the Administrator (ADM), the ADM stated they had not interviewed other residents during the investigation. The ADM further stated, interviewing other residents was part of the policy and in principle, they should have to make sure no other residents were affected. A review of the facility policy titled, Abuse Investigation, dated 2/08, indicated the individual conducting the investigation, would, as a minimum, interview the resident's roommate and other residents to whom the accused employee provides care or services.

Based on observation, interview, and record review, the facility failed to accommodate five residents' (Resident 119, Resident 14, Resident 43, Resident 44, and Resident 129) food allergies, intolerances, and preferences for a census of 142, when:1.Resident 119 had lactose allergy and was served mashed potatoes with sour cream; and2.Resident 14, Resident 43, Resident 44, and Resident 129's food preferences were not served as indicated on their meal tray tickets.These failures increased the residents' potential to sustain an allergic reaction and unmet nutritional needs.Findings:1. A review of an admission record indicated Resident 119 was admitted to the facility in July 2022 with a diagnosis of lactose allergy.A review of Resident 119's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/4/25, indicated Resident 119 was cognitively intact.During an observation on 9/24/25 at 10:30 a.m., Prep [NAME] 1 (PC1) was preparing mashed potatoes per the facility's recipe which included sour cream.A review of the facility's recipe for mashed potatoes, dated 2025, indicated the recipe was not intended for residents with lactose allergy.During a concurrent observation and interview on 9/24/25 at 12:53 p.m. with the Dietary Services Supervisor (DSS), lunch tray line was observed. Resident 119 was served mashed potatoes. Resident 119's tray ticket indicated lactose allergy. DSS confirmed Resident 119 was plated mashed potatoes with sour cream and stated the followed recipe was not recommended to residents with lactose allergy. DSS further stated the mashed potatoes with sour cream should have not been plated and served to Resident 119.During an interview on 9/25/25 at 8:34 a.m. with Resident 119, Resident 119 stated if she ate foods containing lactose, her lips will double in size, she will get blisters in her mouth, and her throat will close up.During an interview on 9/25/25 at 9:48 a.m. with the Director of Nursing (DON), DON stated it would have been a problem if Resident 119 ate the food she was allergic to which might significantly affect her health.2. During an observation of the lunch tray line on 9/24/25 at 12:06 p.m., four residents were not served their requested food items:- Resident 14's tray had no fruit and meal ticket indicated she requested fruit with her meal;-Resident 43's tray had no soup and meal ticket indicated she requested soup with her meal;-Resident 44's tray had one portion of protein and meal ticket indicated he requested double portions of protein with his meal; and-Resident 129's tray had no fruit and meal ticket indicated she requested fruit with every meal.During an interview on 9/24/25 at 2 p.m. with the DSS, DSS confirmed there were discrepancies in the four residents' plated foods and expected the cooks to follow the tray tickets' written requests during tray line. DSS stated meal ticket requests were not followed. DSS further stated it was important to serve residents the food they liked to eat because good nutrition might improve their overall quality of life.During an interview on 9/25/25 at 9:48 a.m. with DON, DON stated it could potentially be a problem if residents were not served food they like. DON further stated residents could potentially not eat the food served to them which could negatively affect their health and nutrition. A review of the facility's policy and procedure titled, Allergies and Intolerances, revised 8/17, indicated, Residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen(s).

Based on observation, interview, and record review, the facility failed to implement their medication storage policy and procedure (P&P) for a census of 142 residents, when multiple medications were not labeled and stored in a safe manner.This failure decreased the facility's potential to prevent unsafe medication administration to residents.Findings:During a concurrent observation and interview on [DATE] at 10 a.m. with Licensed Nurse 1 (LN 1), medication cart 2A was observed. The following findings were identified and confirmed by LN 1:1. Budesonide inhaler (an inhaled respiratory medication) was found open with no open date;2. Fluticasone/salmeterol Diskus (an inhaled respiratory medication) and a decongestant nasal spray were found with resident information on outer packaging only, not on the actual product;3. Beclomethasone inhaler (an inhaled respiratory medication) was found with an expiration date of 8/25 and only a room number written on it; and 4. An unidentified peach oval shaped tablet was found loose in a drawer.During an interview on [DATE] at 9 am with the Director of Nursing (DON), DON stated she was aware of the labeling problems and expired inhaler and that was not her expectation. DON further stated expired non-controlled medications should have been placed in the white bins in the medication room, logged and destroyed.A review of the facility's P&P titled, Medication ordering and receiving from Pharmacy, Medication Labels, revised 1/18, indicated the Resident's name, at least, must be maintained directly on the actual product container and that resident specific non-prescription medications must be kept in the original container and identified with the resident's name.A review of the facility's P&P titled, Disposal of Medications and Medication- related Supplies, Medication Destruction for Non-Controlled Medications, revised 1/18, indicated unused, unwanted, and non-returnable medications should be removed from their storage area and secured until destroyed.

