Every finding on record at Crenshaw Nursing Home

Based on observation, interview, and record review, the facility failed to maintain an environment that was clean, safe, sanitary and homelike for two of 3 residents, (Residents 1 and 2). This failure had the potential to negatively affect the residents' dignity, comfort and quality of life.Findings: During a concurrent observation and interview on 8/24/2026 at 1:20 p.m., with the Housekeeper, the floor of the janitor's closet had two visibly soiled, discolored and crumpled towels. The housekeeper stated, I do not know why those towels are there, they have been there for a while. 1). During an observation on 8/24/2026 at 2:00 p.m., a peeling, cracked, flaking paint was observed at the entrance of Resident 1's door surrounding the name plate, leaving a visibly deteriorated uneven surface. Inside Resident 1 's room, the baseboard (floor molding) was observed dirty, damaged, and separated from the wall, leaving an exposed gap (space) with dark discoloration and accumulated debris (wastes). During a review of Resident 1's Face Sheet (a summary of the resident's critical information), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Bipolar (sometimes called manic-depressive disorder: mood swings that range from the lows of depression to elevated periods of emotional highs), and cerebrovascular accident with right side hemiplegia (CVA stroke, loss of blood flow to part of the brain, with weakness on the right side of the body hands legs). During a review of Resident 1's Minimum Data Set (MDS -a resident assessment tool) dated 7/31/2026, the MDS indicated Resident 1's cognition (thought process) was intact. The MDS indicated Resident 1 required partial to moderate assistance (helper does less than half of effort) for showering and upper body dressing. Resident 1 required substantial /maximal assistance (a helper does more than half the effort) for toileting, lower body dressing, and putting on and taking off footwear. 2). During an observation on 8/24/2026 at 2:45 p.m. in Resident 2's room, the window blinds had several slats missing, bent and damaged, causing large gaps that failed to block the sunlight and compromised Resident 2's privacy. Resident 2 was observed with a sheet covering his head. During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was severely impaired. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) for personal hygiene, lower body dressing, toileting and bathing. During an interview on 8/24/2026 at 3:00 p.m. with the Director of Nurses (DON), the DON stated the dirty towels on the floor, broken window blinds, peeling paint and damaged baseboard were unacceptable and not aligned with a homelike environment the facility should provide the residents with. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, dated 3/2023, the P&P indicated the facility should provide residents a safe, clean, comfortable and homelike environment.

Based on interviews and records review, the facility failed to ensure one of three sampled residents (Resident 1), did not elope (left the facility unsupervised) from the facility on 7/17/2026. The facility failed to: 1. Ensure Resident 1's elopement evaluation dated 11/21/2025 was completed, to accurately determine Resident 1's elopement risk. 2. Ensure Resident 1's care plan titled, Risk for Wandering/Elopement Identified, had intervention to minimize the resident's tendency to leave the facility unsupervised, as indicated in its Policy and Procedure (P&P) titled, Wandering and Elopements, which indicated, if a resident was identified at risk for wandering, elopement or other safety issues, the resident's care plan should include strategies and interventions to maintain resident's safety. 3. Monitor Resident 1 every one hour as indicated in the resident's care plan titled Elopement Risk. 4. Implement the facility's P&P titled, Exits or Means of Egress, which indicated to conduct regular checks and inspection of the alarm (alert when the door is opened) activation and alarm sounding to ensure the alarm system was functioning properly. These failures resulted in Resident 1 leaving the facility unsupervised on 7/17/2026, placing the resident at risk for accidents and injuries.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE]. Resident 1's was readmitted on [DATE]. Resident 1's diagnoses included paranoid schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), mood disorder (feelings may range from being very sad, empty or cranky to being very happy - going back and forth between each mood), and depressive disorder (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities). During a review of Resident 1's History and Physical (H&P) dated, 7/12/2026 the H&P indicated Resident 1 did not have the mental capacity to understand and make medical decisions. During a review of Residents 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/25/2026, the MDS indicated Resident 1 had severe cognitive impairment. The MDS indicated Resident 1 required supervision or touching assistance on staff with Activities of Daily Living (ADLs) such as dressing, toilet use, shower/bathing. Resident 1 required set-up or clean-up assistance with transferring and mobility. During a review of Resident 1's Elopement Evaluation dated 11/21/2025, the elopement evaluation was not completed. During a review of Resident 1's care plan titled Elopement Risk, revised 6/15/2026, the care plan indicated Resident 1 was identified as being at risk for leaving safe areas without authorization, secondary to mental illness, and sitting by exit doors. The care plan intervention indicated to monitor Resident 1 every one hour. During a review of Resident 1's care plan titled Risk for Wandering/Elopement Identified, revised on 6/15/2026, the interventions did not indicate monitoring and supervision measures for Resident 1. During a review of Resident 1's Change of Condition (COC) dated 7/17/2026, the COC indicated, during changing shift rounds on 7/17/2026 at 11:00 p.m., Resident 1 was not in his room. Nursing staff searched for Resident 1 in common areas and Resident 1 was not found in the facility. During a review of Resident 1's General Acute Care Hospital (GACH) Emergency Department (ER) progress notes, dated 7/18/2026 at 6:07 p.m., the ER progress notes indicated, on 7/18/2026 at 11 a.m., Resident 1 was found by the police on the (unspecified) street, lying under hot weather, with hyperthermia (abnormally high internal (core) body temperature) and was unresponsive. During an interview on 7/20/2026 at 1:20 p.m. with the Receptionist, he stated that the emergency doors were checked every two hours and documented in a log. The receptionist stated, I lost the logs. The receptionist stated, I did not work on 7/17/2026 and the facility did not have a receptionist assigned to monitor the gates on that date. During a concurrent review of the 7/17/2026 facility video footage and interview on 7/20/2026 at 2:08 p.m. with the Director of Nursing (DON), the video review indicated the following: On 7/17/2026 at 8:50 p.m., Resident 1 was observed inside the facility, standing at the main entrance door that had a keypad. Resident 1 attempted to open the door, but the door was closed. No staff were observed at the main entrance/ patio. On 7/17/2026 at 8:54 p.m., Resident 1 was observed inside the facility by the main entrance (facing the street). No staff were observed. Resident 1 pushed the emergency exit door of the facility's main entrance with both hands and exited (left) the building. The DON stated that when Resident 1 pushed the emergency exit door opened, the alarm did not activate (went off). The DON stated staff did not check if the alarm was locked or was functioning properly. The DON the alarm did not sound because it was not turned on. The DON stated Resident 1's elopement could have been prevented if the emergency exit door alarm was activated. During an interview on 7/20/2026 at 1:20 p.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 1 was last seen on 7/17/2026, at approximately 8:30 p.m. CNA 3 stated around 10:50 p.m., the incoming shift CNA went to Resident 1's room and found that he was not in the room. CNA 3 stated that he did not know Resident 1 was at high risk for elopement. CNA 3 stated that it was important to check residents often (unspecified) for their safety to prevent him (Resident 1) from eloping. During an interview on 7/21/2026 at 1:00 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 1 was not considered a high risk for elopement. LVN 3 stated that she did not know what the procedures were in monitoring the residents or how often Resident 1 should have been monitored. During a concurrent interview and record review on 7/21/2026 at 1:58 p.m., with Registered Nurse (RN) 1, Resident 1's Elopement Evaluation, Risk for Wandering/Elopement, dated 11/21/2025 and the Elopement Risk care plans were reviewed. RN 1 stated that the Elopement Evaluation dated 11/21/2025 was not completed. RN 1 stated not completing Resident 1's Elopement Evaluation affected the resident's care. RN 1 stated the staff should have supervised Resident 1 every hour or frequently due to his elopement risk as indicated in the resident's care plan titled Risk for Elopement. RN 1 stated that the Wandering/Elopement care plan did not indicate how often Resident 1 should be monitored. RN 1 stated that failing to create Resident 1's personalized care plan resulted in Resident 1 not receiving proper supervision. During an interview on 7/21/2026 at 3:32 p.m. with the Director of Nursing (DON), the DON stated the Receptionist was required to check the doors and alarms every two hours and document the results. The DON stated nurses did not check Resident 1 every one hour and as needed. The DON stated that licensed nurses must check on residents every two hours at a minimum. The DON stated it was the facility's responsibility to know Resident 1's whereabouts and to maintain appropriate safety measures. During a review of the facility's P&P titled, Exits or means of Egress, dated 1/2019, the P&P indicated the facility should conduct regular alarm check/ inspection to ensure that alarm system is functioning properly, including alarm activation, alarm sounding. During a review of the facility P&P titled, Wandering and Elopements, dated 3/2023, the P&P indicated, if a resident was identified at risk for wandering, elopement or other safety issues, the resident's care plan should include strategies and interventions to maintain resident's safety. During a review of the facility P&P titled, Care Plans, Comprehensive Person-Centered, dated 3/2023, the P&P indicated, comprehensive, person-centered care plan should describe the services to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Change In a Resident's Condition, which indicated the facility will notify the Resident's representative (RP) of changes in the resident's medical condition and/or status for one of three sampled resident's (Resident 1), when Resident 1's Public Guardian (PG) was not notified of the Resident's transfer to the General Acute Care Hospital (GACH) on 4/4/2026.This failure had the potential to violate Resident 1's RP to be informed regarding the patient's condition and result in the inability for the RP to make informed decisions regarding the Resident's care.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included other psychotic disorder not due to a substance or known physiological condition (a mental health diagnosis for symptoms like hallucinations [sensing things such as visions, sounds or smells that seem real but are not] that do not meet criteria for a specific psychotic disorder) and dementia (a progressive state of decline in mental abilities). The admission Record indicated Resident 1 had a PG as the first Emergency contact. During a review of Resident 1's History and Physical (H&P), dated 1/8/2026, the H&P indicated Resident 1 lacked capacity to make medical decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 4/4/2026, the MDS indicated Resident 1 had severe cognitive impairments (problems with the ability to think, remember, and solve problems). The MDS indicated Resident 1 was dependent (helper does all the effort) for Activities of Daily Living (ADLs) such as toileting, personal hygiene self and the ability to transfer from bed to chair.During a review of Resident 1's Progress Notes dated 4/4/2026, the Progress Notes indicated Resident 1 was transferred to the GACH for further evaluation. The Progress Notes did not indicate Resident 1's PG was notified of the transfer.During an interview on 5/7/2026 at 1:52 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated staff should inform the first listed contact for changes in condition or transfers of residents. LVN 1 stated if a resident were to have a PG listed, the PG must be notified to ensure that the PG was aware of what was going on with the resident.During an interview on 5/8/2026 at 11:48 a.m., with LVN 2, LVN 2 stated the facility notified Resident 1's conservator and did not attempt to notify Resident 1's PG when the resident was transferred to the GACH on 4/4/2026. During a concurrent interview and record review on 5/8/2026 at 2:32 p.m., with the Director of Nursing (DON), Resident 1's admission Record and Progress Notes, dated 4/4/2026, were reviewed. The DON stated because Resident 1's PG was first emergency contact and responsible party listed, the PG should have first been made aware of Resident 1's transfer to the hospital and not Resident 1's conservator.A review of facility's P&P titled, Change in a Resident's Condition dated 3/2023, the P&P indicated, the facility promptly notifies the resident representative of changes in the resident's medical condition and/or status. The P&P indicated unless otherwise instructed by the resident, a nurse will notify the resident's representative when it is necessary to transfer the resident to a hospital/treatment center.

Based on observation and interview, the facility failed to:Ensure the Annex medication storage refrigerator temperature was below 40 degrees Fahrenheit.This deficient practice had the potential to result in the loss of potency and expired medication.Findings:During a concurrent observation and interview, on [DATE] at 8:45 a.m., with Licensed Vocational Nurse 3 (LVN 3), the Annex station medication storage refrigerator which contained 7 insulin pens and vials was observed with an internal temperature of 49 degrees Fahrenheit. LVN 3 stated the refrigerator was reading at 49 degrees and was warm. LVN 3 stated the appropriate refrigerator temperature for refrigerated medications should have been below 40 degrees. LVN 3 stated that the risk when the refrigerator is not within the acceptable temperature range is that the medications could lose its potency.During a review of the facility's policy and procedures (P&P), titled Storage of Medications, dated 3/2023, the P&P indicated Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls.

Based on interview and record review, the facility failed to ensure a written informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was obtained and an interdisciplinary team ([IDT] - team members from different disciplines who come together to discuss resident care) meeting was conducted before the initiation of a psychotropic drug (any drug that affects brain activities associated with mental process and behavior) for one of one sampled resident (Resident 26) who had diagnosis of dementia (a progressive state of decline in mental abilities).This deficient practice placed Resident 26 at risk for sustaining adverse effects (undesired effect of a drug) from psychotropic medication.Findings:During a review of Resident 26's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 26 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 26's diagnoses included dementia, mood disorder (a mental health condition that primarily affects a person's persistent emotional state, causing intense, long-lasting highs or lows that interferes with daily life), and major depressive disorder (a mood disorder that causes a persistent felling of sadness and loss of interest).During a review of Resident 26's History and Physical (H&P), dated 1/11/2026, the H&P indicated, Resident 26 did not have the capacity to understand and make decisions.During a review of Resident 26's Minimum Data Set ([MDS] - a federally mandated resident assessment tool), dated 2/9/2026, the MDS indicated, Resident 26's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 26 required setup assistance (helper assists only prior to or following the activity) from staff with oral hygiene, lower body dressing, and personal hygiene.During a review of Resident 26's Order Summary Report (a document containing active orders), dated 4/23/2026, the Order Summary Report indicated, the physician placed a telephone order on 1/11/2026 for Resident 26 to start on Depakote (drug used to treat mood disorder) 250 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) by mouth twice a day (9:00 a.m. and 5:00 p.m.) for mood swings manifested by uncontrollable extreme mood swings causing outburst of anger. The Order Summary Report indicated, the physician placed a telephone order on 1/11/2026 for Resident 26 to start on Trazodone (drug used to treat depression) 25mg by mouth at bedtime (9:00 p.m.) for major depressive disorder manifested by withdrawn behavior.During a concurrent interview and record review on 4/23/2026 at 10:05 a.m., with Registered Nurse 2 (RN 2), Resident 26's Informed Consent, dated 1/11/2026, was reviewed. The Informed Consent signed by Resident 26 indicated, Resident 26 was on Depakote 250 mg twice a day and Trazodone 25 mg at bedtime. RN 2 stated Resident 26's informed consent for Depakote and Trazodone was not signed by the IDT. RN 2 stated Resident 26 lacks capacity to give informed consent because Resident 26 has a diagnosis of dementia. RN 2 stated Resident 26 should have been placed under the care of the IDT or the bioethics committee (multidisciplinary group designed to address, analyze, and advise on complex ethical challenges). RN 2 stated the facility needs to have an IDT meeting before the initiation of psychotropic medication so the IDT could decide if the psychotropic medication is necessary to the resident.During an interview on 4/23/2026 at 10:26 a.m., with the Social Service Director (SSD), the SSD stated Resident 26 was not under the care of the IDT. The SSD stated there was no IDT or bioethics committee meeting that were completed before the initiation of Resident 26's psychotropic medications. The SSD stated the facility had an IDT meeting with Resident 26 on 2/9/2026 one month after the initiation of psychotropic medication. The SSD stated informed consent signed by Resident 26 was not valid. The SSD stated psychotropic medications have lots of side-effects (unwanted effects of medication) that would be detrimental to resident's health and safety.During a review of the facility's policy and procedure (P&P) titled, Lack of Capacity when Medical Interventions Requires Informed Consent, undated, the P&P indicated, The facility shall conduct an interdisciplinary team review of the prescribed medical interventions prior to the administration of the medical intervention. The P&P also indicated when the resident lacks capacity for informed consent and a psychoactive medication is ordered by the physician, a bioethics meeting will be held and will include the resident's primary physician, another physician along with the facility interdisciplinary team member.

Based on observation, interview, and record review, the facility failed to ensure the dishwasher chlorine test paper strips (used to test commercial dishwasher for proper sanitation level) were not expired.This deficient practice could result in inaccurate readings that would lead to under-sanitized dishes.Findings: During a concurrent observation and interview on 4/22/2026 at 12:25 p.m., in the kitchen dishwashing machine area, the Dietary Aide 2 (DA 2) tested the dishwashing machine sanitation running water after it was sanitized with chlorine test paper strip. The DA 2 stated the chlorine test paper strip bottle indicated an expiration date of 3/2026. The DA 2 stated he did not check the expiration of the chlorine test paper strip prior to testing. During an interview on 4/22/2026 at 12:30 p.m., with the Dietary Service Supervisor (DSS), the DSS stated using an expired chlorine test paper strip would give a false or inaccurate reading that would lead to improperly sanitized water. During a review of the 2022 U.S. Food and Drug Administration Food Code titled Equipment Code#4-501.114, the Food Code indicated Verifying the adequacy of chlorine-based solutions can be accomplished on an on-going basis by confirming that the concentration, temperature, and pH of the sanitizing solutions comply with paragraph 4-501.114 (A) using acceptable test methods and equipment.