Based on observation, interview, and record review, the facility failed to follow the recipe for a pureed diet (consists of foods that have been blended or mashed to a smooth, pudding-like consistency) for nine residents of a census of 142, when [NAME] 1 (C 1) did not add the correct amount of bread slices and broth cups while preparing pureed lunch for residents.This failure decreased the facility's potential to serve the right food consistency to residents with specific nutritional needs and dysphagia (difficulty swallowing).Findings:A review of the facility's menu, dated 9/24/25, indicated the lunch menu consisted of smothered pork chop, whipped potatoes, mixed vegetables, bread or roll with margarine, and lemon chiffon dessert.A review of the facility's recipe titled, Pureed Bread or Roll and Margarine (Pureed Diet Level 4 [PU4- a specialized dietary modification designed for individuals with severe dysphagia]), dated 2025, indicated the amount of white bread slices to add for 15 servings was seven and a half slices.A review of the facility's recipe titled, Pureed Smothered Pork Chop (PU4), dated 2025, indicated the amount of broth to add to 15 servings was one and a half cups.During a concurrent observation and interview on 9/24/25 at 10:30 a.m. with C 1 and the Dietary Services Supervisor (DSS), C 1 began preparing hot lunch items for residents with pureed diets. C 1 stated she was making 14 servings of the pureed food items. C 1 put 14 slices of white bread in a blender, followed by warm milk, and pureed it. C 1 then put 15 boneless pork chops into a food processor and added four cups of beef broth and pureed the mixture. The mixture was watery and sloshed around in its container when C 1 was handling it. C 1 stated she had finished making the pureed pork chop mixture and confirmed she did not follow the recipe.During a concurrent interview and record review on 9/24/25 at 11:03 a.m. with DSS, DSS confirmed C 1 did not follow the pureed recipe for the lunch meal. DSS stated because C 1 did not follow the recipe, residents might not receive the recommended daily allowance (RDA - the average daily intake level of nutrients sufficient to meet a person's dietary requirements) of nutrients they need, which could damage their health. DSS further stated watered down foods could lead to weight loss in vulnerable residents.A review of the facility's job description titled, Dietary Services-Head Cook, dated 2003, indicated one of the cook's responsibilities was to Prepare food for therapeutic diets in accordance with planned menus . Prepare food in accordance with standardized recipes and special diet orders.A review of the facility's dietary manual titled, Long Term Care Diet Manual - Pureed Diet, dated 2022, indicated, Weigh or measure the number of . portions required for the standardized recipe . Add measured amounts of hot liquid for cooked foods . and process until a smooth consistency is achieved.

Based on observation, interview, and record review, the facility failed to ensure residents' rights to confidentiality for a census of 142 residents, when residents' meal tickets containing personal and medical information were found in a kitchen trash can.This failure decreased the facility's potential to protect the residents' personal details and health information.Findings:During a concurrent observation and interview on 9/22/25 at 9:29 a.m. with the Dietary Services Supervisor (DSS) in the kitchen, a dietary aide was scraping food off breakfast plates into a large trash can. Numerous resident meal tickets were found in the trash can along with discarded food. Trash bags were then tossed into an unsecured dumpster behind the building. DSS stated the kitchen team had always discarded the meal tickets in the trash along with uneaten food, and this had been their practice for over a year. DSS also stated she was not aware that resident meal tickets' confidential information needed to be protected, nor was she familiar with the method of shredding meal tickets. DSS further stated this was a privacy issue for the residents and a violation of the Health Insurance Portability and Accountability Act (HIPAA - a U.S. federal law that sets national standards for the privacy and security of health information). During an interview on 9/25/25 at 10:27 a.m. with the Registered Dietician (RD), RD stated the practice of throwing out residents' meal tickets in the trash was a HIPAA violation on multiple counts, and the meal tickets should have been put through a paper shredder to protect residents' private information.A review of the facility's policy titled, Resident Rights, revised February 2021, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . privacy and confidentiality.A review of the facility's policy titled, Confidentiality of Information and Personal Privacy, revised October 2017, indicated, The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records . Access to resident personal and medical records will be limited to authorized staff and business associates.

Based on observation, interview, and record review, the facility failed to properly prepare and store food for a census of 142 residents, when:1. Food items were found undated, unlabeled, unsealed and expired;2. Food bins were stored on a corroded metal shelf;3. One cutting board had brown stains, another contained a sticky substance, one frying pan had an oily substance and brown residue on the inside, a steam warmer tray had brown residue on the outside;4. Two insect control machines were placed on walls above a food preparation area and a toaster;5. The inside of a ceiling ventilation fan had a thick, black substance; and6. The second step of the cool down log for cooked food items was incomplete from June to September 2025.These failures increased the facility's potential to serve contaminated food and cause foodborne illnesses among vulnerable residents.Findings:1. During a concurrent observation and interview on 9/22/25 at 9:04 a.m. with the Dietary Services Supervisor (DSS), the following items were found:- In the reach-in refrigerator: a container of fresh minced garlic with an expiration date of 9/21/25, an open jar of pickle relish with an expiration date of 9/18/25, and an unsealed bag of parsley containing yellowing sprigs with an open date of 9/8/25 and no expiration date.- In the dry goods storage room: multiple packages of open and unopened bread items were found unlabeled and undated. DSS stated expired bread could be moldy and served to residents, causing gastrointestinal problems.