Based on interview and record review, the facility failed to ensure the recommendation from the Consultant Pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) for one of five sampled residents (Resident 26), was acted upon. This failure had the potential to result in Resident 26 experiencing a delay in treatment. Findings: During a review of Resident 26's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 26 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 26's diagnoses included dementia (a progressive state of decline in mental abilities), mood disorder (a mental health condition that primarily affects a person's persistent emotional state, causing intense, long-lasting highs or lows that interferes with daily life), and major depressive disorder (a mood disorder that causes a persistent felling of sadness and loss of interest). During a review of Resident 26's History and Physical (H&P), dated 1/11/2026, the H&P indicated, Resident 26 did not have the capacity to understand and make decisions. During a review of Resident 26's Minimum Data Set ([MDS] - a resident assessment tool), dated 2/9/2026, the MDS indicated, Resident 26's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 26 required setup assistance (helper assists only prior to or following the activity) from staff with oral hygiene, lower body dressing, and personal hygiene. During a review of Resident 26's Order Summary Report (a document containing active orders), dated 4/23/2026, the Order Summary Report indicated, on 1/11/2026, a telephone order was placed by the physician for Resident 26 to start Depakote (drug used to treat mood disorder) 250 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) by mouth twice a day (9:00 a.m. and 5:00 p.m.) for mood swings manifested by uncontrollable extreme mood swings causing outburst of anger. During a concurrent interview and record review on 4/23/2026 at 9:25 a.m., with Registered Nurse 2 (RN 2), Resident 26's Consultant Pharmacist Medication Regimen Review ([MRR] - a structured, comprehensive evaluation of a resident's entire medication list, conducted by a pharmacist to ensure safety and effectiveness), dated 2/10/2026, was reviewed. The MRR indicated to consider ordering a Depakote level (a blood test that measures the concentration of the medication to ensure it is within the therapeutic range) for routine monitoring because Resident 26 was receiving Depakote for mood disorder. RN 2 stated the timeframe to follow-up the Consultant Pharmacist MRR report to the resident's physician was 5-7 days. RN 2 stated Resident 26's Consultant Pharmacist MRR report was not communicated to the physician and there was no documentation by facility staff on the progress notes that the Consultant Pharmacist MRR for Resident 26 was completed. RN 2 stated it was important to check Depakote level to monitor drug toxicity (the harmful, damaging, or lethal effects caused by an excessive accumulation of medication in the bloodstream) and for medication adjustment. During an interview on 4/23/2026 at 10:55 a.m., with the Director of Nursing (DON), the DON stated Resident 26's physician should have addressed the Consultant Pharmacist MRR report within a week (from 2/10/2026) after the report was completed. The DON stated it was important to check Resident 26's Depakote level to better regulate the medication and to manage resident's mood condition. During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Reviews, dated 5/2019, the P&P indicated, The attending physician documents in the medical record that the irregularity has been reviewed and what action was taken to address it.

Based on observation, interview, and record review, the facility failed to ensure one of one resident's (Resident 11) blood pressure was checked prior to the administration of hydrochlorothiazide (drug used to treat high blood pressure). This deficient practice had the potential to result in severe hypotension (low blood pressure) for Resident 11.Findings: During a review of Resident 11's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 11 was admitted to the facility on [DATE]. Resident 11's diagnoses included hypertension ([HTN] - high blood pressure), cerebral infarction (a condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it) with hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 11's History and Physical (H&P), dated 3/19/2026, the H&P indicated, Resident 11 can understand and make own medical decisions. During a review of Resident 11's Minimum Data Set ([MDS] - a resident assessment tool), dated 3/25/2026, the MDS indicated, Resident 11 was independent (decisions consistent and reasonable) in cognitive (ability to think and reason) skills for daily decision making. Resident 11 required moderate assistance (helper does less than half the effort) from staff with oral hygiene, toileting hygiene, and upper body dressing. During a review of Resident 11's Order Summary Report (a document containing active orders), dated 4/23/2026, the Order Summary Report indicated on 3/19/2026, a physician's telephone order for Resident 11 to start hydrochlorothiazide 12.5 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) 1 tablet by mouth, daily (9 a.m.) for HTN. To hold if systolic blood pressure ([SBP] - top number in a blood pressure reading) less than 110. During an observation on 4/22/2026 at 8:09 a.m., with Licensed Vocational Nurse 1 (LVN 1) in Resident 11's room, LVN 1 was about to administer Resident 11's hydrochlorothiazide 12.5 1 tablet without checking Resident 11's blood pressure. During an interview on 4/22/2026 at 8:11 a.m., with LVN 1, LVN 1 stated it was important to follow the physician's order to check Resident 11's blood pressure before administering the hydrochlorothiazide since it has a medication parameter (a measurable, specific instruction or characteristic used to manage drug therapy). LVN 1 stated giving Resident 11's hydrochlorothiazide medication without first checking the blood pressure would cause hypotension, dizziness and fatigability that would endanger Resident 11's health and safety. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, Medications are administered in a safe and timely manner. The P&P also indicated medications are administered in accordance with prescriber orders.

Based on interview and record review, the facility failed to:1). Ensure care plan for oxygen use was initiated for two of 8 sampled residents (Resident 22 and Resident 6).This deficient practice had the potential to result in a delay in delivery of care and services.Findings: a. During a review of Resident 22's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 22 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), acute respiratory failure (a critical condition where the lungs cannot adequately transfer oxygen to the blood), pneumonia (an infection/inflammation in the lungs), and bronchitis (inflammation or swelling of the airway tubes that carry air to the lungs, commonly causing a hacking cough with mucus, chest tightness, and wheezing). During a review of Resident 22's Minimum Data Set (MDS- a resident assessment tool), dated 10/17/2025, the MDS indicated Resident 22's cognitive (thinking) skills were moderately impaired. The MDS indicated Resident 22 required maximal assistance from staff members with Activities of Daily Living (ADLs). During an observation, on 4/21/2026 at 10:37 a.m., Resident 22 was observed receiving oxygen via nasal cannula running at 5 liters per minute. During a review of Resident 22's medical chart, on 4/23/2026 at 9:59 a.m., there was no oxygen care plan to be found. During a concurrent interview and record review, on 4/23/2026 at 10:31a.m., with Registered Nurse 2 (RN 2), RN 2 stated care plans were initiated to focus on a resident and how to care for their needs. RN 2 stated care plans were initiated on admission and during a residents' change of condition. RN 2 stated Resident 22 did not have a care plan for oxygen. RN 2 stated the oxygen care plan should have been initiated. RN 2 stated the risk of not initiating care plans could result in not being able to provide care based on the resident's needs. b. During a review of Resident's 6 sheet, the face sheet indicated Resident 6 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses which included COPD, emphysema (a chronic lung disease where the tiny, stretchy air sacs in the lungs are damaged and destroyed), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive (thinking) skills were severely impaired. The MDS indicated Resident 6 was dependent on staff members with ADLs. During an observation, on 4/21/2026 at 12:07 p.m., Resident 6 was observed receiving oxygen via nasal cannula running at 4 liters per minute. During a record review of Resident 6's medical chart, on 4/23/2026 at 10:01 a.m., there was no oxygen care plan to be found. During a concurrent interview, on 4/23/2026 10:38 a.m., with RN 2, RN 2 stated there was no oxygen care plan for Resident 6. RN 2 stated Resident 6 should have had an oxygen care plan. RN 2 stated the risk of not providing an oxygen care plan could result in not being able to provide care for a resident who receives oxygen therapy. During a review of the facility's policy and procedures (P&P), titled Oxygen Administration, dated 10/2010, the P&P indicated, Review the resident's care plan to assess for any special needs of the resident.

Based on observation, interview and record review, the facility failed to:1). Conduct a Level 2 Pre-admission Screening and Record Review (PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) for one of 8 sampled residents (Resident 5). This deficient practice had the potential to result in a delay of necessary care and mental health services.Findings: During a review of Resident 5's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 5 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses which included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizoaffective disorder, bipolar type (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool), dated 2/23/2026, the MDS indicated Resident 5's cognitive skills were severely impaired. The MDS indicated Resident 5 required partial assistance by staff members with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a record review, on 4/22/2026 at 10:46 a.m., Resident 5's positive Level 1 PASRR screening, dated 4/18/2021, indicate Resident 5 required a Level 2 PASRR screening. There was no Level 2 PASRR screening in Resident 5's medical chart. During a concurrent interview and record review, on 4/22/2026 at11:11 a.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated she and all other staff were responsible for conducting PASRR screenings. LVN 4 stated Resident 5's Level 1 PASRR indicated a Level 2 PASRR screening was required. LVN 4 stated Resident 5 did not have a Level 2 PASRR screening performed. LVN 4 stated the facility should had followed up for Resident 5's Level 2 PASRR and did not. LVN 4 stated the risk of not resubmitting PASRR for a resident could result in not being able to provide the mental services that a resident needs. During a review of the facility's policy and procedures (P&P), titled Pre admission Screening and Resident Review (PASRR), dated 6/2024, the P&P indicated, If the DHCS/DDS (undefined) contractor deems a Level 2 evaluation is necessary, the facility will assist the DHCS contractor with additional information, face-to-face visit for further evaluation as indicated.

Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level 1 screening (a federally required preliminary screening for individuals seeking admission to a Medicaid-certified nursing facility) was completed and resubmitted for one of two sampled residents (Resident 7), who had diagnoses of mental illness (abnormal behavior or disturbing feelings, thoughts, or actions that interfere with every day functioning) and was receiving psychotropic medications (any drug that affects brain activities associated with mental process and behavior).This deficient practice had the potential to result in Resident 5 not appropriately evaluated and not provided the necessary specialized services for mental illness.Findings: During a review of Resident 7's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 7's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest), and anxiety disorder (excessive, persistent, and uncontrollable fear, worry, or dread that interferes with daily life). During a review of Resident 7's History and Physical (H&P), dated 1/22/2026, the H&P indicated, Resident 7 had the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/26/2026, the MDS indicated, Resident 7 was independent (decisions consistent and reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 7 required moderate assistance (helper does less than half the effort) from staff with eating, oral hygiene, and upper body dressing. During a review of Resident 7's Order Summary Report (a document containing active orders), dated 4/23/2026, the Order Summary Report indicated, the physician placed a telephone order on 2/15/2026 for Resident 7 to start on Olanzapine (a drug used to treat mental illness) 10 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) by mouth at bedtime (9:00 p.m.) for schizoaffective disorder manifested by episodes of paranoid (baseless or excessive suspicion of the motives of others) delusion (false beliefs not based on reality). The Order Summary Report indicated, the physician placed a telephone order on 4/2/2026 for Resident 7 to start on Trazodone (a drug used to treat depression) 150mg by mouth at bedtime (9:00 p.m.) for depression manifested by episodes of feeling sad. During a concurrent interview and record review on 4/22/2026 at 2:00 p.m., with the Licensed Vocational Nurse 4 (LVN 4), Resident 7's PASARR Level 1 completed by General Acute Care Hospital (GACH) on 7/29/2025, was reviewed. LVN 4 stated the PASARR Level 1 screening indicated, Resident 7 had no serious mental illness diagnoses and not on prescribed psychotropic medications. LVN 4 stated PASARR Level II (an in-depth, face-to-face or telehealth assessment triggered when a Level I screen suspects a serious mental illness, intellectual disability, or related condition) mental health evaluation was not required. LVN 4 stated the facility should have completed and resubmitted a new PASARR Level 1 under Resident Review (RR - Status Change) because Resident 7 had a new diagnosis of mental illness and was prescribed psychotropic medications. LVN 4 stated it is important to complete and resubmit a new PASARR Level under Resident Review so the facility would know what kind of psychiatric care and treatment to provide for Resident 7. During a review of the facility's policy and procedure (P&P), titled Preadmission Screening and Resident Review, dated 6/2024, the P&P indicated, The facility will submit a new Level 1 PASARR if the MDS does not match the Level 1 Screening from the GACH or any error or discrepancy in the previous PASARR screening.

Based on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] - a federally mandated resident assessment tool) for two of 14 sampled residents (Residents 2 and 32) reflected an accurate assessment, by failing to:A. Ensure Resident 2's Gabapentin (a medication used primarily used as anticonvulsant and for treatment of certain types of nerve pain) medication was encoded as anti-convulsant medication in the MDS assessment Section N0415 (High-Risk Drug Classes) K1(Anticonvulsant).B. Ensure Resident 32's dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment was encoded in the MDS assessment Section O (Special Treatments, Procedures, and Programs) 0110 (J1 - Dialysis). This deficient practice resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and delivery of care and services for Residents 2 and 32.Findings:A. During a review of Resident 2's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included End Stage Renal Disease ([ESRD] - irreversible kidney failure), dependence on renal dialysis, and Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 2's History and Physical (H&P), dated 11/20/2025, the H&P indicated, Resident 2 had the mental capacity to understand and make decisions.During a review of Resident 2's Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from 3/1/2026 to 3/10/2026, the MAR indicated, Resident 2 was given Gabapentin 100 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) at bedtime (9:00 p.m.) for nerve pain.During a review of Resident 2's MDS assessment, dated 3/10/2026, the MDS indicated, Resident 2 was independent (decisions consistent and reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 2 required substantial assistance (helper does more than half the effort) from staff with toileting hygiene and showering.During a concurrent interview and record review on 4/22/2026 at 7:37 a.m., with the Minimum Data Set Nurse (MDSN), Resident 2's MDS assessment, dated 3/10/2026, was reviewed. The MDSN stated Resident 2's MDS was completed inaccurately. The MDSN stated there should be a checked mark on Resident 2's MDS Section N0415 (K1) because Resident 2 was taking Gabapentin which was classified as anticonvulsant medication. The MDSN stated accurate coding of medications in the MDS was important so the facility could provide proper care and treatment to the residents.During an interview on 4/22/2026 at 10:54 a.m., with the MDSN, the MDSN stated the facility has no policy and procedure (P&P) for MDS assessment. The MDSN stated the facility follows the Resident Assessment Instrument ([RAI] - a guide that helps nursing home staff use to assess residents and develop care plans) manual for completing the MDS assessment.During an interview on 4/23/2026 at 10:58 a.m., with the Director of Nursing (DON), the DON stated MDS is a coordination of care with the interdisciplinary team ([IDT] team members from different disciplines who come together to discuss resident care). The DON stated it is important to complete the MDS assessment accurately so the CMS would know the condition of the resident.During a review of Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.20.1, dated 10/2025, page N-6, indicated to code all high-risk drug class medications in item N0415 according to their pharmacological classification, not how they are being used.B. During a review of Resident 32's Face Sheet, the Face Sheet indicated, Resident 32 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 32's diagnoses included ESRD, dependence on renal dialysis, and hypertension ([HTN] - high blood pressure).During a review of Resident 32's physician order, dated 11/22/2024, the physician orders indicated, Resident 32 has an order for dialysis treatment every Monday, Wednesday, and Friday.During a review of Resident 32's MDS, dated [DATE], the MDS indicated, Resident 32 was independent in cognitive skills for daily decision making. The MDS indicated, Resident 32 was independent (resident completes the activity with no assistance from a helper) with oral hygiene, toileting hygiene, and personal hygiene.During a review of Resident 32's H&P, dated 2/14/2026, the H&P indicated, Resident 32 had the capacity to understand and make medical decisions.During a concurrent interview and record review on 4/22/2026 at 7:25 a.m., with the MDSN, Resident 32's MDS assessment, dated 2/4/2026, was reviewed. The MDSN stated Resident 32's MDS was completed inaccurately. The MDSN stated there should be a checked mark on Resident 32's MDS Section O 0110 (J1) because Resident 32 had a dialysis treatment and did not refuse or missed dialysis treatment during the 14 days look back period (the specific time frame within which certain resident conditions and events are assessed) before the Assessment Reference Date ([ARD] - observation end date) of 2/4/2026. The MDSN stated accuracy of assessment in the MDS was important so the facility staff could identify the needs of the resident.During an interview on 4/22/2026 at 10:50 a.m., with the MDSN, the MDSN stated the facility has no P&P for MDS assessment. The MDSN stated the facility follows the RAI manual for completing the MDS assessment.During a review of Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.20.1, dated 10/2025, page O-7, indicated for Section O 0110 J1 (Dialysis) to code peritoneal or renal dialysis which occurs at the nursing home or at another facility.

Based on observation, interview, and record review, the facility failed to meet the required room size measurement of 80 square feet of room space per resident in rooms with multiple residents.This deficient practice could potentially result in the residents not being able to move around freely and could potentially affect residents' health and safety.Findings:During a review of the facility's Client Analysis form, on 4/22/2026 at 10:18 a.m., the facility's Client Analysis form indicated:House Station Roomsa. room [ROOM NUMBER] had three resident beds, which measured 216 square feet.b. room [ROOM NUMBER] had two resident beds, which measured 144 square feet.c. room [ROOM NUMBER] had four resident beds, which measured 252 square feet.d. room [ROOM NUMBER] had three resident beds, which measured 198 square feet.e. room [ROOM NUMBER] had three resident beds, which measured 208 square feet.f. room [ROOM NUMBER] had three resident beds, which measured 208 square feet.f. room [ROOM NUMBER] had four resident beds, which measured 260 square feet.g. room [ROOM NUMBER] had one resident bed, which measured at 99 square feet.h. room [ROOM NUMBER] had one resident bed, which measured at 99 square feet.Annex Station Rooma. room [ROOM NUMBER] had three resident beds, which measured at 168 square feet.b. room [ROOM NUMBER] had four resident beds, which measured at 312 square feet. During an interview on 4/24/2026, at 11:34 a.m., with the Assistant Administrator (AA), the AA stated the Administrator submitted a room waiver form on 4/20/2026. The AA stated some of the facility's rooms were smaller than the required square footage of 80 square feet per resident. The AA stated the risk of not meeting the required square footage for each resident could result in residents not being able to move around freely. The AA stated there was no harm caused to the residents in the affected rooms.During observations made to the multiple affected rooms in the House Station Rooms (Rooms 1, 2, 3, 4, 6, 7, 8, 9 and 10) and Annex Station Room (rooms [ROOM NUMBERS]) on 4/21/2026 to 4/24/2026, the room sizes of the above rooms did not adversely affect the residents health and or safety.The Department is recommending a waiver.

Based on observation, interview, and record review the facility failed to implement policies and procedures for one out of three sampled residents (Resident 1) that an abuse allegation was reported within two hours to the California Department of public Health (CDPH) and other agencies. This deficient practice of not reporting an abuse allegation within two hours caused a delay in investigating by the CDPH.Findings:a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses hemiplegia (a condition characterized by loss of muscle strength), hemiparesis (weakness on one side of the body), osteoarthritis (a condition that causes pain, stiffness, and impaired mobility. During a review of Resident 1's History and Physical (H&P), dated 3/26/2025, the H&P indicated Resident 1 had the ability to make decisions for activities of daily living. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/9/2025, the MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) by staff for toileting hygiene, showering, and dressing. The MDS indicated Resident 1 was always incontinent (inability to control the flow of urine from the bladder) with urine. b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses epilepsy (a chronic neurological condition characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain), idiopathic neuropathy (a type of peripheral neuropathy where the cause of nerve damage cannot be identified), and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 2's History and Physical (H&P), dated 7/24/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 required partial/moderate assistance by staff for toileting hygiene, showering, and dressing. During a record review of facility's termination notice, Notice to Employee as to Change Relationship, dated 7/22/2025, the termination notice indicated Certified Nursing Assistant (CNA) 1 was discharged effective 7/22/2025 due to unprofessional behavior. During an interview on 8/12/2025 at 8:45 a.m. with Resident 1, Resident 1 stated the Certified Nursing Assistant (CNA) 1 on the night shift (11 p.m. to 7 a.m.)had pushed on his leg, hit him with his pillow, and was telling him he can clean himself with a rude tone (a manner of speaking that is disrespectful, impolite, and often characterized by a harsh aggressive, or dismissive attitude). Resident 1 stated he had notified the head nurse (Director of Staff Development) that morning. During an interview on 8/12/2025 at 9:00 a.m. with Resident 2 stated Resident 1 had told Certified Nursing Assistant (CNA) 1 was speaking rudely to Resident 1. Resident 2 stated she was telling Resident 1 to change himself, and that he could wipe himself if he did not want to wait to be changed. During an interview on 8/12/2025 at 9:17 a.m. with Director of Staff Development (DSD), the DSD stated during morning rounds on 7/17/2025 at 6 a.m. Resident 1 had told her CNA 1 had rough handled him while CNA 1 was cleaning him and spoke rudely. The DSD stated that these alleged actions of CNA 1 were considered abuse and needed to be reported within two hours. During an interview on 8/12/2025 at 12:55 p.m. with the Administrator (ADM), the ADM stated the DSD reported CNA 1 was rude and rough handled Resident 1. The ADM stated the DSD was a mandated reporter and had reported to the him about the alleged abuse. The ADM stated Resident 1 was told by CNA 1 to clean up his own sh The ADM stated when there is an allegation of abuse the staff were to report within two hours. The ADM stated CNA 1 had displayed unprofessional conduct she was suspended on 7/16/2025 and later terminated on 7/22/2025. During a review of facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigation, dated 3/2023, the P&P indicated if resident abuse is suspected, the suspicion must be reported immediately. The P&P indicated immediately is within two hours of an allegation involving abuse or within 24 hours of an allegation that does not involve abuse or result in serous bodily injury. The P&P indicated any employee will be placed on leave pending investigation. The P&P indicated if the investigation reveals that the allegation of abuse are founded, the employee is terminated.

Based on observation, interview, and record review the facility failed to ensure one out of three sampled residents (Resident 1) was treated with dignity when requesting to be cleaned by the Certified Nursing Assistant (CNA) 1.This deficient practice of not cleaning Resident upon request left Resident 1 to feel frustrated and upset. Findings:a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses hemiplegia (a condition characterized by loss of muscle strength), hemiparesis (weakness on one side of the body), osteoarthritis (a condition that causes pain, stiffness, and impaired mobility. During a review of Resident 1's History and Physical (H&P), dated 3/26/2025, the H&P indicated Resident 1 had the ability to make decisions for activities of daily living. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/9/2025, the MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) by staff for toileting hygiene, showering, and dressing. The MDS indicated Resident 1 was always incontinent (inability to control the flow of urine from the bladder) with urine. During an interview on 8/12/2025 at 8:45 a.m. with Resident 1, Resident 1 stated the Certified Nursing Assistant (CNA) 1 on the night shift (11 p.m. to 7 a.m.)had pushed on his leg, hit him with his pillow, and was telling him he can clean himself with a rude tone (a manner of speaking that is disrespectful, impolite, and often characterized by a harsh aggressive, or dismissive attitude). Resident 1 stated the way she had treated me made him feel bad and If I did not need help; I would not ask for help. b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses epilepsy (a chronic neurological condition characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain), idiopathic neuropathy (a type of peripheral neuropathy where the cause of nerve damage cannot be identified), and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 2's History and Physical (H&P), dated 7/24/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 required partial/moderate assistance by staff for toileting hygiene, showering, and dressing. During an interview on 8/12/2025 at 9:00 a.m. with Resident 2 stated CNA 1 did speak to Resident 1 rudely telling him to change himself and that he could wipe himself since he did not want to wait to be changed. During an interview on 8/12/2025 at 9:17 a.m. with Director of Staff Development (DSD), the DSD stated during morning rounds on 7/17/2025 at 6 a.m. Resident 1 had told her CNA 1 had rough handled him while CNA 1 was cleaning him and spoke rudely. The DSD stated CNA 1 role was to provide care upon request from Resident 1 in a respectful manner. The DSD stated when the CNA 1 did not provide proper care when Resident 1 requested it to be changed. The DSD stated CNA 1 behavior caused Resident 1 to not trust her care and to not want her assistance. During an interview on 8/12/2025 at 2:10 p.m. with Director of Nursing (DON), the DON stated CNA 1 was to treat Resident 1 with dignity and assist him with care. The DON stated CNA 1 was to clean Resident 1 and speak to him respectfully. The DON stated not treating Resident 1 with dignity could make him feel belittled (to make someone feel less important, capable, or worthy). During a review of facility's policy and procedure (P&P) titled, Dignity, dated 2/2021, the P&P indicated residents were to be treated with dignity and respect at all times. The P&P indicated staff are to speak respectfully to residents at all times. The P&P indicated demeaning practices and standards of care that compromise dignity was prohibited and to assist the resident promptly to resident's request for toileting assistance. The P&P indicated staff were expected to not challenge or contradict the resident's beliefs or statements.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) who had severe cognitive impairment, was safely discharged when the facility failed to: 1. Ensure an Interdisciplinary Meeting ([IDT] gathering where healthcare professionals from different disciplines collaborate to discuss a patient's care, develop shared understandings, and coordinate treatment plans) for discharge planning was conducted for Resident 1. 2. Ensure Resident 1 ' s discharge location (house) could meet the resident ' s needs. 3. Follow up with Resident 1 after his discharge from the facility to the house, to ensure Resident 1 was safe and comfortably settled. 4. Ensure Resident 1 had a designated individual to safely administered his medications including Risperdal (medication to treat mental health conditions) and gabapentin (medication to treat nerve pain). 5. To contact the Local Contact Agency (a state-designated entity that provides options counseling to individuals in long-term care facilities interested in exploring community-based services and supports) to notify of Resident 1 ' s discharge. 6. Implement its Policies and Procedures (P&P) titled, Transfer or Discharge, Facility-Initiated, which indicated facility-initiated transfers and discharges, must meet specific criteria, and require resident/representative notification, orientation, and documentation. These deficient practices resulted in Resident 1 being discharged to a house in which her needs could not be met, and the resident was placed at risk for falls, injuries, and worsening medical and psychiatric conditions. On 4/7/2025, Resident 1 became unconscious and was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment. On 4/9/2025 at 3:54 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the AssistantAdministrator (AADM) and Director of Nursing (DON) due to the facility ' s failure to ensure Resident 1 who had severe cognitive impairment, was safely discharged . On 4/11/2025 at 3:39 p.m., the facility submitted an acceptable IJ Removal Plan ([IJRP] a plan with interventions to correct the deficient practice). After validating the IJRP ' s implementation onsite, the IJ was removed on 4/11/2025 at 4:01 p.m. in the presence of Administrator (ADM), AADM, DON, Quality Assurance (QA), and Quality Assurance Consultant (QAC) The IJRP included the following immediate actions: 1. On 4/7/2025, the DON contacted staff member at the property (house) regarding Resident l's discharge location and verified the correct address and contact information. 2. The facility DON and Registered Nurse (RN) supervisor provided in-service to all licensed nurses regarding resident assessment prior to discharge to ensure residents with impaired cognition and inability to make decision to ensure that the receiving facility is safe and appropriate to provide the needed care to the resident after being discharged from the facility. 3. The DON provided in-service to licensed nurses regarding medication safety for discharges. The licensed nurse who assists with discharge will provide detailed instructions to include but not limited to: a. Medication administration, including medication name, dosage, frequency and route, quantity of each medication provided to the resident/responsible party, to ensure sufficient quantity of medications will be provided upon discharge. b. Home health (a healthcare provider that provides medical services to patients in their homes) follow-up to ensure medication compliance after being discharged . 4. The DON provided one-to-one in-service to the social service personnel and emphasized the following: a. 24 hours prior to discharge, the social service will verify the receiving facility/home to ensure accurate address, contact information and a valid license as indicated. b. Within 72 hours after discharge, the social service will contact the resident/responsible party/receiving facility/home health to ensure the resident is well settled-in at the new environment after the discharge. 5. On 4/9/2025, the ADM and the DON notified all licensed nurses and the Social Service personnel of the findings outlined in the IJ template dated 4/9/2025 and conducted in-services regarding the Transfer/Discharge policy, which included the following key components: Conduct a Discharge IDT meeting and develop a discharge care plan after admission to the facility, and then quarterly and as needed to assist the resident in discharge planning and to ensure all discharges are appropriate and safe. 6. The DON provided in-service to licensed nurses and social service personnel regarding measures to ensure residents are discharge to a location that can meet the resident's individual needs. The measures include but not limited to: a. Develop and implement discharge care plan for all residents after admission, and then quarterly and as needed. b. Conducting assessments prior to discharge. c. Verifying the receiving facility/home health to ensure accurate information. d. Following up with resident/responsible party/receiving facility after discharge to ensure the discharge location can meet the resident's needs. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of dementia (progressive decline in cognitive abilities, such as memory, thinking, and problem-solving,) traumatic fracture (a break in a bone caused by a forceful impact or injury, like a fall or car accident), and schizophrenia (chronic mental health condition characterized by disruptions in thought processes, perceptions, emotions, and behavior.) During a review of Resident 1 ' s Care Plan titled Falls/Injury because of behavioral problems, dementia, and impaired cognition dated 5/8/2022, the care plan indicated to provide 1:1 (one-on-one patient care, where a healthcare professional provides constant attention to a single patient) every shift as ordered due to poor safety awareness. During a review of Resident 1 ' s Minimum Data Set ([MDS], a resident assessment tool), dated 1/29/2024, the MDS indicated Resident 1 was sometimes able to understand and be understood by others. The MDS indicated Resident 1 required supervision for eating, and upper body dressing. The MDS indicated Resident 1 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene, toileting hygiene, showering/bathing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 required supervision with rolling left to right, sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, tub/shower transfer, and walking 10, 50 and 150 feet. The MDS indicated Resident 1 required moderate assistance to sit, stand and for toilet transfer. The MDS indicated Resident 1 required a mechanically altered diet (change in texture of food or liquids e.g. pureed food, thickened liquids.) The MDS indicated Resident 1 was on antipsychotic (medications used to treat mental health conditions characterized by psychosis [mental health condition characterized by a loss of touch with reality], such as schizophrenia and bipolar [mental health condition characterized by extreme mood swings between periods of high energy, elevated mood, and low mood, loss of interest, and fatigue] disorder) medications. During a review of Resident 1 ' s Order Details dated 1/22/2025, the order indicated Risperidone (drug used to treat certain mental disorders, such as schizophrenia and bipolar disease) 3 milligrams ([mg] unit of measurement), give 1 tablet by mouth at bedtime, for schizophrenia. During a review of Resident 1 ' s Order Details dated 2/21/2025, the order details indicated Gabapentin (medication for seizures or nerve pain) oral capsule 300 mg by mouth, two times a day for neuropathy (condition where nerves are damaged or malfunctioning), hold for drowsiness. During a review of Resident 1 ' s Multidisciplinary Progress Record dated 2/26/2025, the record indicated Resident 1 remained disorganized, delusional with positive agitation. During a review of Resident 1 ' s Order Details dated 3/14/2025, the order details indicated may discharge Resident 1 to an Assisted Living Facility. During a review of Resident 1 ' s Los Angeles Fire Department (LAFD) Patient Care Report dated 4/7/2025 at 6:29 p.m., the LAFD report indicated Resident 1 was unconscious, and her mental status was deteriorating (to become worse in condition). The LAFD report indicated a private ambulance was called but upon arriving to the house, 911 had been called due to Resident 1 ' s altered level of consciousness. The LAFD report indicated Resident 1 was not alert and oriented and her vital signs were normal. During a review of Resident 1 ' s GACH records titled emergency room (ER) template dated 4/8/2025 at 8:20 a.m., the report indicated, Resident 1 was brought for altered mental status. The report indicated Resident 1 was non-verbal and did not follow commands or open her eyes and move to pain. During a review of Resident 1 ' s GACH records titled Resident Family Medicine History and Physical (H&P) dated 4/8/2025 at 2:39 p.m., the record indicated Resident 1 was stuporous (confused and slow to react ) with a Glasgow Coma Scale ([GCS] tool used to assess a patient's level of consciousness after a brain injury or other neurological issue) 10 (score of 10 suggests the person is drowsy, reduced alertness or consciousness, but may still be able to open their eyes and respond to painful stimuli). The H&P indicated Resident 1 was non-verbal and not following commands. Resident 1 was able to open her eyes and move to pain. The H&P indicated Resident 1 ' s laboratory (lab) results indicated the resident had a urinary tract infection ([UTI] bacterial infection that affects any part of the urinary system,). The report indicated Resident 1 was started on empiric (used when the cause of an illness is uncertain) antibiotics (medications that kill or stop the growth of bacteria). During an interview on 4/8/2025 at 8:26 a.m., with Resident 1 ' s Family Member (FM 1), FM 1 stated the facility called him on 3/14/2024 to inform him Resident 1 was being transferred to another facility because Resident 1 no longer needed the services at facility. FM 1 stated the facility gave him the name and address of the new facility (house)but when he attempted to google the address, he could not find it. FM 1 stated he then attempted to find the name of the facility (house) provided to him and he could not find it either. FM 1stated he called the Skilled Nursing Facility ([SNF] long-term care facility that provides specialized nursing care and rehabilitation services to individuals who need medical or nursing care, or rehabilitation services due to injury, disability, or illness), but the facility told him Resident 1 was no longer under their care and they were no longer responsible for the resident. FM 1 stated Resident 1 did not have a cell phone and was unable to use one because the resident had dementia. During an interview on 4/8/2025 at 8:49 a.m., with the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), the Ombudsman stated she had received a complaint from FM 1 stating he could not locate Resident 1. The Ombudsman stated FM 1 called the facility, but the facility was not responding. The Ombudsman stated she had not received a discharge notification for Resident 1. During an interview on 4/8/2025 at 10:48 a.m., with Certified Nurse Assistant (CNA 1), CNA 1 stated Resident 1 had a sitter because she was confused and would try to get out of bed without assistance. CNA 1 stated Resident 1 was at high risk for falling which was the reason the facility had to keep a close eye on her. During a concurrent interview and record review on 4/8/2025 at 11:00 a.m., with Licensed Vocational Nurse (LVN 1), Resident 1 ' s Social Services (SS) Note dated 3/14/2025 at 2:41 p.m., was reviewed. LVN 1 stated the note indicated Resident 1 was accepted at an assisted living facility. LVN 1 attempted to look up the address provided in the SS note through a google search but could not find the listed address. LVN 1 stated she did not know the location of the assisted living facility. LVN 1 stated FM 1 called to inquire about the where abouts of Resident 1, but the facility did not have the information. LVN 1 stated there were no IDT notes, or discharge care plans noted in Resident 1 ' s medical record. During a concurrent interview and record review on 4/8/2025 at 12:17 p.m., with the SS, Resident 1 ' s Social Services IDT Resident Discharge Planning dated 10/30/2024 at 9:26 a.m., was reviewed. The SS stated the record indicated Resident 1 was in the facility without a discharge potential (the likelihood to be discharged ). The SS stated the record indicated Resident 1 preferred not to return to the community. The SS stated Resident 1 required a dementia unit, and she (the SS) had not conducted an IDT meeting regarding sending Resident 1 to a house, or assisted living facility. The SS stated the facility ' s marketer initiated Resident 1 ' s transfer and the discharge location was not a dementia unit. The SS stated she received an incorrect address from the marketer, which she provided to FM 1 on 3/14/2025. The SS stated the facility ' s process was to conduct an IDT meeting on admission, quarterly, and as needed to identify the needs and goals for a resident and create a care plan with interventions that would assist the staff to achieve each resident ' s goals. The SS stated she did not conduct an IDT meeting for Resident 1 discharge on [DATE]. The SS stated she did not notify the Local Contact Agency (not known), or Ombudsman and she did not follow up to ensure Resident 1 was comfortably settled after discharge. The SS stated it was important to inform the Ombudsman because the Ombudsman was the resident ' s advocate and could follow up on Resident 1 ' s concerns if there were any. The SS stated the facility met Resident 1 ' s needs and she did not know why the resident was discharge to a house, where his needs could not be met. The SS stated Resident 1 or FM 1 and 2 were not involved in selecting the new location because the marketer found it (the house). The SS stated on 3/14/2025, she informed Resident 1, of the transfer but she was not sure Resident 1 understood. The SS stated with transfers or discharges, the facility was supposed to provide discharge documents to the new (receiving) facility, where Resident 1 was discharged , but no one answered her calls, so she did not provide any discharge documents or information about Resident 1 to the discharge location. The SS also stated that she never followed up to ensure Resident 1 was comfortably settled after discharge. During an interview on 4/8/2025 at 1:33 p.m., with FM 2, FM 2 stated when he visited the house on 4/7/2025 (time unknown), he noticed Resident 1 looked pale (when the skin appears whiter than usual, often due to illness or fear), like she had lost weight, and the resident could not even talk. FM 2 stated he asked the Landlord (owner of the house) to call 911 for Resident 1 to be transferred to a GACH for evaluation and treatment. During an interview on 4/9/2025 at 10:08 a.m., with the Landlord, the Landlord stated it was his home and he was not running an assisted living facility. The Landlord stated he advertised to rent a bedroom on craigslist (free online classified ads platform where individuals can post and browse listings for jobs, housing, items for sale, services, and more) to help him pay his mortgage. The Landlord stated he was contacted by a Marketer (MK) about a resident (Resident 1) at the facility looking for a place to live. The Landlord stated MK told him (the Landlord) that Resident 1was to be discharged and the resident had no medical issues. The Landlord stated he was not in the healthcare profession and only accepted Resident 1 into his home for rent. The Landlord stated FM 2 requested Resident 1 be sent to a GACH because Resident 1 bruises and FM wanted the GACH to document the bruises. Landlord stated even though he did not observe any bruises on Resident 1 ' s body, he agreed to send Resident 1 to GACH for safety. During an interview on 4/9/2025 at 2:18 p.m., with Physical Therapist (PT), PT stated Resident 1 was unsteady and required someone to walk with her at all times, for safety. PT 1 stated that was the reason she had a sitter otherwise she would fall. During an interview on 4/9/2025 at 1:03 p.m. with Registered Nurse (RN), RN 1 stated on 3/14/2025 around 3:10 p.m. he discharged Resident 1 to what he thought was an assisted living facility. RN 1 stated he attempted to call the receiving facility (house) to give a handoff report on the resident, but the facility (house) did not answer the phone, and he did not call back. RN 1 stated Resident 1 ' s verbal report was not provided to the facility. RN 1 stated on 3/14/2025 at 3:10 p.m., he gave the Emergency Medical Technician (EMT) Resident 1 ' s verbal medication administration information and a printout list of the resident ' s medications. RN 1 stated he did not document the medications Resident 1 was discharged with and did not remember how many pills he gave the resident. RN stated Resident 1 was given important medications like Risperdal and Gabapentin. RN 1 stated if Resident 1 did not take her medications it could lead to worsening of symptoms. RN 1 stated there was also a potential for Resident 1 to overdose, and it was important to educate the resident about his medications, administration times, dosages, and side effects. During an interview on 4/9/2025 at 4:05 p.m., with Resident 1 ' s Physician (MD 1), MD 1 stated she did not give an order for Resident 1 to be discharged because Resident 1 was not ready for discharge to a lower level of care. MD 1 stated no staff notified her that Resident 1 was discharged from the facility. MD 1 stated Resident 1 still required care from the facility. MD 1 stated all communications with the facility were done through messages and the orders were signed by her in batches (group of multiple orders). MD 1 stated she did not review it individually and might have signed the discharge order by accident. MD 1 stated Resident 1 still required care from the facility ' s staff and should not have been discharged . During a review of the facility ' s Policies and Procedures (P&P) titled Transfer or Discharge, Facility-Initiated, dated October 2022, the P&P indicated facility-initiated discharges, must meet specific criteria, and required resident/representative notification, orientation, and documentation. The P&P indicated the facility should provide the resident and his representative thirty (30)-day advance written notice of an impending discharge from the facility. The P&P indicated the resident, and representative should be notified in writing, the specific reason for the transfer or discharge, including the effective date of the transfer or discharge, the specific location to which the resident is being discharged . The P&P indicated the facility must send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman at the same time the notice of discharge was provided to the resident and representative. The P&P indicated a post-discharge plan should be developed for each resident prior to her discharge, and must be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge from the facility. The P&P indicated the nursing notes should include documentation of appropriate orientation and preparation of the resident prior to the discharge. The P&P indicated if the resident was discharged for any reason, the basis for the discharge, contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, all special instructions or precautions for ongoing care should be communicated to the receiving facility.