- In the walk-in refrigerator: sliced ham with use by date of 9/20/25. DSS confirmed the ham was past its expiration date and stated residents could get foodborne illnesses if they ingested the lunch meat.During a concurrent observation and interview on 9/23/25 at 8:41 a.m. with DSS, chopped parsley with yellow leaves was being prepared for the day's lunch. DSS ascertained it was the same parsley with an open date of 9/8/25 and it had not been removed from the reach-in refrigerator the day prior.2. During a concurrent observation and interview on 9/22/25 at 8:52 a.m. with DSS, a metal storage shelf housing plastic food bins had a reddish-brown substance on its bottom rack. DSS stated the material on the shelf looked like rust and it was inappropriate to store food bins there.3. During a concurrent observation and interview on 9/22/25 at 8:55 a.m. with DSS, a green cutting board was found to have several brown stains, and a blue cutting board had a sticky substance approximately 3 x 8 inches (a unit of measure) in area. DSS confirmed the presence of the stains and sticky residue and stated the cutting boards should not be used for food preparation due to the possibility of food contamination.During a concurrent observation and interview on 9/23/25 at 8:35 a.m. with DSS, a frying pan was found with an oily substance near the rim, in addition to a hard brown residue inside the pan. DSS confirmed the oily substance was cooking oil and stated it was no longer safe to use the pan. A steamer food tray was also found with two small areas of brown residue. DSS stated the brown residue in the frying pan and steamer tray could be dried on food.4. During a concurrent observation and interview on 9/22/25 at 9:39 a.m. with DSS, two electric insect control machines were found affixed to walls, one over a food preparation area, the other over a toaster. DSS stated placing the insect control systems above food preparation areas was problematic because flies could fall from the machines onto food surfaces.5. During a concurrent observation and interview on 9/22/25 at 9:25 a.m. with DSS, a ceiling ventilation fan with a thick layer of black substance on the inner casing and fan blades was found over a food preparation area. DSS stated the maintenance department was supposed to clean the fan on a scheduled basis and noted this fan was very dirty.6. During a concurrent interview and record review on 9/22/25 at 9:56 a.m. with DSS and Kitchen Supervisor (KS), the cool down logs (a record showing monitoring of temperatures during a two-step cooling process of hot foods prepared in advance) were not completed for June 2025 - September 2025. DSS acknowledged the log should have been filled out completely to reflect accurate cool down techniques. KS stated the dietary aides who filled out the log should have taken the food temperature during the second step to ensure a proper cool down technique, thereby keeping food safe and averting foodborne illness in residents. KS further stated if the food items were not at the correct temperatures, the food would need to be thrown away immediately.During an interview on 9/22/25 at 2:41 p.m. with Dietary Aide 2 (DA 2) and DSS, DA 2 explained he was not aware that the temperature should have been taken a final time during the second step of the process. DSS stated it was her duty to monitor the cool down log daily to ensure staff were correctly practicing the cool down method and since she was not aware of the full process of the cool down procedure's second step, the blank log entries of the missed step were unnoticed. DSS further stated food which had not been cooled down properly would possibly harbor toxic germs which could harm residents' health. During an interview on 9/25/25 at 10:27 a.m. with the Registered Dietician (RD), RD stated having unlabeled, undated, and expired kitchen food was considered unsafe. RD expressed concern about using oily or stained food preparation devices or rusty storage equipment due to possible food contamination. RD also stated dead insects could fall out of the wall-mounted insect control machines, and since they were above food preparation areas, they exposed the residents to unnecessary risks. RD further stated all kitchen staff should know the importance of documenting temperatures of the second step of the cool down process and all these issues could result in serious foodborne illnesses for many residents.A review of the facility's policy and procedure (P&P) titled, Food Preparation and Service, revised 2022, indicated, Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness . Cross-contamination can occur when harmful substances, i.e. chemicals or disease-causing organisms are transferred to food .A review of the facility's P&P titled, Storage of Food and Supplies, dated 2023, indicated, All shelves and storage racks or platforms should be in accordance with state and federal regulations . Labels should be visible . All food will be dated - month, day, year. P&P further indicated, Food in unlabeled, rusty, leaking, broken containers or cans . shall not be retained or used.A review of the facility's P&P titled, Labeling and Dating of Foods, dated 2023, indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated . Newly opened food items will need to be closed and labeled with an open date and used by the date that follows the various storage guidelines within this section .A review of the facility's document titled, Storing Produce, dated 2023, indicated, When storing vegetables that should remain crisp, such as . fresh herbs . they will stay fresher longer if [placed] in a sealed bag or container . A review of the facility's guide titled, Dry Goods Storage, dated 2023, indicated opened or unopened bread should be stored 5-7 days.A review of the facility's guide titled, Refrigerated Storage, dated 2023, indicated luncheon ham should be stored in the refrigerator 5 days before discarding.A review of the facility's guide titled, Produce Storage, dated 2023, indicated parsley should be stored in the refrigerator for 2-3 days and diced garlic should be kept 3 days.A review of the facility's policy titled, Pot and Pan Washing, dated 2023, indicated, Pots and pans will be properly sanitized.A review of the facility's procedure titled, Shelves, Counters, and Other Surfaces, dated 2023, indicated, Remove any large debris .A review of the facility's document titled, Hoods, Filters, and Vents, dated 2023, indicated, Vents must be free of dust and dirt.A review of the facility's P&P titled, Cooling and Reheating of Potentially Hazardous Food (PHF): the Two Stage Method, dated 2023, indicated, When cooked PHF food will not be served right away it must be cooled as quickly as possible . P&P also indicated, Cool cooked food from 140 F [degrees Fahrenheit; a unit of measure] to 70 F within two hours. Then cool from 70 F to 41 F or less in an additional four hours for a total cooling time of six hours . When writing in the cool down log, staff are to, Note menu item, date, temperature, and cook's initials on the cool down log used. P&P further indicated corrective action to be taken when the cool down procedure is performed incorrectly: Discard cooked hot food immediately when the food is: above 70 F and more than 2 hours into the cooling process, or above 41 F and more than 6 hours into the cooling process.