Based on observation and interview, the facility failed to ensure the medication room storage refrigerator was maintained below 46 degrees as indicated in the facility's policy and procedure (P&P) titled, Medication Storage in the Facility. This deficient practice had the potential for medications be stored in improper temperature, or humidity and can alter the effectiveness of the medication. Findings: During an observation, on 3/19/2025, at 12:20 p.m., at the medication room storage refrigerator, the refrigerator had unopened insulin (a hormone that lowers the level of blood sugar in the blood) vials, insulin pens, and unopened multidose tuberculin (a substance used in a skin test to help diagnose tuberculosis [TB] infection) injection vials. The medication storage refrigerator temperature was observed at 48 degrees Fahrenheit. During a concurrent observation and interview, on 3/19/2025, at 12:22 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated per policy, the temperature for the refrigerator should be maintained between 36-46 degrees. LVN 1 stated the refrigerator temperature was 48 degrees. LVN 1 stated the risk of having an out of range temperature of the medication refrigerator could result in medications expiring. During a review of the facility's P&P titled, Medication Storage in the Facility, dated 4/2008, the P&P indicated, medications requiring refrigeration or 'temperatures between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit), should be kept in a refrigerator with a thermometer to allow temperature monitoring.

Based on observation, interview, and record review, the facility failed to: 1. Ensure the low air loss mattress ([LALM] a mattress designed to prevent and treat pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) was set and maintained at the correct setting according to the manufacturer's setting for two of three sampled residents (Residents 16 and 41). 2. Ensure one out of six sampled residents (Resident 105) had a LALM to prevent pressure ulcer. These deficient practices placed Residents 16 and 41 at risk for discomfort and skin breakdown. and had the potential to result in the worsening of Resident 105 pressure ulcer. Findings: 1. During a review of Resident 16's Admission Record, the Admission Record indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 16's diagnoses included anxiety disorder (a mental health condition characterized by excessive, persistent, and irrational worry or fear that interferes with daily life), chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty of breathing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 16's Minimum Data Set ([MDS] a resident assessment tool) dated 1/10/2025, the MDS indicated Resident 16's cognitive (ability to think and reason) skills was severely impaired (never/rarely made decisions). The MDS indicated Resident 16 was dependent from staff with oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 16 was at high risk for developing pressure ulcers. During a review of Resident 16's Order Summary Report dated 3/20/2025, the Order Summary Report indicated the physician placed a telephone order on 2/7/2025 for Resident 16 to have LALM for skin maintenance. During a review of Resident 16's Weight Summary Report dated 3/7/2025, the Weight Summary Report indicated Resident 16's weight was 106 pounds (lbs.). During a review of Resident 41's Admission Record, the Admission Record indicated Resident 41 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 41's diagnoses included anxiety disorder, anemia (a condition where the body does not have enough healthy red blood cells), and protein calorie malnutrition (a condition caused by a severe lack of protein and calories). During a review of Resident 41's MDS dated [DATE], the MDS indicated Resident 41's cognitive skills for daily decision making was severely impaired. The MDS indicated, Resident 41 required maximal assistance (staff does more than half the effort) with eating, upper body dressing, and personal hygiene. The MDS indicated Resident 41 was high risk for developing pressure ulcers. During a review of Resident 41's Order Summary Report dated 3/20/2025, the Order Summary Report indicated, the physician placed a telephone order on 2/7/2025 for Resident 41 to have LALM for skin maintenance. During a review of Resident 41's Weight Summary Report dated 3/7/2025, the Weight Summary Report indicated Resident 41's weight was 87 lbs. During a concurrent observation and interview on 3/18/2025 at 9:14 a.m., with Licensed Vocational Nurse (LVN) 3 in Residents 16 and 41's room, LVN 3 stated Resident 16 was lying on a LALM with a setting of 300 lbs. and Resident 41 was lying on a LALM with a setting of 350 lbs. LVN 3 stated Residents 16 and 41 LALM was set to an incorrect setting. LVN 3 stated LALM setting should be based on the current weight of the resident. LVN 3 stated incorrect setting of the LALM would put resident at risk for skin breakdown. During an interview on 3/19/2025 at 11:41 a.m., with the Director of Nursing (DON), the DON stated, it was the responsibility of the licensed nurses to check the setting of the LALM. The DON stated Residents 16 and 41 had fragile skin and they were at risk for development of pressure ulcers. The DON stated if the LALM was not properly set based on the resident's weight then it would defeat its purpose and cause the resident to be uncomfortable. During a review of the facility's undated policy and procedure (P&P) titled, Pressure-Reducing Mattresses, the P&P indicated, To provide mattresses that will prevent and/or minimize pressure on the skin. During a review of Drive user manual, titled Med-Aire Essential 8 Alternating Pressure and Low Air Loss Mattress System, the Driver user manual indicated, Turn the pressure adjust knob to set a comfortable pressure level using the weight scale as a guide. 2. During a review of Resident 105's Admission Record, the Face Sheet indicated Resident 105 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 105's diagnoses included end stage renal disease ([ESRD] irreversible kidney failure), diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 105's MDS dated [DATE], the MDS indicated Resident 105's cognitive skills was moderately impaired. The MDS indicated Resident 105 was dependent on staff for showering, dressing, and from lying to sitting in chair. The MDS indicated Resident 105 had an unstageable pressure ulcer (ulcer where the wound bed is obscured by slough or eschar). During an observation on 3/18/2025 at 10:26 a.m. in Resident 105's room, there was no LAL mattress observed on Resident 105's bed. During a concurrent interview and record review on 3/20/2025 at 10:23 a.m. with the DON, Resident 105's Order Summary Report dated 3/12/2025 was reviewed. The DON stated Resident 105 had a physician's order for a LALM for skin integrity (the state of the skin being intact, unbroken, and healthy) however the LALM had not been provided for Resident 105. The DON stated Resident 105 was at high risk for pressure ulcers and had an unstageable to the sacrococcyx (refers to the area between the sacrum and coccyx (tailbone). The DON stated the delay of not providing the LALM for Resident 105 had the potential for worsening of the unstageable wound. During a review of the facility's P&P titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol dated 4/2018, the P&P indicated the nursing staff, and practitioner will assess risk factors for developing pressure ulcers. The P&P indicated the physician will order pertinent wound treatments, including pressure reduction surfaces. The P&P indicated the physician will help identify medical interventions related to wound management.

Based on observation, interview and record review, the facility failed to ensure the results of the most recent survey of the facility was posted in a place readily accessible to residents. This deficient practice had the potential to violate the rights of residents to examine the survey results of the facility and could lead to residents not being fully informed of the facility's deficient practices and how they were corrected. Findings: During an observation, on 3/20/2025 at 9:00 a.m., at the Annex Station, a signage was observed posted on the wall, inside of the nursing station indicating, CDPH survey information available upon request. During a concurrent observation and interview on 3/20/2025 at 9:47 a.m., with the Director of Nursing (DON), the DON stated all recertification survey results should have been in a folder at the nursing station, freely accessible to all residents. The DON stated the survey binder was not placed near the signage or around the nurse's station. The DON stated the risk of not providing free access to the facility's survey binder could result in residents not being informed of the facility's previous survey information and if any corrections were made. A review of the facility's policy and procedures (P&P) titled, CDPH 327- Attachment F: Resident [NAME] of Rights dated 5/2011, indicated A resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. The P&P indicated, The facility must make the results available for examination in a place readily accesible to residents and must post a notice of their availability.