Based on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented for a census of 142 residents, when:1. Two washing machines in the behavioral unit were found closed while not in use with moisture inside and the washing machine in station B had black spots around the door seal;2. Licensed Nurse 2 (LN 2) did not perform proper hand hygiene prior to medication preparation; and3. Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce the spread of multidrug-resistant organisms [MDRO]) were not followed for Resident 5, Resident 135, and Resident 4.These failures had the potential to spread infection among residents, staff, and visitors.Findings: 1.During a concurrent observation and interview on 9/25/25 at 9:05 a.m. with Director of Environmental Services (DES) in station A's laundry room in the behavioral unit, the washing machine was found not in use with the door closed and with visible moisture inside the washer. DES confirmed the washer was closed with moisture inside and stated staff were supposed to leave the washing machine door open after use for infection prevention and to prevent the washing machine from acquiring a smell. During a concurrent observation and interview on 9/25/25 at 9:11 a.m. with DES in station B's laundry room in behavioral unit, the washing machine was found not in use with the door closed, with visible moisture inside the washer, and with black spots around the door seal. DES confirmed the washing machine was closed, with visible moisture and with black spots. DES stated the black spots were mold. DES further stated the residents' washed clothes in the washing machine would not be considered clean and mold could affect the residents' health. During an interview on 9/25/25 at 10:09 a.m. with Infection Preventionist (IP), IP stated closing the washing machines with moisture inside while not in use could cause bacteria build-up and could contaminate the residents' clothes. A review of the facility's policy titled, Departmental (Environmental Services) – Laundry and Linen, revised January 2014, indicated, Leave washing machine doors open when not in use . 2.During an observation on 9/23/25 at 8:10 a.m., LN 2 blew his nose using a tissue paper and proceeded to prepare medications without performing hand hygiene. During an interview on 9/23/25 at 10 a.m. with LN 2, LN 2 confirmed that he forgot to perform hand hygiene after blowing his nose and before preparing medications. During an interview on 9/25/25 at 10 a.m. with the Director of Nursing (DON), DON stated nurses should perform proper hand hygiene to prevent the spread of infections and protect residents. A review of the facility's policy titled, Handwashing/Hand Hygiene, revised in 2023, indicated, This facility considers hand hygiene the primary means to prevent spread of healthcare-associated infection . All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. 3.A review of Resident 5's admission record, indicated Resident 5 was admitted to the facility in July 2025. A review of Resident 5's Order Listing Report, dated 9/25/25, indicated Resident 5 was on EBP for left foot wound and urinary catheter (a small, flexible tube that is inserted into the bladder to drain urine) and staff to wear personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when providing care for Resident 5. During an observation on 9/22/25 at 9:38 a.m. outside Resident 5's room, two staff members entered Resident 5's room wearing gloves without a gown. During an interview on 9/22/25 at 9:40 a.m. with Wound Nurse (WN), WN stated she was in Resident 5's room with Physician Assistant (PA) to assess Resident 5's wound. A review of Resident 135's admission Record, indicated Resident 135 was admitted to the facility in August 2025. A review of Resident 135's Order Listing Report, dated 9/25/25, indicated Resident 135 was on EBP for left heel blister (a small, fluid-filled sac that forms on the outer layer of the skin) and staff to wear PPE when providing care for Resident 135. During an observation on 9/22/25 at 9:47 a.m. in Resident 135's room, PA entered the room wearing gloves. PA then removed Resident 135's dressing on the left foot and told Resident 135 a wound debridement (removal of dead or damaged tissue and foreign objects from a wound to promote healing) was needed. During an observation on 9/22/25 at 9:49 a.m. in Resident 135's room, PA was performing wound debridement on Resident 135's left heel. WN was assisting PA by holding Resident 135's leg. Both PA and WN were observed without a gown. During an interview on 9/22/25 at 9:52 a.m. with WN, WN stated she performed the wound dressing on Resident 135's left foot and PA did the wound debridement. During an interview on 9/24/25 at 4:13 p.m. with IP, IP stated PA and WN should have worn a gown and gloves when they assessed Resident 5's wound and when they debrided and dressed Resident 135's wound. IP further stated it was her expectation for staff to follow EBP to prevent the residents from acquiring infection and to prevent the spread of infection among residents and staff. A review of Resident 4's admission Record, indicated Resident 4 was admitted to the facility in April 2025 with a diagnosis of gastrostomy tube (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During an observation on 9/23/25 at 8:53 a.m., Certified Nursing Assistant 1 (CNA 1) was observed changing the linens on Resident 4's bed. CNA 1 was wearing gloves but no gown. An EBP sign was observed on Resident 4's open door. During an interview on 9/23/25 at 8:54 a.m. with CNA 1, CNA 1 confirmed Resident 4 was on EBP and stated she was not wearing a gown while changing the linens and should have been. CNA 1 further stated it was important to follow EBP precautions to protect the residents from spread of infection. During an interview on 9/25/25 at 8:16 a.m. with DON, DON stated it was her expectation for staff to follow EBP to prevent the spread of infection and for resident safety. DON further stated a gown and gloves should be worn for any personal care for residents with a G-tube. A review of Resident 4's care plan, dated 4/21/25, indicated, Resident [4] on Enhanced Barrier Precautions (EBP) . wear gown and gloves for high contact resident care activities such as . changing linens. A review of the facility's policy and procedure titled, Enhanced Barrier Precautions, dated August 2022, indicated, EBPs employ targeted gown and glove use during high contact resident care activities . examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include . changing linens . EBPs are indicated . for residents with . indwelling medical devices [e.g. urinary catheter] regardless of MDRO colonization .

Based on observation, interview, and record review, the facility failed to ensure call systems (an electronic communication network that allows residents to alert staff when they need assistance) were provided for 46 residents out of a census of 142, when the residents' rooms and bathrooms in the behavioral unit (a specialized area that provides focused care for residents who have mental health disorders, substance use disorders, or complex behaviors) were found without a functioning call system. This failure decreased the facility's potential to maintain residents' safety.Findings:A review of Resident 102's admission Record, indicated Resident 102 was admitted to the facility in February 2025 with a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought).A review of Resident 102's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 8/13/25, indicated Resident 102's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 14 out of 15 with good memory.During a concurrent observation and interview on 9/22/25 at 10:25 a.m. with Resident 102, no call button was observed in the room. Resident 102 confirmed there was no call button in the room and stated if he needed help, he would go to the nurses' station to ask for help.A review of Resident 105's admission Record, indicated Resident 105 was admitted to the facility in May 2024 with a diagnosis of bipolar type schizoaffective disorder (a chronic mental condition where a person experiences symptoms of both schizophrenia and a mood disorder simultaneously).A review of Resident 105's MDS, dated [DATE], indicated Resident 105's BIMS score was 15 out of 15 with no memory impairment. During a concurrent observation and interview on 9/22/25 at 1:09 p.m. with Resident 105, no call button was observed in the room. Resident 105 confirmed there was no call button in the room and stated he would make a noise, bang the wall, and yell for help if he needed help.During an interview on 9/23/25 at 11:48 a.m. with the Psychiatric Technician 1 (PT 1), PT 1 confirmed residents' rooms and bathrooms in the behavioral unit did not have a call system and stated the call system in the unit had not worked for years. During an interview on 9/24/25 at 2:58 p.m. with the Program Director (PD), PD confirmed behavioral unit did not have a call system and stated it was important to have a call system to add a level of safety for the residents.A review of the facility's policy titled, Call System, Residents, dated September 2022, indicated, Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor . The resident call system remains functional at all times .

Based on interview and record review, the facility failed to ensure supervision for one of three sampled residents (Resident 1) when Resident 1 eloped (the act of leaving a facility unsupervised and without prior authorization) fell and sustained injuries. This failure resulted in Resident 1 sustaining a fracture (broken bone) of the left distal phalanx (a small bone on the tip of the thumb located under the nail) and abrasions (a partial loss of skin, usually due to scraping) to his face and both knees. Findings: A review of Resident 1's admission record indicated he was admitted on [DATE] with diagnoses including cerebral infarction (stroke- loss of blood flow to the brain). A review of Resident 1's clinical record included the following documents: A Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 2/14/24, indicated Resident 1 had severe memory impairment and had impairment in both arms and legs requiring assistance with walking. A Fall Risk Assessment, dated 2/7/24, indicated Resident 1 was at moderate risk for falls. A Fall Risk Care Plan, initiated 2/7/24, indicated Resident 1 was at high risk for falls related to neuromuscular/functional problems such as recent stroke. An Elopement Risk Assessment, dated 2/7/24, indicated Resident 1 was at low risk for wandering. A Wandering Risk Assessment (WRA), dated 2/7/24, indicated Resident 1 was at low risk for wandering. An Elopement Care Plan, initiated 2/15/24, indicated Resident 1 was an elopement risk related to his wandering around, trying to go outside or attempting to leave the facility. A Physician's Order, dated 2/15/24, indicated a brand name wandering device (WMD -a sensory device placed on residents that alarms if near a monitored exit) was to be placed on Resident 1. A nursing progress note, dated 2/15/24 at 1:06 p.m., indicated Resident 1 was confused, wandering, wanted to go home and was attempting to elope the facility by himself. The note further indicated a WMD alarm had been placed on Resident 1's wheelchair. A nursing progress note, dated 2/22/24 at 9:07 p.m., indicated Resident 1 had been trying to leave the facility through the back door of his room throughout the evening. The note further indicated Resident 1 had stated he wanted to go home and he needed constant monitoring for elopement. A nursing progress note, dated 2/23/24, indicated around 12 a.m. staff were unable to locate Resident 1, searched the facility and found his empty wheelchair in the lobby. The note indicated a Certified Nursing Assistant (CNA) found Resident 1 lying on the sidewalk outside the facility. A SBAR note (situation, background, assessment, recommendation- a communication