Based on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to administering a psychotropic medication (any drug that affects brain activities associated with mental process and behavior) for two of four sampled residents (Residents 16 and 41). This deficient practice violated the resident's right to make an informed decision regarding the use of psychotropic medication. Findings: 1. During a review of Resident 16's Admission Record, the Admission Record indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 16's diagnoses included anxiety disorder (a mental health condition characterized by excessive, persistent, and irrational worry or fear that interferes with daily life), chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty of breathing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 16's Minimum Data Set ([MDS] a resident assessment tool) dated 1/10/2025, the MDS indicated, Resident 16's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 16 was dependent on staff for oral hygiene, upper body dressing, and personal hygiene. During a review of Resident 16's Order Summary Report dated 3/20/2025, the Order Summary Report indicated, the physician placed a telephone order on 2/1/2025 to administer lorazepam (a medication used to relieve anxiety) 0.5 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) by mouth every 12 hours as needed for anxiety manifested by restlessness (unable to stay still in bed) for Resident 16. 2. During a review of Resident 41's Admission Record, the Admission Record indicated 41 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 41's diagnoses included anxiety disorder, anemia (a condition where the body does not have enough healthy red blood cells), and protein calorie malnutrition (a condition caused by a severe lack of protein and calories). During a review of Resident 41's MDS dated [DATE], the MDS indicated Resident 41's cognitive skills for daily decision making was severely impaired. The MDS indicated, Resident 41 required maximal assistance (staff does more than half the effort) for eating, upper body dressing, and personal hygiene. During a review of Resident 41's Order Summary Report dated 3/20/2025, the Order Summary Report indicated, the physician placed a telephone order on 2/25/2025 to administer lorazepam to give 0.25 milliliter ([ml] - unit of fluid volume) by mouth every 4 hours as needed for anxiety manifested by restlessness causing shortness of breath for Resident 41. During a concurrent interview and record review on 3/19/2025 at 2:44 p.m., with the Minimum Data Set Nurse (MDSN), Residents 16 and 41's clinical records were reviewed. The MDSN stated there were no documentation to indicate that the physician of Residents 16 and 41 obtained informed consent and discussed the side-effects with the residents and/or responsible party regarding the use of lorazepam. The MDSN stated the informed consent should be completed with the signature of the physician and filed in resident's medical records. The MDSN stated the psychotropic medication should not have been administered to the residents if there was no informed consent. The MDSN stated it was a violation of resident rights for not getting an informed consent for use of psychotropic medication. During a review of the facility's policy and procedure (P&P) titled, Informing Residents of Health, Medical Condition and Treatment Options dated 2/2021, the P&P indicated, Each resident is informed of his/her total health status and medical condition, including diagnosis, treatment recommendations and prognosis, in advance of treatment and on an ongoing basis. If a resident has an appointed representative, the representative is also informed. During a review of the facility's P&P titled, Use of Psychotropic Medication dated 7/2022, the P&P indicated, Resident and/or representative have the right to decline treatment with psychotropic medications and the staff and physician will review the risks related to not taking the medications as well as appropriate alternatives.

Based on observation, interview and record review, the facility failed to protect one of three sampled residents (Resident 1), from physical abuse (willful infliction of injury with resulting physical harm, pain, or mental anguish) by Resident 2, by failing to: 1. Ensure Resident 1 (victim) was not subjected to a repetitive physical abuse from Resident 2 (aggressor). 2. Ensure Resident 1 and Resident 2 were separated and were not left to continue residing in the same room, after Resident 1 reported to a Licensed Vocational Nurse (LVN 1) that Resident 2 hit him on 4/1/ 2024. 3. Ensure Resident 1 and Resident 2 were separated, after Resident 2 hit Resident 1 on the right eye on 4/23/2024, causing Resident 1 to sustain a red bruise (an injury appearing as an area of discolored skin on the body, caused by a blow or impact) and swelling around the right eyelid. 4. Develop a care plan for Resident 1 and 2, with interventions to prevent further abuse on 4/1/2024 and 4/23/2024, after Resident 1 alleged to have been hit by Resident 2. 5. Follow their policy and procedure (P&P) Abuse & Mistreatment of Residents, which indicated when incidents involved the health, welfare, or safety of residents were reported, the involved resident(s) should be removed from the environment that threatened resident's health, welfare, or safety. As a result, Resident 2 hit Resident 1, and Resident 1 sustained a swelling and red discoloration to the right eyelid on 4/23/2024.This deficient practice also placed Resident 1 and other residents at risk for further abuse, that could result in serious physical harm/ injuries, hospitalization , and death. On 4/24/2024 at 2:30 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of Director of Nursing (DON) and Administrator (ADM) due to the facility ' s failure to protect Resident 1 from physical abuse by Resident 2 on 4/1/2024 and 4/23/2024, that resulted to swelling and red bruise (when a part of the body is injured and small blood vessels leak out) on the right eyelid. On 4/26/2024 at 11:01 a.m., the facility submitted an acceptable IJ removal plan ([IJRP] interventions to immediately correct the deficient practices). After verification of IJRP ' s implementation through observation, interview, and record review, the IJ was removed while onsite on 4/26/24 at 12:18 p.m., in the presence of the DON, ADM, Nurse Consultants 1 and 2. The IJRP included the following immediate actions: 1. On 4/23/2024, the facility moved Resident 1 from room B to C. 2. On 4/24/2024, the psychiatrist (a physician specializes in mental illness) conducted a bedside evaluation for Resident 1 and Resident 2. 3. On 4/23/24, the DON updated the care plan for Residents 1 and 2 and addressed the allegations of abuse. 4. On 4/24/2024, LVN 1 was placed on suspension pending investigation. 5. On 4/24/2024, the DON informed Resident 2 ' s physician of the alleged abuse, the physician ordered Resident 2 to be transferred to the general acute care hospital (GACH) for further evaluation, but Resident 2 refused. The physician was made aware and instructed the facility to continue to monitor Resident 2. 6. On 4/24/2024, the DON informed Resident 1 ' s physician of alleged abuse. The physician ordered Resident 1 to be transferred to GACH for further evaluation. 7. On 4/24/24, The DON notified the California Department of Public Health (CDPH), local police department, and Ombudsman (patient advocate) regarding two alleged physical abuse incidents that occurred on 4/1/24 and 4/23/24. 8. On 4/24/24, the ADM and the DON initiated investigations for the two allegations that occurred on 4/1/24 and 4/23/24. 9. On 4/24/2024, the ADM/DON/QA Consultant conducted in-services for all staff regarding the facility ' s abuse prevention policy. The staff were trained on securing the resident (victim) by removing and/or separating the resident from the alleged perpetrator, conduct assessments on resident(s) who were involved in the allegation, investigate the incident and report to mandated agencies. Findings: a). A review of Resident 1 ' s Admission record, dated 4/23/2024, indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of essential primary hypertension (high blood pressure) type 2 diabetes mellitus (abnormal blood sugar) and muscle weakness. A review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 1/5/2024, indicated Resident 1 had an intact cognition (mental capacity), required supervision (oversight help) with toileting and showers and was independent with personal hygiene and mobility (resident completes the activity with no assistance). A review of Resident 1 ' s History and Physical (H&P), dated 1/30/2024 indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s care plan, titled Abuse, dated 4/1/2023, indicated Resident 1 will be free from abuse. One of the interventions indicated, I am aware of the facility policy for reporting abuse and completing the concern form. b). A review of Resident 2 ' s Admission record, dated 4/23/2024, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses of schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves) with striking out behavior, hypertensive heart disease (high blood pressure that affects the heart). A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 had intact cognition and was independent with mobility. The MDS indicated Resident 2 had schizophrenia and was on antipsychotic medication (medication to manage schizophrenia). A review of Resident 2 ' s H&P, dated 7/21/2023 indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 2 ' s care plan, titled Episodes of striking out, dated 1/12/2024, indicated staff will monitor and record episodes of striking out behavior. A review of Resident 2 ' s physician ' s order dated 9/13/2023, indicated quetiapine fumarate (medication for mental disorders) 50 milligrams ([mg] unit of measurement) at bedtime for schizophrenia manifested by episodes of striking out. A review of LVN 1 ' s progress notes dated 4/1/2024 at 0152 (1:52 a.m.), indicated the LVN 1 responded to a loud, slammed door at Resident 2 ' s room. The progress notes indicated when LVN 1 asked Resident 2 what happened, Resident 2 stated he slammed the door because the M F kept opening the door (referring to Resident 1). The notes indicated Resident 2 shouted at LVN 1 to close the door. During a concurrent observation and interview on 4/23/2023 at 8:17 a.m. with Certified Nurse Assistant (CNA) 1, Resident 1 and Resident 2 were observed in the same room. CNA 1 confirmed Resident 1 and Resident 2 were still in the same room (Room B). During a concurrent observation and interview on 4/23/2024 at 8:17 a.m., Resident 1 and Resident 2 were in the same room (Room B). Resident 1 stated Resident 2 hit him on the face on 4/1/2024, and on 4/23/2024 early morning. Resident 1 was observed with a red bruise and a swollen right eye lid. Resident 1 stated Resident 2 hit him on the face (pointing to both eyes and bridge of the nose). Resident 1 stated he told the licensed nurses, and CNA that Resident 2 kept hitting him. Resident 1 stated Resident 2 used to close the door so no one would see him hitting Resident 1. Resident 1 stated the facility did not offer him a room change and he did not feel safe with sharing a room with Resident 2. During an interview with Resident 2 on 4/23/2024 at 8:46 a.m., Resident 2 stated he did not like Resident 1 leaving the door open. Resident 2 stated he preferred the door closed so he could sleep better, and for privacy. During an interview with CNA 1 on 4/23/2024 at 8:46 a.m., CNA 1 stated Resident 1 complained Resident 2 hit him on the right eye on 4/23/2024 at approximately 1:30 a.m. CNA 1 stated he immediately informed LVN 1 and LVN 1 assessed Resident 1. CNA 1 stated the concerns about Resident 2 hitting Resident 1 had been reported to the DON and ADM. CNA 1 stated he did not know if anything had been done for Resident 1. During a phone interview with former Housekeeping Supervisor (HKS) on 4/23/2024 at 9:12 a.m., the HKS stated, on 4/1/2024, he observed Resident 2 and Resident 1 in their room, and Resident 2 hit Resident 1. The HKS did not remember the part of Resident 1 ' s body Resident 2 hit. The HKS stated a CNA and LVN (unable to recall names) went into the room to check the residents but left both residents in the same room. The HKS stated he did not know the facility ' s protocol regarding resident-to-resident abuse incidents. During a phone interview with the facility ' s Secretary on 4/23/2024 at 10:58 a.m., the Secretary stated he translated (Spanish to English) for LVN 1, when LVN 1 was interviewing Resident 1 on 4/1/2024, regarding the alleged abuse incident. The Secretary stated Resident 1 reported that Resident 2 wanted the door to their room (Resident 1 and 2) closed but Resident 1 wanted the door open (date and time unknown). The Secretary stated, on 4/23/2024 at approximately 1:30 a.m., she also translated for LVN 1, regarding a second abuse incident involving Residents 1 and 2. The Secretary stated Resident 1 reported that Resident 2 hit him on his face and rib cage. The Secretary stated LVN 1 notified the ADM and DON of both incidents but did not move the residents to separate rooms. During a concurrent interview and record review with the DON on 4/23/2024 at 11:12 a.m., Resident 2 ' s Medication Administration Records (MAR) for March and April 2024, were reviewed. The DON stated the MAR indicated a total of six (6) episodes of striking out behavior from 3/31/2024 to 4/2/2024. The DON stated staff ' s interventions for Resident 2 ' s striking out behavior included monitoring the resident for 72 hours after each incident, deescalating the situation, distracting the resident, and having one staff monitor the resident closely. The DON stated staff did not intervene on 4/1/2024, when or after Resident 2 hit Resident 1. During a concurrent observation and interview with the DON on 4/23/2024 at 11:20 a.m., in the residents ' room, Resident 1 was observed sitting at the edge of his bed. The DON stated Resident 1 ' s right eyelid was swollen `with a red bruise. The DON stated Resident 1 pointed at the bridge of his nose and partially to both eyes when asked where Resident 2 had hit him. The DON stated he did not think Resident 1 was hit on the right eyelid. The DON stated both residents should have been separated after the first alleged abuse incident dated 4/1/2024, to prevent further abuse. The DON stated he did not investigate the abuse incident on 4/1/2024, because he did not know about it. The DON also stated on 4/23/2024, LVN 1 texted the DON to report that Resident 2 hit Resident 1. The DON stated the residents were left in the same room because Resident 1 was asleep. During a phone interview with LVN 1 on 4/23/2024 at 12:07 p.m., LVN 1 stated CNA 1 reported to her (LVN 1) that Resident 1 alleged Resident 2 hit him on the face, on 4/23/2024 around 1:30 a.m. LVN 1 stated she left both residents in the same room, did not document the incident in the residents ' progress notes, or change of condition (COC) form. LVN 1 stated she did not create a care plan with interventions to prevent further abuse and did not start a 72-hour monitoring for both residents. LVN 1 stated she should have moved Resident 1 to another room, for safety and prevent further abuse. LVN 1 stated if the residents were moved to separate rooms after the first incident on 4/12024, Resident 2 could not have hit Resident 1 for the second time on 4/23/2024. A review of the facility ' s undated P&P titled, Abuse & Mistreatment of Residents, indicated when incidents involved the health, welfare, or safety of residents were reported, the involved resident(s) should be removed from the environment that threatened the resident ' s health, welfare, or safety. The P&P indicated the charge nurse and/or nursing supervisor should conduct an immediate resident assessment to identify any injuries or extent of injuries, if any, notify the attending physician of incident for necessary interventions. The P&P indicated the charge nurse and/or nursing supervisor shall initiate resident care plan to reflect current conditions and measures taken to prevent recurrence of event, document findings and if the suspected perpetrator was another resident, the resident shall be separated to avoid further contact.