tool used by healthcare workers when there is a change of condition in the resident), dated 2/23/24 at 3:07 a.m., indicated Resident 1 had eloped and fell on the sidewalk. The note further indicated Resident 1 had abrasions to his face, both knees were bleeding and 911 was called. An X-ray report from the hospital, dated 2/23/24, indicated Resident 1 had an recent fracture at the left thumb. A nursing progress note, dated 2/23/24 at 8:06 a.m., indicated Resident 1 had returned to the facility. During an interview, on 1/7/25 at 1:30 p.m., the Social Services Director (SSD) stated she remembered Resident 1 and he kept trying to leave the facility. The SSD stated he was a high risk for elopement if a WMD was ordered for him. During an interview, on 1/7/25 at 2:01 p.m., the Director of Nursing (DON) agreed Resident 1's WRA on 2/15/24 was inaccurate and he should have had a higher risk score since both an elopement care plan was initiated and a WMD had been ordered that same day. The DON stated WMDs were typically placed on the resident's wrist or ankle and not placed on a resident's wheelchair. The DON stated, but the reason should have been documented in the elopement care plan and confirmed it was not. The DON agreed Resident 1 was not adequately supervised and the facility was responsible for ensuring resident safety. The DON confirmed there was a breakdown in the system which resulted in Resident 1 eloping the facility on 2/23/24 without staff knowledge. During a review of a facility policy titled, Use of WMD undated, indicated WMDs were used for those residents at risk for leaving the facility unassisted. This facility believes that good technology saves lives to maintain a safe and secure environment to all residents. During a review of a facility policy titled, Safety and Supervision of Residents, dated 7/17, stipulated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 3) was free from physical and psychological abuse, when the facility did not protect Resident 3 from being attacked by Resident 1 who had increasing aggression. This failure resulted in Resident 3's suffering facial pain and fear of being hit again by other residents. (Cross Reference F 657) Findings: During a review of Facility-Reported Incident form, dated 8/27/19, indicated the facility reported a witnessed resident-to-resident altercation. Attached documents indicated the altercation on 8/26/19 at 12:30 p.m. involved Resident 1 and Resident 3. Resident 3 sustained a non-life-threatening injury. Upon a concurrent entrance tour of the facility, and interview with Administrator, on 9/4/19 at 1:50 p.m., Administrator stated Resident 1 had a previous aggressive behavior towards another resident (Resident 2 on 8/20/19) six days prior to Resident 1 hitting Resident 3 (Resident 3 on 8/26/19). During a concurrent observation and interview with Lic Nurse A, on 9/4/19, at 2:16 p.m., Lic Nurse A stated she was at the nurse's station on 8/26/19 at 12:30 p.m. when she witnessed Resident 1 raise his fist, and Resident 1 was trying to jump on Resident 3. Lic Nurse A stated she went towards the facility's interview room across the nurse's station and saw Resident 3 covering and protecting Resident 3's head with both hands, and head facing downward. Lic Nurse A stated other staff members came to help to pull apart Resident 1 and 3, and despite attempts of separation, Resident 1 was still trying to go after Resident 3. Lic Nurse A stated the staff notified physician who was on-site. Physician ordered for Resident 1 restraints and seclusion. Lic Nurse A stated Resident 3 stayed in the seclusion unit for an hour and then transported via ambulance to the crisis stabilization unit (acute facility). Lic Nurse A stated after the incident, she assessed Resident 3 and noted red cheeks, left jaw soreness, and gave Resident 3 ice packs for pain relief. During a concurrent observation and interview on 9/4/19 at 2:30 p.m., Resident 3 stated she was sitting down in the interview room across from Resident 1 when Resident 1 attacked her. Resident 3 stated she went down on the floor during the attack. Resident 3 touched her face, left forehead, and cradled her left jaw as she described that her jaw and temples hurt after the attack. Resident 3 stated that after the altercation with Resident 1, her body shook from pain and fear. Resident 3 stated feeling scared of other people who may be violent. Resident 3 stated she was now 'watching her back' and expressed concern about possible future physical attacks. During an interview, on 9/10/19 at 2:10 p.m., Lic Nurse A stated Resident 1's interventions for focus problem of Risk for Assault/ Aggression was to approach Resident 1 in a calm way, asked if Resident 1 needed help or want to talk about anything. Resident 1 was not on one on one monitoring or supervision. Lic Nurse A stated Resident 1 was on every 15-minute safety checks and hourly rounds by Certified Nurse Assistants who use an iPad to check off each residents to ensure they are physically present in the unit. Review of Resident 1's clinical records indicated the following: - Admission Record, dated 9/4/19 at 2:35 p.m., indicated the facility admitted Resident 1 on 8/9/19. Resident 1 had a [DIAGNOSES REDACTED]. - General Progress Note, dated 8/20/19 