Based on observation, interview, and record review, the facility's licensed nurses failed to provide the necessary care and services for one of seven sampled residents (Resident A). Resident A, who had a long history of psychotic behavior (disorganized or incoherent speech confused thinking strange, possibly dangerous behavior) and a diagnosis that included schizophrenia (a mental disorder often characterized by abnormal social behavior and failure to recognize what is real), to meet the mental/physical care needs of Resident A. The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN 2) conducted a comprehensive assessment for Resident A upon admission to identify the resident's diagnoses of schizophrenia, psychotic disorder (a mental disorder characterized by a disconnection from reality), and suicidal ideations (preoccupation with thoughts of to commit suicide) with a plan in place to prevent self-harm. 2. Ensure LVN 2 identified and verified with Resident A's admitting physician (Physician 1) the order for a medication Zyprexa (a medication used to treat schizophrenia) 10 milligrams ([mg] a unit of measurement) at bedtime) that was ordered, administered by the discharging hospital while in the hospital to control Resident A's behavior and recommended for Resident A upon discharge to control behaviors. 3. Ensure the licensed nurses develop a care plan (CP) for Resident A with goals and staff's interventions related to the resident's diagnoses of schizophrenia and psychotic disorder with suicidal ideations with a plan in place to prevent self-harm with notification to Physician 1 for the possible need of an antipsychotic medication (work by altering brain chemistry to help reduce psychotic symptoms like hallucinations, delusions, and disordered thinking). As a result of these deficient practices, Resident A's care needs based on his long history of schizophrenia and psychotic disorder with suicidal ideations without receiving any antipsychotic medications to control his behavior resulted in the resident obtaining a knife, stabbing two residents, Resident B in the neck and chest and Resident C in the abdomen. Resident B was pronounced dead at the scene at the facility from wounds sustained when Resident A stabbed him. Resident C was transferred to a general acute care hospital (GACH) for evaluation and treatment of his wounds and had to undergo emergency surgery. On [DATE], Resident A was transferred to the facility from a GACH with diagnoses including schizophrenia, psychotic disorder, and suicidal ideations with a physician's order for Zyprexa 10 milligram (mg) at bedtime. On [DATE], upon admission to the skilled nursing facility (SNF) Resident A's diagnoses of schizophrenia, psychotic disorder, and suicidal ideations along with an order for the administration of Zyprexa 10 mg at bedtime was not transcribed to Resident A's current and active care regimen. On [DATE] at approximately 3:45 p.m., Resident A used a knife to stab Resident C in the abdomen and Resident B in his neck and chest. Resident C was taken to a GACH for evaluation and treatment of his stubbing wounds and Resident B was pronounced dead and expired at the facility on the same day from sustained stabbing injuries. On [DATE] at 4:35 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) due to the facility's failure to provide Resident A with care and services based on his psychiatric diagnoses, and due to the failure to identify and verify with the resident's admitting physician, and carry over to the resident's active/current medication regiment for a prescription for Zyprexa, was called in the presence of the facility's Administrator (ADM), the Quality Improvement (QI) Nurse who was the facility's Acting Director of Nursing (DON), the Corporate Assistant Administrator (CAADM), the Human Resources (HR) specialist and the Corporate Chief Nurse. On [DATE] at 5:30 p.m., the facility submitted an acceptable IJ Removal Plan (IJRP). After an onsite verification of the facility's IJRP implementation through observation, interview, and record review, the ADM, QI/Acting DON, and CAADM were notified the IJ situation was removed. The following immediate corrective actions were included in the IJRP: 1. The QA Consultant notified the licensed staff of the findings stated in the IJ template dated [DATE] and provided in-services regarding admission. During the in-services, the QA Consultant demonstrated on how to transcribe the admission orders from the transferring facilities with return demonstration. 2. Identification of Others There were 13 residents' admissions/re-admissions from [DATE] to-date. The MDS nurse has reviewed the physician orders against the hospital transfer records on [DATE] and [DATE] and there is no transcription error noted. 3. Preventive Recurrence The QA Consultant notified the licensed staff of the findings stated on the IJ dated [DATE] and gave in-services to the licensed staff on [DATE] and [DATE], regarding admission process. During the in-services, the QA Consultant demonstrated on how to transcribe the admission orders with return demonstration. The QA Consultant will repeat the in-services every month for 3 months to ensure compliance. The MDS nurse and/or designee will review all admission orders on the following business day to ensure accuracy. 4. Monitoring Performance The QA Consultant will visit the facility every week to checking admission orders to ensure compliance. The MDS nurse and/or designee will present the recapitulations of the findings to the monthly QA meeting for review and action as indicated. Findings: A review of Resident A's GACH records including Face Sheet, History of Present Illness (HPI), Past Psychiatric History (PPH), Past Medical History (PMI), Mental Status Examination (MSE), Medical Impression and Plan (MIP), Discharge Instructions (DI), and Clinical Summary Report (CSR) was conducted. The reviewed records indicated the following: 1. According to the GACH's Face Sheet, Resident A was admitted to the GACH on [DATE]. 2. According to the HPI, Resident A, a [AGE] year-old male with a history of depression, psychotic disorder, and substance abuse, was admitted to the GACH for suicidal ideation with intention to cut himself. Resident A presented with target symptoms of depressed mood, anhedonia (inability to feel pleasure), anxiety (extreme worry), hopelessness, helplessness, insomnia (inability to sleep and/or remain sleep), and mood lability (rapid, often exaggerated changes in mood, where strong emotions or feeling [uncontrollable laughing or crying, or heightened irritability or temper] occur with suicidal thoughts. 3. According to the PPH, Resident A had a long history of chronic depression, psychosis as well as suicidal thoughts and has not been consistently taking his medications. 4. According to the MSE, Resident A was awake, oriented to self, place, and situation. His mood was depressed and anxious, his affect was blunted (a prominent symptom of schizophrenia in which the patient has difficulty expressing their emotions, characterized by diminished facial expression, expressive gestures, and vocal expressions in reaction to emotion provoking stimuli), and his thought process was linear (following one path a process in which answers are yes or no). Resident A's thought content was positive for suicidal ideation, his cognition was intact and his insight and judgment (awareness of themselves and their condition) was limited. 5. According to the PMI, Resident A was diagnosed with schizophrenia and psychotic disorder. 6. According to the MIP, Resident A needed psychiatric care and to continue medications. 7. According to the DI, dated [DATE], under section titled, Problem List, Resident A had schizophrenia and suicidal ideations. 8. According to the CSR, Resident A was receiving Zyprexa 10 mg at bedtime, as an active medication ordered/recommended on discharge from the GACH. During a review of Resident A's skilled nursing facility (SNF) Admission Records (Face Sheet), the Face Sheet indicated Resident A was admitted to the facility on [DATE] with diagnoses including pneumonia (lung infection), extrapyramidal ([EPS] involuntary movement disorders induced usually by antipsychotic medications and other mental and emotional conditions) and movement disorder (a group of nervous system (neurological) conditions that cause either increased movements or reduced/slow movements), recurrent major depressive disorder (MDD), hypertension ([HTN] a condition where the pressure of the blood in the blood vessels was higher than it should be), lack of coordination, and generalized muscle weakness. During a review of Resident A's SNF entire clinical record, the clinical record indicated there was no written documentation of Resident A's diagnoses of schizophrenia, psychotic disorder, and/or suicidal ideations with intentions for self-harm. During a review of Resident A's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated [DATE], the MDS indicated Resident A had no difficulty seeing, hearing, expressing his ideas and wants, understanding others or making himself understood. The MDS indicated Resident A was able to make independent decisions that were consistent and reasonable. During a review of Resident A's history and physical (H/P), dated [DATE], the H/P indicated the resident had diagnosis of pneumonia, EPS disorder, MDD, HTN, lack of coordination, muscle weakness and a history of substance abuse. During a review of all Resident A's care plans, the review indicated there was no written documentation to indicate a care plan (CP) for the resident's diagnoses of schizophrenia, suicidal ideations, and/or the need for the administration of Zyprexa medication was developed to identify Resident A's care goal and staff's interventions related to Resident A's psychiatric diagnoses or the need for administration of Zyprexa medication. A review of Resident A's Physician's Orders from [DATE] through [DATE], there was no written documentation to indicate Resident A's diagnoses of schizophrenia, psychotic disorder, suicidal ideations, or an active order to administer Zyprexa or any antipsychotic medications to Resident A were included. During an interview on [DATE] at 2:45 p.m., and subsequent interviews on [DATE] at 1:10 p.m., and [DATE] at 1:45 p.m., with the ADON, the ADON stated Resident A's H/P, from the transferring GACH, should have been reviewed by the admitting nurse and a care plan developed based on Resident A's care needs identified during admission to the facility and ongoing as the resident's care needs changed. The ADON stated Resident A's clinical records were reviewed and the staff were aware of Resident A's diagnoses of schizophrenia, psychotic disorder, and suicidal ideations, as well as the medication, Zyprexa, that was not transcribed to Resident A's orders upon admission ([DATE]) to the SNF. The ADON stated they (staff) were looking into what happened why the resident's medication was not transcribed as recommended by the GACH. The ADON stated during the residents' admission process the admitting orders and H/P from the transferring GACH should be reviewed by the admitting nurse and verified with the resident's attending physician and documented. On [DATE] through [DATE] (nine days), multiple attempts to interview the admitting nurse, LVN 2, by telephone and texts to no avail. During a review of Resident A's Change of Condition (COC) documentation, dated [DATE] and timed at 3:45 p.m., the COC indicated the staff reported Resident A had an altercation with another resident. The residents were separated and 911 (emergency service) was called. The police arrived and Resident A was handcuffed and escorted out of the building by the police. During a review of Resident A's Nurses Progress Note (NPN) dated [DATE] and timed at 2:32 a.m., the NPN indicated staff reported Resident A had an altercation with another resident. The residents were separated and 911 was called. During an observation on [DATE] at 7:25 p.m., from approximately ,d+[DATE] feet away from the resident, Resident B was observed lying on the floor after being pronounced deceased (time unknown) by the local coroner (an official who investigates violent, sudden, or suspicious deaths). At approximately 8:15 p.m., on [DATE], Resident C was observed being transported by the coroner out of the facility. On [DATE] at approximately 9:30 a.m., during a view of the facility's surveillance video (close observation through a camera) of the stabbing incident on [DATE], there were two different views of the stabbing incident as follows: View #1 Resident C was seen entering the Annex (name of area in the facility) side of the facility through a door near the Annex nursing station. Resident C walked around the Annex nursing station and proceeded down the hallway. Resident C was halfway down the hallway and Resident A abruptly stood up and quickly walked down the same hallway toward Resident C. When Resident A was next to Resident C, he (Resident A) pulled out an object, resembling a knife, and stab Resident C in his left side (flank/abdomen area). Resident C turned and ran back toward the facility's exit and through the door he had previously came in. After Resident A stabbed Resident C and Resident C ran, Resident A turn his attention to Resident B, who was sitting in a wheelchair along the wall in the hallway. Resident A lunged at Resident B making at least three thrusting/jabbing motions, stabbing Resident B while Resident B was trying to push away and/or hold onto Resident A. Resident B fell from the wheelchair to the floor. Resident A was restrained by LVN 2 and the facility's Marketer while the staff attended to Resident B's injuries and started performing Cardiopulmonary Resuscitation ([CPR] an emergency procedure to help save a person's life when breathing and/or the heart stops). View #2 Resident A was seen entering the Annex side of the facility through a door on the outside patio area. Resident A sat in a chair that was lined up along the wall in the hallway, next to another resident, and Resident A started fidgeting (movements, especially of the hands and feet through nervousness or impatience). Resident A was seen pulling a wrapped object from the pocket of his jacket and unwrapped the object and placed the object on top of his thigh covering the object with his hand. A certified nurse assistant (CNA 1) was seen standing at the end of the hallway, approximately 10 feet from Resident A. CNA 1 appeared to be monitoring the hallway. CNA 1 was seen moving toward the door away from Resident A, while Resident C was seen walking down the hallway toward Resident A. Resident C was seen walking closer to Resident A and Resident A abruptly jumped up and raised his right arm and forcibly stabbed Resident C on the left side (flank area [lower side of the stomach/abdomen). Resident C was seen running back towards the Annex nursing station, while Resident A turned and stabbed Resident B, who was sitting in a chair next to the wall, at least three times. LVN 2 and the facility's Marketer was seen restraining Resident A while the staff attended to Resident B's injuries. The police then the paramedics arrived. Resident C was taken away on a gurney and Resident A was later taken away by the police. A knife measuring approximately 8.0 inches long was seen being handled by a police officer. During an interview on [DATE] at 8:59 p.m. with LVN 1, LVN 1 stated he works on the 3 p.m. to 11 p.m. shift and was assigned to the House side of the facility, where Resident A resided. LVN 1 stated Resident A was alert and oriented to his name, place, date, and was ambulatory (walk) with no behaviors. LVN 1 stated the day of the incident ([DATE]) he came to work and did his rounds taking a head count of all the residents and saw Resident A smoking on the smoking patio. LVN 1 stated he spoke to Resident A and Resident A spoke back, there was nothing abnormal about Resident A at that time. LVN 1 stated he was passing medications when he heard a Code Blue (notification of a cardiac/respiratory medical emergency) paged over the intercom. LVN 1 stated he ran to the Annex side of the facility and saw Resident B on the floor bleeding. LVN 1 stated while one staff was getting oxygen, another staff was using a towel to stop the bleeding from Resident B's chest and neck wounds. LVN 1 stated Resident B was not alert and/or responding so staff were performing CPR on Resident B. LVN 1 stated LVN 2 and the admission staff (the facility's Marketer) restrained Resident A on the floor in the door of the activity room. LVN 1 stated Resident C was bleeding from the left side of his abdomen, but he was up and walking. LVN 1 stated he did not see the weapon Resident A used but heard it was a knife. LVN 1 stated he was not sure where Resident A got the knife but heard Resident A left the facility earlier with the staff during the 7 a.m. to 3 p.m. shift. During a review of Resident B's Admission Records (Face Sheet), the face sheet indicated Resident B was initially admitted to the facility on [DATE] and last readmitted on [DATE]. During a review of Resident B's MDS, dated [DATE], the MDS indicated Resident B's cognitive (thought process) skills for daily decision-making was severely impaired. During a review of Resident B's Nurses Progress Note (NPN), dated [DATE] and timed at 11:56 p.m., the NPN indicated at 3:45 p.m., on [DATE], Resident B sustained injuries following an altercation with another resident, CPR was initiated by staff and 911 was called. Resident B was declared deceased by the paramedics. During a review of Resident C's Admission Records (Face Sheet), the Face Sheet indicated Resident C was initially admitted to the facility on [DATE] and last readmitted on [DATE]. During a review of Resident C's MDS, dated [DATE], the MDS indicated Resident C made independent decision that were reasonable and consistent. During a review of Resident C's Change of Condition (COC) document, dated [DATE] and timed at 3:45 p.m., the COC indicated at 3:45 p.m. Resident C had an altercation with another resident with blood coming from Resident C's lower left abdomen, 911 was call, and Resident C was transferred to a GACH for further evaluation. During a review of Resident C's NPN, dated [DATE] and timed at 11:18 p.m., the NPN indicated Resident C had been transferred out earlier to the GACH via 911 for a medical emergency. During a review of the facility's undated policy and procedure (P/P) titled, Mental/Behavior Management, the P/P indicated the facility will provide proper care to ensure all residents who have dementia and/or behavior management will receive the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. The P/P indicated the facility would conduct assessments including trauma care evaluation for all residents upon admission. The facility will develop and implement person-centered care plans. During a review of the facility's undated P/P titled, The Resident Care Plan, the P/P indicated the resident care plan shall be implemented for each resident on admission. This should be completed within seven days of admission, or after a professional's initial contact with the resident. The care plan is updated at the first meeting of the health team. The first meeting is to be held within 14 days of admission. Care plans are considered comprehensive in nature and should be reviewed in its entirety. Although the care area assessment (CAA) triggers most problem areas, all other problems not identified in the CAAs must also be included in the care plan. It is the responsibility of the Director of Nursing to ensure that each professional involved int eh care of the resident is aware of the written plan of care. During a review of the facility's undated policy and procedure (P/P), titled, Suicidal Residents the P/P indicated for a non-acute threat/concern of resident who is threatening suicide or has suicidal ideations social services shall be contacted and involved, activities shall be provided to redirect resident's thought and behavior, a quiet environment shall be provided for the resident, a safe environment shall be provided for the resident. For a resident with a history of suicidal ideations but appear controlled a with no signs and symptoms of behavior relating to suicide. Monitor for signs and symptoms of behavior every shift, social services will visit monthly to assess mood. During a review of the facility's P/P titled, Physician Orders and Telephone Orders dated ,d+[DATE], the P/P indicated all orders must include the date and time received and must be noted by the professional staff taking the order.