at 10:15 a.m., indicated Resident 1 punched Resident 2 (elderly roommate of Resident 1) multiple times, causing a 13-inch long abrasion on Resident 2's back and a reddened forehead. - General Progress Note, dated 8/21/19 at 4:48 p.m., indicated Resident 1 moved to new room for assaulting roommate (Resident 2) on 8/20/19 and on every 15-minute monitoring by staff for assault. - Behavior Notes, dated 8/21/19 at 8:05 p.m., indicated when the staff set boundaries, Resident 1 kicked the nursing station door, threw dirty laundry carts down the hallway, pushed a clean laundry cart down the hallway towards other residents where it hit the wall. Resident 1 was given medication to help manage his symptoms, agreed to not hurt himself or others, released from restraints, returned to his room and was placed on every 15-minute safety checks, and 72-hour charting. - General Progress Note, dated 8/25/19 at 10:54 a.m., indicated Resident 1 assisted to his room by nurse, injections given. Resident 1 started going at and trying to kick at staff. Resident 1 assisted by staff to quiet room. - General Progress Note, dated 8/25/19 at 3:57 p.m., indicated Resident 1 became verbally and physically aggressive by attempting to use right shoulder to ram staff, and by attempting to punch staff with closed fists. Resident 1 was offered medication, but refused and attempted to assault two staff members by kicking them. The staff called a Code Grey (sic) (Code Gray - urgent response intervention for combative person/ behavior) to intervene and staff assisted Resident 1 to the seclusion room. Resident 1 continued to charge towards staff and attempted to hit staff and self with a closed right and left fist. The staff notified the Physician and obtained seclusion and restraint order. Resident 1 closely monitored every 15 minutes. - General Progress Note, dated 8/25/19 at 12:50 a.m., indicated Resident 1 became verbally and physically aggressive towards staff when he and other residents were informed patio will be closing for the night. Resident 1 attempted to strike staff with closed fists screaming, [***] you [***] es. The staff called Code Grey (sic) and escorted Resident 1 to his room. Resident 1 appeared to calm down and then again attempted to strike and kick staff. Physician notified and gave order for seclusion and restraints. - General Progress Note, dated 8/26/19 at 4:40 a.m., indicated the staff called Administrator at 5:00 a.m., and suggested to call Crisis Stabilization Unit (outside facility/ different entity) to see if Resident 1 can be sent out. - General Progress Note, dated 8/26/19 at 9:37 a.m., indicated the staff gave Resident 1 [MEDICATION NAME] (medication to treat mental disorder) and [MEDICATION NAME] (anti-anxiety medication), shortly after; Resident 1 was quiet with eyes closed, appeared to be sleeping, and provided gradual reduction of restraints. At 9:00 a.m., Resident 1 was released from restraints and contracted for no further aggression or assault, refused breakfast and went to his room to lay down. The staff would continue to monitor. - General Progress Note, dated 8/26/19 at 2:45 p.m., signed by Lic Nurse A, indicated at 12:30 p.m., Resident 1 was sitting in the room across from nurse's station waiting for lunch. Resident 3 was sitting across from Resident 1 and Resident 3 asked if Resident 1 was gay. Resident 1 began yelling, You want to fight? Resident 1 waved clenched fists toward her. Resident 3 tried to escape and leave the room but Resident 1 leaped from the chair and started punching her multiple times in the face with closed fists. Staff responded and separated Resident 1 and Resident 3. Resident 1 attempted to hit staff. Resident 3 had reddened areas on both cheeks and handprint on right hand. Review of Resident 3's clinical records indicated the following: - Admission Record, dated 9/4/19, indicated the facility admitted Resident 3 on 11/30/18 with a [DIAGNOSES REDACTED]. - General Progress Note, dated 8/26/19 at 4:18 p.m., indicated Lic Nurse A witnessed Resident 1 physically assaulting Resident 3 and interventions done after the incident. - General Progress Note, dated 8/26/19 at 10:39 p.m., indicated Resident 3 complained of soreness of the right side of her jaw. - Physician Note, dated 8/27/19 at 1:22 p.m., indicated Resident 3 was punched in the face yesterday, assessment with facial trauma - mild and no evidence of serious trauma. - General Progress Note, dated 8/27/19 at 2:50 p.m., signed by Clinical Therapist, indicated Resident 3 accepted that she had control over what she says, but asserted that it would be other person's fault if they assaulted her. Resident 3 state she wanted to press charges against Resident 1 for assault and battery. Review of the facility's policy and procedure, titled Assault/ Altercation - Resident to Resident, no date, indicated, Client to client assault is a potentially dangerous behavior that can lead to client or staff injury and allow clients to feel that their living arena is unsafe, which compromises the objective of operating a safe therapeutic nursing led milieu. For this reason, all nursing and clinical staff need to respond in the most active manner to predict, intervene, and reduce the frequency and intensity of client to client assault.