Based on observation, interview, and record review the facility's nursing staff failed to ensure a resident, who was taken out of the facility, by staff (the facility's Marketer) to a local general store without a physician's order to go out on pass, was always supervised to ensure the resident's safety and prevent incidents from occurring for one of one sampled resident (Resident A). The facility failed to: 1. Ensure the Resident A did not leave the facility without an out on pass order from the physician, per the facility's policy and procedure titled Out on pass. 2. Ensure the facility's Marketer has always supervised Resident A while out on pass at a local general store to prevent Resident A from stealing a knife to use it later to stab and kill Resident B and stab and injure Resident C. This deficient practice resulted in Resident A being left alone and unsupervised at the general store on [DATE], which subsequently led to Resident A stealing a 7.5-inch-long kitchen knife from that store and later the same day ([DATE]) to use that knife to stab Resident B in his neck and chest and Resident C in his abdomen (belly). Resident B was pronounced dead at the scene at the facility from sustaining stabbing wounds and Resident C was transferred to a general acute care hospital (GACH) for evaluation and treatment of his stabbing wounds and undergo surgical intervention and a blood transfusion. Findings: During a review of Resident A's Admission Records (Face Sheet), the Face Sheet indicated Resident A was admitted to the facility on [DATE] with diagnoses including pneumonia, extrapyramidal symptoms ([EPS] involuntary movements that cannot be controlled, effects are most common when taking antipsychotic medication [a class of medicines used to treat psychosis (abnormal condition of the mind) and other mental and emotional conditions) movement disorders (a group of nervous system (neurological) conditions that cause either increased movements or reduced/slow movements), recurrent major depressive disorder (MDD), hypertension ([HTN] a condition where the pressure of the blood in your blood vessels is higher than it should be), lack of coordination and generalized muscle weakness. During a review of Resident A's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated [DATE], the MDS indicated Resident A had no difficulty seeing, hearing, or expressing his ideas and wants, understanding others or making himself understood. The MDS indicated Resident A was able to make independent decisions that were consistent and reasonable. During a review of Resident A's Change of Condition (COC) dated [DATE] and timed at 3:45 p.m., and Nurses Progress Notes (NPN), dated [DATE] and timed at 2:32 a.m., the COC and NPN indicated, staff reported Resident A had an altercation with another resident. The residents were separated and 911 was called. A local police agency arrived, Resident A was handcuffed and escorted out of the building by the police. During an observation on [DATE], at 7:25 p.m., Resident B was observed lying on the floor after being pronounced deceased by the Los Angeles County Coroner (LACC) (time of death unknown). At approximately 8:15 p.m., Resident B was observed being transported by the LACC out of the facility. During a review of the facility's video surveillance the following was seen: On [DATE], at approximately 3 p.m., Resident A was seen sitting on a cement wall adjacent to the facility's outside patio and across from the entrance to the House side of the facility. At approximately 3:,d+[DATE]:15 p.m., Resident A was seen leaving the facility with a staff person, identified as the facility's Marketer. Approximately, ,d+[DATE] minutes later Resident A and the Marketer were seen on the video returning to the facility. Resident A was then seen going into the building's entrance leading to the House (name of area in the facility) side of the facility. Later in the video Resident A was seen coming from the House side of the facility, initially going toward the outside walkway (he is out of video view), then appearing again in the video, sitting on a chair just outside the door leading to the Annex (name of area in the facility) side of the facility. Resident A again goes out of video view for a few minutes but is assumed to have entered the facility because commotion of the staff indicated the stabbing incident happened during the time Resident A is out of video view. During a viewing of the facility's surveillance video (close observation through a camera) of the stabbing incident on [DATE], two views of the stabbing incident were captured: View #1 Resident C was seen entering the Annex side of the facility through a door near the Annex nursing station walking past the Annex nursing station and proceeding down the hallway. As Resident C gets halfway down the hallway, Resident A abruptly stands up and quickly walks down the same hallway toward Resident C. As Resident A gets next to Resident C, Resident A pulls out an object and thrust that object (knife) into the left side of Resident C's abdomen. Resident C turns and runs back in the direction and through the door he had previously came in from. Resident A is then seen turning to Resident B who is sitting in a wheelchair along a wall in the hallway. Resident A lunges at Resident B making at least three thrusting/jabbing motions, stabbing Resident B multiple times in various areas of his body. Resident B is seen attempting to push away and/or hold onto Resident A. Resident B is seen falling from his wheelchair to the floor and Resident A is restrained by the Licensed Vocational Nurse (LVN 2), and the facility's Marketer while staff attended to Resident B's injuries and started performing Cardiopulmonary Resuscitation ([CPR] an emergency procedure to help save a person's life when breathing and/or the heart stops). View #2 Resident A is seen entering the Annex side of the facility through a door on the outside patio area and proceeds to sit in chair next to another resident along a wall in the hallway. Resident A is observed looking around and fidgeting and is then seen pulling a wrapped object (knife) from the pocket of his jacket or pants. Resident A unwraps the knife and places it on top of his thigh while covering it with his hand. A nurse can be see standing at the end of the hallway, approximately 10 feet from Resident A and she appears to be watching/monitoring the hallway. The nurse is then seen moving toward the door away from Resident A. Resident C is seen coming down the hallway passing the Annex nursing station. As Resident C gets closer to Resident A, Resident A is seen abruptly standing up and quickly walking towards Resident C. As Resident C gets closer to Resident A, Resident A suddenly raises his right arm and forcibly stabs Resident C in the left side of his abdomen. Resident C can be seen running back toward the Annex nursing station, where he came from, while Resident A turns to Resident B, who is sitting in a wheelchair against a wall in the hallway, and stabs Resident B at least three times in multiple parts of his body. LVN 2 and the facility's Marketer can be seen restraining Resident A while staff attending to Resident B's injuries. Eventually the police, then the paramedics arrive. Resident C is taken away on a gurney and Resident A is later taken away by the police. A knife measuring approximately 8.0 inches long was seen being handled by a police officer. During an interview with a Certified Nursing Assistant (CNA 1) on [DATE] at 3:38 p.m., CNA 1 stated Resident A was alert and oriented to his name date and place. Resident A was quiet, stayed mostly to himself in his room, coming out of his room during smoking breaks and to walk around the facility. CNA 1 stated Resident A had no behaviors and was independent with his activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting). CNA 1 stated, she was assigned to Resident A the day of the incident ([DATE]) and stated she saw the facility's Marketer and Resident A walking outside the facility going toward the store when she was leaving the facility at approximately 3:30 p.m. During an interview with the Licensed Vocational Nurse (LVN 3) on [DATE] at 5:06 p.m., LVN 3 stated she was sitting at the nursing station on the Annex side of the facility when the stabbing incident occurred ([DATE]). LVN 3 stated she heard a commotion, she looked at a mirror located at the nursing station that was positioned in such way that it was visible what is going on around the corner from the nursing station. LVN 3 stated she looked up and saw Resident C jumping up and over other residents and she ran towards the commotion. LVN 3 stated she saw Resident B holding onto Resident A's arm as he (Resident B) was about to fall from his wheelchair, and she (LVN 3) reached out to grab Resident B. LVN 3 stated, Resident B fell to the floor and that was when she saw his shirt was covered in blood and an open gash on his neck. LVN 3 stated, Resident A had no behaviors, he kept to himself, was respectful, followed commands and walked around the facility a lot. LVN 3 stated, after Resident A stabbed Resident B, the facility's Marketer had Resident A restrained on the floor. LVN 3 stated she heard the Marketer asked Resident A where he (Resident A) got the knife and why did he do that? LVN 3 stated, Resident A replied he stole the knife from the store, and he just wanted to stab somebody. LVN 3 stated, LVN 2 searched Resident A's room after the stabbing incident and found a package where the knife came from. LVN 3 stated LVN 2 showed her a package that appeared as though it had just been opened, it was a clear plastic package, with Chef Knife written on it, it had a knife sharpener still in the package and there was an empty section where the knife had been but was missing from the package. LVN 3 stated Resident A left the facility with the Marketer on the day of the incident ([DATE] [not sure of the time]). LVN 3 stated, that was the first time she knew of Resident A leaving the facility to go to the store with anybody and she only found out that he left the facility that day ([DATE]) with staff to go to the store because she overheard the Marketer saying he took Resident A all the way to the store, and he (Resident A) did not buy anything. Aa review of Resident A's Physician's Orders indicated there was no documentation of a physician's order for Resident A to go out on pass. During a review of the facility's undated policy and procedure (P/P), titled Out on Pass, the P/P indicated residents may go out on pass with physicians' order. The attending physician will determine ability to go out on pass/self-responsibility. Residents/responsible party will be asked to sign out-on passbook at nurses' station to indicate date, time, and destination of out-on-pass. During a review of the facility's out on pass log for ,d+[DATE], there was no documentation indicating Resident A went out on pass on [DATE]. The facility was not able to provide any other policies related to resident outings and the responsibility of the staff taking the resident's out of the facility. During an interview on [DATE], at 5:15 p.m., the ADON confirmed there was no documentation on the out of facility (OOF) log when Resident A left the facility with their Marketer to go to the store. The ADON stated Residents should sign out or be signed out on the OOF log when they leave the facility with staff and/or family. During an observation on [DATE] at 6 p.m., at the local area store, located approximately less than a minute by car and less than 4 minutes by foot, a 7.5-inch kitchen knife with a sharpener was observed in plastic packaging with the words, Chef Knife W/Sharpener on the package. The store had multiple rows of merchandise in a [NAME] type configuration, the knife/sharpener set was located near the back of the store down one of the rows. During a review of Resident B's Admission Records (Face Sheet), the face sheet indicated Resident B was initially admitted to the facility on [DATE] and last admitted on [DATE]. During a review of Resident B's MDS, dated [DATE], the MDS indicated Resident B's cognitive skills for daily decision-making were severely impaired. During a review of Resident B's Nurses Progress Notes (NPN), dated [DATE] and timed at 11:56 p.m., the NPN indicated at 3:45 p.m., Resident B sustained injuries following an altercation with another resident, CPR was initiated by staff and 911 was called. Resident B was eventually declared deceased by the paramedics. During a review of Resident C's Admission Records (Face Sheet), the Face Sheet indicated Resident C was admitted initially admitted to the facility on [DATE] and last admitted on [DATE]. During a review of Resident C's MDS, dated [DATE], the MDS indicated Resident C made independent decision that were reasonable and consistent. During a review of Resident C's Change of Condition (COC), dated [DATE] and timed at 3:45 p.m., the COC indicated at 3:45 p.m. Resident C had an altercation with another resident, blood was noted coming from Resident C's lower left abdomen, 911 was call and Resident C was transferred to a GACH for further evaluation. During a review of Resident C's NPN, dated [DATE] and timed at 11:18 p.m., the NPN indicated Resident C was transferred out via 911 for a medical emergency. During a review of Resident C's GACH Emergency Department (ED) record, the ED records indicated Resident C was admitted to the GACH on [DATE] at 4:15 p.m., with a stab wound and abdominal pain. A view of a photo of Resident C's stab wound as well as a description of the wound indicated a 5.0 centimeter [(cm) -a unit of measurement] deep stab wound to Resident C's left upper quadrant of his abdomen, left thoracoabdominal area (chest and abdomen), with possible blood in his chest. Continued review of the ED records indicated Resident C was taken directly to the operating room for emergent surgical evaluation with an exploratory laparotomy (a surgery where the abdomen is opened, and the abdominal organs are explored for injury or disease). During a review of Resident C's Operating Room (OR) report from GACH, dated [DATE], the OR report indicated Resident C had a diaphragmatic (the thin muscle below the lungs and heart that separates the chest from the abdomen) laceration repair and a second exploratory laparotomy on [DATE] was unremarkable (no findings). Continued review of Resident A's GACH record indicated Resident A received one unit of packed red blood cells (non-whole blood given to a person whose blood volume is low) due to his hemoglobin ([Hgb] a protein inside red blood cells that carries oxygen from the lungs to tissues and other organs in the body) of 7.9 (normal reference range - male 13.8 to 17.2 grams per deciliter [g/dL] {a unit of measurement}). Resident A was transferred to a different skilled nursing facility on [DATE].