Based on interview and record review, the facility failed to: 1. Follow policies and procedures for care planning when the facility did not evaluate the effectiveness of the interventions for Resident 1's increasing aggressive behaviors and, 2. Develop care plan for victimization for Resident 3. This failure resulted in ineffective interventions that led to Resident 3 being attacked and suffering from facial pain and fear of violent people in her surroundings (Cross Reference F 600). Findings: 1. a) During an interview and concurrent record review with Director of Nursing (DON), on 9/4/19 at 3:30 p.m., stated Resident 1 was on every 15-minute safety check the entire time Resident 1 was inpatient in the facility (8/9/19 to 8/26/19). During an interview with Assistant Director of Staff Development (ADSD), on 9/11/19, at 10:50 a.m., ADSD stated care plans were opened at the time of admission and some items may or may not apply to residents when they are admitted . ADSD stated some of the items are not complete because Resident 1 did not make it in the first two weeks for Interdisciplinary Team (IDT) meeting. ADSD described the process in order to gather information and make appropriate care plans for each resident. ADSD stated the IDT meeting was for Resident 1 on 8/29/19 but was transferred on 8/26/19 and officially discharged on [DATE]. During an interview with Director of Nursing (DON) on 9/13/19 at 10:36 a.m., stated the facility does not conduct one on one monitoring in the post-acute facility, and if one on one monitoring were needed, the facility would place resident in an acute facility. During a review of Resident 1's clinical record, Care Plan: Risk for Assault, initiated 8/9/19, indicated Resident 1's care plan noted his aggressive behavior history. Resident 1's goals included he would not assault anyone for 90 days was initiated on 8/20/19 (after Resident 1 and Resident 2 altercation). The care plan interventions indicated: - Staff to offer Resident 1 a safe and quiet environment as needed initiated on 8/12/19 - Staff will work with Resident 1 to develop a safety plan to prevent aggressive behaviors initiated on 8/12/19 - Staff will work with resident to develop a safety plan to prevent aggressive behaviors, initiated on 8/12/19 - Staff to encourage resident to express feelings of anger/ fear before aggressive behaviors occurs, initiated 8/20/19 - Staff to increase safety checks as indicated, initiated 8/27/19 The care plan did not indicate any changes on interventions addressing Resident 1's escalating aggressive behaviors. The care plan did not indicate that an IDT meeting occurred to review and update the care plan for significant change in resident's condition. The facility policy and procedure titled Care Planning - Interdisciplinary Team (IDT), revised 12/16, indicated a comprehensive care plan for each resident is developed within seven days of completion of the required comprehensive resident assessment (MDS). It indicated, Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change. It indicated IDT 'must review and update the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met.' Review of Resident 1's Assault Risk Assessment on the following dates and times indicated: 1. On 8/20/19, indicated Resident 1 was placed in category for moderate to high risk due to Resident 1 physically assaulting Resident 2. Resident 1's interventions included routine rounds, every 15-minute checks, licensed nurse assessment every shift, and for Licensed Nurse to initiate Care Plan on Potential for Assaultiveness. 2. On 8/26/19, indicated Resident 1 was placed Resident 1 in category for a high risk due to assaulting Resident 3. The care plan did not indicate changes or new interventions compared to the first Assault Risk Assessment on 8/20/19. During a review of the facility's policy and procedure titled Assault/ Altercation - Resident to Resident, no date, indicated, All residents with a history of assault will have a potential for assault care plan upon admission. Charge Nurse will begin or update the client's care plan and decide whether to proceed with the formulation of a potential for assault problem on the client's care plan based on clinical indicators, history, frequency, and severity. 1. b) During a concurrent interview and record review with Assistant Director of Staff Development (ADSD), on 9/11/19, at 10:50 a.m., ADSD stated that Resident 1 was aware that Testosterone (hormone therapy in transgender males - female to male) affects Resident 1's feelings and behaviors, and Resident 1 did not like that. ADSD stated Resident 1 was concerned about getting very angry, very concerned about taking testosterone as it was making Resident 1 have behaviors of aggression and would lash out more so on the day of injection. ADSD stated treatment team was working with Resident 1 on this issue. ADSD stated monitoring for increased aggression/ agitation after Testosterone injection was part of the monitoring that nurses do. Resident 1 was on hourly rounds and every 15-minute checks since he was admitted to observe his behaviors. ADSD verified there was no care plan interventions for Testosterone for Resident 1's risk for medication side effects from hormone therapy treatment secondary to gender transitioning related to testosterone treatment. During a review Resident 1's clinical record, Medication Administration Record [REDACTED]. Testosterone side effects included emotional instability, loss of strength/energy, [MEDICAL CONDITION], depression, mood changes, behavioral changes, and thoughts of suicide (thinking about harming or killing oneself or planning or trying to do so). During a review of the clinical record for Resident 1, Care Plan, initiated on 8/9/19, indicated Resident 1 was at risk for medication side effects from hormone therapy treatment secondary to gender transitioning related to testosterone treatment. The goal was for Resident 1 to report feelings of side effects from testosterone treatment to his nurse and or doctor as needed through next review date. The care plan did not indicate any interventions. 2) During a concurrent observation and interview on 9/4/19 at 2:30 p.m., Resident 3 stated she was sitting down in the interview room across from Resident 1 when Resident 1 attacked her. Resident 3 stated she went down on the floor during the attack. Resident 3 touched her face, left forehead, and cradled her left jaw as she described that her jaw and temples hurt after the attack. Resident 3 stated that after the altercation with Resident 1, her body shook from pain and fear. Resident 3 stated feeling scared of other people who may be violent. Resident 3 stated she was now 'watching her back' and expressed concern about possible future physical attacks. During a review of Resident 3's clinical record, Care Plan, received on 9/4/19, the care plan did not indicate Resident 3's future safety to prevent behavioral regression after the physical abuse on 8/26/19. The care plan did not indicate how the facility could ensure Resident 3's safety and or interventions to prevent further abuse. The facility policy and procedure titled Assault/ Altercation - Resident to Resident, no date, indicated care planning interventions to consider include: 1. [MEDICAL CONDITION] medication evaluation and administration 2. Restriction from certain groups and public activities 3. Enhanced supervision including 1:1 supervision, as needed 4. Development of special positive based reinforcement programs to support assault free days 5. Room changes or hallway separation and eating in separate dining rooms During a review of the facility's policy and procedure, Assault/ Altercation - Resident to Resident, no date, indicated, Clients who frequently fall victim to assault will need to be care planned for Potential for Victimization. The Clinical Director/ or treating Psychiatrist will evaluate for continued stay in the program if indicated.