Based on observation, interview, and record review, the facility failed to provide supervision to prevent the resident, who was at risk for elopement and had a physician order for one-to-one [(1:1) one staff to resident supervision] monitoring, from eloping (leaving unnoticed/unsupervised without permission/authorization) from the facility, for one of five sampled residents with elopement risks (Resident 1). The facility failed to: 1. Ensure the Licensed Vocational Nurse (LVN 3) assigned staff to conduct 1:1 monitoring of Resident 1 on the night shift of 12/29/2022 as ordered by the physician. 2. Ensure the nursing staff monitor Resident 1 at frequent intervals as documented in the resident's care plan titled 'Elopement/Wandering Risk.' 3. Ensure the nursing staff provided 1:1 monitoring of Resident 1 to prevent complications as documented in the resident's care plan titled 'Resident on multiple medications.' Resident 1, had a history of elopement, had impaired cognitive (ability to think and reason) skills for daily decision making, with wandering behavior (walking around aimlessly without a fixed plan), became agitated and combative (eager to fight), striking out at staff and pacing anxiously while continuing to escalate (increase in extent) a hostile behavior. On 12/29/2022 Resident 1 was placed on 1:1 monitoring by the resident's psychiatrist (medical doctor who diagnose and treats mental, emotional, and behavioral disorders) as verbal order, until Resident 1's transferred out to the hospital. On 12/13/2022, Resident 1 went missing and was last seen on 12/30/2022 at approximately 4 a.m. On 12/30/2022, at approximately 8:15 a.m. (over four hours after the resident was last seen), the facility's staff noticed Resident 1 was missing and called a Code Green (to alert staff of a missing resident). The facility conducted an official head count of all the residents at the facility and confirmed Resident 1 had eloped from the facility. This deficient practice resulted in Resident 1 eloping from the facility on 12/30/2022 at an unknown time and was last seen approximately 4 a.m. that morning, which placed Resident 1 at high risk for exposure to harsh environmental conditions including excessive cold and rain, at risk for injuries and medical complications including malnutrition (lack of proper nutrients [molecules in food that are needed for growth and energy]), dehydration (not enough water in the body), respiratory problems due to the resident's diagnosis of chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing-related problems) and possible death. As of 1/11/2023 (12 days later), Resident 1's whereabouts remains unknown. On 1/9/2023 at 3:57 p.m., an Immediate Jeopardy [(IJ) a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause, serious injury, harm, impairment, or death to a resident] was identified due to facility's staff failing to implement Resident 1's one-to-one monitoring as ordered and a care plan for Resident 1's elopement including the resident's supervision and monitoring. Resident 1 eloped from the facility on 12/30/2022 without staff knowledge, placing Resident 1 at risk for serious injury or death. The IJ was called in the presence of a minimum data set (MDS) coordinator registered nurse, Director of Medical Records, and the Administrator (ADM). On 1/11/2023 at 3:50 p.m., the ADM submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practice). The IJ was removed on 1/11/2023 at 4 p.m., while onsite, after observations, interviews, and record reviews were completed to confirm implementation of the IJRP. The acceptable IJRP included the following for the other residents at risk for elopement, as Resident 1's whereabouts remain unknown, as follow: 1. The facility shall ensure all residents with physician's order for 1:1 monitoring shall be followed and will only be discontinued when the physician gives the discontinuance order. All orders given by the physician shall be in writing. If or when an order is given verbally or by telephone order by the physician, the licensed nurse receiving the order shall transcribe/input the order(s) and communicate the new order(s) to other licensed nurses. Licensed nurse(s) shall initiate care plan to reflect 1:1 monitoring order and update 1:1 monitoring care plan quarterly or as needed. An in-service will be conducted by the DON/designee to all licensed nurses regarding 1:1 monitoring and care planning on 1/11/2023 until all licensed staff have been in-serviced. All newly hired licensed staff shall undergo an in-service by the DON/designee on 1:1 monitoring and care planning. In-service on 1:1 monitoring shall be conducted by DON/designee every six (6) months. 2. Implementing staffing contingency plan, utilizing registry and offer overtime, in case of staffing shortage. The administrator and the DSD will review the projected and actual staffing daily, to ensure adequate staffing. The MDS nurse reviewed all risk assessments and identified one resident requiring hourly monitoring. The MDS nurse shall initiate a review of current residents on 1:1 order today, 1/10/2023, and shall present findings to the Administrator and DON/designee daily during stand-up meeting for three (3) months. Currently, no other resident is on 1:1 monitoring for elopement. 3. Close monitoring shall be done every hour for 24 hours daily by nursing staff for residents with a high risk for elopement based on their elopement risk assessments and history of elopement. The hourly monitoring shall be done for one week starting 1/11/2023 to 1/18/2023. At the end of one week, the results of monitoring recapitulations shall be presented to the QAPI team for evaluation. The QAPI team shall determine if further monitoring shall be necessary. a. The identified 4 other residents with a high risk for elopement are included in the hourly monitoring. b. All nursing staff shall do a 2-hour monitoring/rounds for all other residents to ensure no elopements occurs. Monitoring will be done using a midnight census log/head count and facility rounds every shift by licensed nurses. c. For any missing resident(s), licensed nurses shall inform the DON/designee and ADM and follow the facility P/P titled Missing Residents. d. The ADM has ordered additional video cameras and replacements for the defective video cameras to ensure more video coverage in and out of the facility. Order was done on 12/13/2022. The video cameras shall be installed upon receipt of the video cameras. The camera is scheduled to be installed on 1/16/2023. e. The facility has hired additional personnel as gate watchers on 1/9/2023. The entrance gate has 24 hours gate watcher coverage. The alarms in the building shall be checked by maintenance/designee and recorded daily in a logbook every shift by staff to ensure that all alarms are in working condition. f. The ADM and the DON shall review the daily monitoring logs during daily stand-up meeting to ensure compliance for three (3) months. The DON/designee shall attend the resident IDT meetings every quarter to ensure that the staff have implemented the elopement care plan. 4. The facility shall ensure all staff are notified of residents with a high risk of elopement through shift reports and group huddles conducted by the charge nurse at the start of each shift for three (3) months. 5. The MDS nurse/ DSD/designee will make rounds daily to ensure licensed nurses are aware of residents' care plans and adhere/implement the care plan. Immediate Action 1.All residents assessed as a high risk for elopement shall be monitored and logged every 1 hour by staff to prevent elopement. Effective 1/11/2023. 2. The facility has a Policy & Procedure titled, Missing Residents which include elopement prevention/interventions for the staff to adhere to. An in-service was conducted by the Nurse Consultant to all staff on 1/5/2023 on missing residents and notifications. All newly hired nursing staff shall undergo an in-service by the DON/designee on Missing Residents. In-service on Missing Residents shall be conducted by DON/designee every 6 months. 3. The facility shall ensure nursing staff are notified of residents with high risk of elopement through shift reports and group huddles at the start of each shift. Findings: During an interview with the Director of Nursing (DON) on 12/31/2022 at 4:10 p.m., while in Resident 1's room, a concurrent observation indicated Resident 1's room located on the second floor of the facility, two rooms away from an exit door. This exit door led to an outside balcony with a cement wall approximately 2-3 feet in height. During this interview, the DON was asked how the staff ensures a resident does not get out from that exit door and climb over the wall, the DON stated, One CNA (a certified nursing assistant) monitors the exit because it is on the second floor and resident would not have a chance to get out from the exit. The DON stated Resident 1 was placed on 1:1 monitoring by CNA 1 (male CNA) on 12/29/2022 from 7 a.m. to 11 p.m. (worked two shifts) for his behavior of striking at CNA during a group activity. The DON stated Resident 1 was provided with 1:1 monitoring on 12/29/2022 until 11 p.m., that night as a nursing intervention. The DON stated Resident 1 was did not have 1:1 monitoring on the nightshift of 12/29/2022 due to shortage of staff. During an interview with CNA 1 on 12/31/2022 at 4:50 p.m., CNA 1 stated he worked on 12/29/2022 from 7 a.m. to 11 p.m. and was assigned to provide 1:1 monitoring to Resident 1. CNA 1 stated Resident 1 struck a staff that morning (12/29/2022) and was placed on 1:1 observation until 11 p.m. on 12/29/2022. CNA 1 stated he came back to work on 12/30/2022 at 7 a.m. and during rounds with other staff noticed Resident 1 was not in his room. During an interview with Resident 2 (Resident 1's roommate) on 12/31/2022 at 5:05 p.m., Resident 2 stated he last saw Resident 1 at approximately 4 a.m. on 12/30/2022 when Resident 1 went to the bathroom. During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including paranoid schizophrenia (serious mental disorder in which reality is interpret abnormal and it impairs daily functioning), major depressive disorder (serious mood disorder; affects how a person feels, think, and handle daily activities, such as sleeping, eating, or working), Bipolar disorder (a brain disorder; shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks), psychosis (effects the mind, where there has been some loss of contact with reality), muscle weakness with difficulty walking, hypertension (high blood pressure), chronic obstructive pulmonary disease ([COPD] a long term lung disease that make it difficult to breathe), and blindness in left eye. During a review of Resident 1's Minimum Data Set (MDS), a standardized e assessment and care-screening tool, dated 12/27/2022, the MDS indicated Resident 1's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 1 required supervision for eating, bed mobility, transferring, walking, dressing, eating, toilet use, and personal hygiene. During a review of Resident 1's Elopement Risk Assessment (ERA), dated 12/20/2022, the ERA indicated Resident 1 was at risk for elopement. The ERA tool indicated the resident was always disoriented and had prior history of elopement on 7/9/2019. During a review of Resident 1's Nurse Progress Note (NPN), completed by an unknown registered nurse (RN) during admission, dated 12/20/2022 and timed at 8:58 p.m., the NPN indicated Resident 1 was awake, disoriented, and unable to state name or where he was. During a review of Resident 1's care plan, initiated on 12/21/2022 and titled, Elopement/Wandering Risk, the care plan indicated Resident 1 was at risk for leaving a safe area without supervision and the goal indicated Resident 1 will have no elopement. The staff's intervention included to monitor the resident at frequent intervals. During a review of Resident 1's care plan initiated on 12/21/2022 and titled, Altered behavior patterns related to bipolar disorder, depression and psychosis manifested by (M/B) inability to process internal stimuli causing anger interfering with the resident's daily living activities, the care plan indicated Resident 1 would have reduced episodes of manifested behavior daily. The staff's intervention included to provide reality awareness. During a review of Resident 1's care plan titled, Resident on multiple medications initiated on 12/21/2022, the care plan indicated the resident would be free of being an endanger to self and others for three months. The staff's interventions included to provide 1:1 monitoring to prevent complications. During a review of Resident 1's Interact Assessment Form indicated a Change of Condition Evaluation (COCE), dated 12/29/2022 and timed at 5:20 p.m., the COCE indicated Resident 1 had aggressive behavior, struck-out at staff and the police and the resident's psychiatrist (Physician 1) was immediately notified. The COCE indicated Physician 1 was notified and a new order to transfer the resident to the hospital for a psychiatric evaluation ([P/E] an evaluation used to diagnose problems with memory, thought processes, and behaviors). During a review of Resident 1's physician order, dated 12/29/2022, the order indicated to transfer the resident to hospital for aggressive behavior and danger to self. During a review of Resident 1's NPNs, from 12/20/2022 to 12/30/2022, the NPNs indicated there was no documented evidence staff monitored Resident 1 for elopement and wandering behaviors as care planned. During a review of Resident 1's NPN, dated 12/30/2022 and timed at 3:05 p.m., the NPN indicated Resident 1 was not in his room at the beginning of the shift (3 p.m.) on 12/30/2022 and a search was initiated, and staff were unable to locate the resident. Code Green was called, and all rooms were searched. According to the NPN, the ADM and the DON were made aware, and the police was called at 9:23 a.m. on 12/30/2022. During a concurrent observation and interview with the director of staff development (DSD) on 1/3/2023 at 2:15 p.m., the DSD stated the facility had six exit doors within the facility and all alarms were working. When the exit doors were opened the alarms activated loudly. The DSD stated there was one exit door in the facility, in the vicinity Resident 1's room, which was leading to a balcony with stairs to the ground floor which had a door that was locked with an alarm in place. During an interview with Licensed Vocational Nurse (LVN 1) on 1/3/2023 at 2:45 p.m., LVN 1 stated he starts his shift at 7 a.m. LVN 1 stated the nurses stated Resident 1 usually goes to breakfast at 7:30 a.m. but did not show up at 7:30 a.m. on 12/30/2022. LVN 1 stated at about 8:15 a.m. on 12/30/2022 the staff did a head count and could not find Resident 1. During a concurrent observation and interview with CNA 2 on 1/3/2023 at 3 p.m., CNA 2 stated she has taken care of Resident 1 many times. CNA 2 stated on the morning of 12/30/2022 (time unknown) while she was in the middle of another resident care, a Code Green was announced. CNA 2 stated on 12/30/2022 the facility was short-staffed. CNA 2 stated she did not know Resident 1 was at risk for elopement. During an interview with the ADM on 1/3/2023 at 4:25 p.m., the ADM stated the surveillance camera (a camera used for the purpose of observing an area) that monitors the facility was not working and he needed to get it repair. The ADM stated, Resident 1 was a runner and had heard the resident elopes all the time. The ADM stated, The alarms in the facility are loud, so he probably did not use the doors, maybe hopped the fence. The ADM stated they were still looking for Resident 1. During a subsequent interview with LVN 1 on 1/4/2023 at 10:31 a.m., LVN 1, who was Resident 1's primary charge nurse, stated he did not know the resident was an elopement risk. LVN 1 stated had he known Resident 1 was an elopement risk, he would have had someone to watch him closely. During a telephone interview with Resident 1's Physician 1 on 1/9/2023 at 12:03 p.m., Physician 1 stated she was familiar with Resident 1 as he has been in and out of the hospital under her care. Physician 1 stated she has treated Resident 1 while in the hospital prior to admission to the facility due to his dual diagnosis of psychiatric illness and alcohol abuse with poor judgement. Physician 1 stated she was called on 12/29/2022, after Resident 1 hit a staff member and she told the DON to place the resident on 1:1 close monitoring (as a telephone order) until he was transferred to the hospital and to call the police. Physician 1 stated the DON did not transcribe her order and place the resident on continuous 1:1 monitoring as she order until the resident was transferred to the hospital. Physician 1 stated Resident 1 was an elopement risk and should have been monitored closely, as the resident was not ready for discharge. An interview with the DON was attempted regarding Physician 1's telephone order, but the DON was not available, as she resigned from the facility on 1/4/2023, per the administrator. During a telephone interview on 1/5/2023 at 7:15 a.m. with LVN 3, LVN 3 stated on 12/29/2022, Resident 1 was staying to himself (not social with others), while talking to himself, screaming at times; and punching in the air in an aggressive manner. LVN 3 stated Resident 1 hit a staff on 12/29/2022 during the 3 p.m.-11p.m. shift and it was the first time he was aware of the resident hitting anyone. LVN 3 stated Resident 1 was placed on 1:1 monitoring. LVN 3 stated Resident 1 was in bed at night when he came to work on 12/29/2022 at 11 p.m. LVN 3 stated the police was called but could not take the resident because of his diagnosis and the hospital had no available beds. LVN 3 stated the staff placed Resident 1 on 1:1 monitoring, as a standing order (an instruction or prescribed procedure in force permanently or until changed or canceled), because he hit a female nurse, and he was the elopement risk. LVN 3 stated the resident was monitored every two hours. LVN 3 stated, I did not have a male CNA that night (12/29/2022 on 11 p.m. shift), that is why I did not put Resident 1 on 1:1 monitoring on the night shift. LVN 3 stated Resident 1 eloped after 4 a.m., because he saw Resident 1 around 4 a.m. on 12/30/2022. LVN 3 stated he did not check on Resident 1 at 6 a.m. on 12/30/2022 because he was busy passing medications. LVN 3 stated Resident 1 had a history of eloping from facilities and should have been monitored closely. During a review of the facility's undated policy and procedure (P/P) titled, 'Physician Orders and Telephone Orders dated 1/2004, the P/P indicated Physician's order shall be obtained prior to the initiation of any treatment from the person lawfully authorized to prescribe for and treat human illness. All orders must be specific and complete, and no standing orders be accepted. The P/P indicated Telephone orders shall be signed in a timely manner or at least by the next routine visit by the physician. Telephone orders shall be noted promptly, all orders must include the date and time received and must be noted by the professional staff taking the order (e.g., licensed nurse).

Based on observation, interview, and record review, the facility failed to ensure the resident, who was a high risk for elopement (when a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired wanders away, walks away, runs away, escapes, or otherwise leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge) was monitored and supervised to prevent the resident's elopement from the facility for one of three sampled residents (Resident 1). The facility failed to: 1. Supervise Resident 1 while on the back patio to ensure the resident did not elope by going through an opened door of the assisted living facility which was sharing the same patio area. 2. Have a system in place to ensure Resident 1 was monitored and in staff's view while on the back patio. 3. Ensure the entrance/exit door to the assisted living facility remained closed. 4. Ensure Resident 1's interventions under plan of care titled Elopement Risk, were implemented including completion of an interdisciplinary team ([IDT], group of people with different skills working toward a common goal) meeting for elopement, redirecting Resident 1, providing 1:1 (assign a specific staff to monitor the resident) monitoring, and medicating the resident as ordered. 5. Complete Resident 1's elopement risk assessment upon re-admission on 4/13/22. 6. Ensure Licensed Vocational Nurse (LVN 1), LVN 2, Certified Nursing Assistant (CNA 1), and CNA 2 activated Code Green Lockdown (signal to notify the care team when a resident was missing). These deficient practices resulted in Resident 1's leaving the facility unnoticed, being exposed to unsafe environmental conditions, and without medication from 4/25/2022 to 4/28/2022 a total of three days. Resident returned to the facility on [DATE] around 2:45pm, unaccompanied. According to the Accuweather forecast report for Los Angeles area from 4/25/2022 to 4/28/2022 https://www.accuweather.com/en/us/los-angeles/ /april-weather/ 5, the temperature was in high 80's degree Fahrenheit (°F) to middle 60's °F during the day, and high to middle 50's °F during the night. According to https://crimegrade.org/murder- the Los Angeles city's overall crime grade for violent crimes for zip code , where the facility was located, the crime grade indicated an F grade (meaning most dangerous). On 4/28/2022 at 2:55 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of Administrator (ADMIN 1) due to the facility's failure to have a system in place to prevent the Resident 1's elopement from the facility. On 5/2/2022 at 2:29 p.m. the facility submitted an acceptable IJ removal plan (IJRP). After verification of IJRP implementation through observation, interviews, and record reviews, the IJ was removed on 5/2/2022 at 4:40 p.m., in the presence of the ADMIN 1, DON and IP. The IJPR included the following immediate actions: 1. The facility's ADMIN 1 and assisted living facility's administrator (ADMIN 2) signed an agreement to keep the back patio door leading into the assisted living closed and to install a fire-exit alarm. The alarm was installed on 4/29/22. 2. A signage was posted on the back patio door that opens to the assisted living facility, indicating to keep the door closed unless it was an emergency. 3. Fire-exit alarms were installed to all doors leading to the back patio, to alert staff to assist residents entering the back patio on 4/29/22. 4. A Certified Nurse Assistant was hired to work night shifts as extra precaution and monitoring, in addition to current staff from 7am-3pm., and 3pm-11pm., shifts to secure and conduct facility rounds on common areas, especially the back patio. 5. The ADMIN 1 and Director of Nursing (DON) created a daily monitoring log to ensure adequate supervision of residents and a safe environment: Resident monitoring log by using the midnight census report per shift. Facility round mentoring by LVNs, Department Heads (DHs), and CNAs per shift. Fire exit door monitoring by staff every two hours. Smoking area monitoring by Activities Director, DHs, and designee daily, in addition to smoking break schedule. 6. DON and licensed nurses completed elopement risk assessments for all residents and no residents were identified to be at risk for elopement. 7. Upon admission or change in condition (COC) residents at risk for elopement will have their care plans updated and interventions implemented to prevent the elopement. 8. ADMIN 1 and DON educated staff on the plan of action and elopement/missing resident policy and procedure, including searching the facility grounds and surrounding areas, activating the code, notifying the police, responsible parties, physicians, and the California Department of Public Health (CDPH). In-services will be repeated every month for three (3) months to ensure compliance. 9. ADMIN 1, DON, and licensed nurses will make rounds daily to ensure adequate supervision and safe environment. 10. ADMIN 1 and DON will review the daily monitoring logs during daily stand-up meetings to ensure compliance. 11. DON or designee will attend the resident IDT meetings to ensure staff have implemented the elopement care plan. 12. The facility has created a Quality Assurance/Performance Improvement ([QAPI] a data driven and proactive approach to quality improvement) for elopement and the QAPI members will present the recapitulations of the findings to the QAPI meeting for review and action as indicated. Findings: During a review of Resident 1's face sheet, the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including [CONDITION(S)] disorder (mental illness that can affect your thoughts, mood, and behavior), [CONDITION(S)] (a chronic and severe mental disorder that affects how the person thinks, feels, and behaves), and [CONDITION(S)] (a condition that affects the way your brain processes information). During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 1/31/2022, the MDS indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 required supervision (oversight, encouragement or cueing from staff) with locomotion on unit (how resident moves between locations in his/her room and corridor on same floor) and locomotion off unit (how resident moves to and returns from off-unit locations and moves to and from distant areas on the floor). During a review of Resident 1's History and Physical (H&P) dated 3/22/2022, the H&P indicated Resident 1 was able to make decisions. A review of Resident 1's Elopement Risk Evaluation dated 3/18/2022, indicated the resident was at risk for elopement. During an interview on 4/26/2022 at 3:44 p.m., Ombudsman (OMB), stated, Resident 1 told her (OMB) that she wanted to leave the facility. During a concurrent interview and record review of Resident 1's monitoring log titled Monitor - Resident Location Everyone Hour, on 4/27/2022, at 10:45 a.m., ADMIN 1 stated, the log indicated on 4/26/2022 around 9:30 a.m., Resident 1 was not in the facility during morning rounds. ADMIN 1stated the facility's surroundings was extremely dangerous, had a big homeless population, and a history of [NAME] and theft. ADMIN 1 stated Resident 1 was seen on facility video footage leaving the facility's back patio unsupervised through the assisted living door, with Resident 2, on 4/25/2022 at 9:28 p.m. ADMIN 1 stated the documentation Monitor - Resident Location Everyone Hour, log for Monitoring Resident 1's whereabouts did not have any indication the resident was monitored on 4/25/2022 from 3pm to 11 pm, and on 4/26/2022 at 12am. During a concurrent interview and record review of Resident 1's Medication Administration Record (MAR), on 4/27/2022 at 3:05 p.m., DON stated the MAR indicated, on 4/26/2022, at 9 a.m., Resident 1 did not receive the following medications as ordered by her physician: [MEDICATION(S)] (antipsychotic medication) 2 milligram ([mg] unit of measurement), and [MEDICATION(S)] (mood stabilizer) 500 mg. The DON stated not taking medications as ordered could lead to a decline in Resident 1's health. During an interview on 4/27/2022 at 11:00 a.m., ADMIN 1 stated there was no system in place or log for staff to document that rounds were made in the patio area to monitor and supervise Resident 1. ADMIN 1 stated the facility did not have any documentation to indicate all facility's doors were checked to ensure they remained close. During an interview on 5/4/2022 at 2:46 p.m., LVN 1 stated Resident 1 attempted to elope through the back patio and activated the emergency fire alarm during the 3 p.m. to 11 p.m. shift on 4/25/2022. LVN1 stated Resident 1 was re-directed back to the facility. LVN 1 stated he was not in charge of taking care of Resident 1 but was aware Resident 1 was at risk for wandering. During a concurrent interview and record review of Resident 1's clinical record, on 4/27/2022, at 12:45 p.m., the MDS nurse stated there was no IDT meeting held for Resident's 1 risk of elopement as indicated in the resident's care plan titled At Risk for Elopement. The MDS nurse stated an IDT should have been done to address Resident 1's elopement risks and prevent the resident from eloping. During a record review of Resident 1's care plan titled Elopement Risk, dated 3/18/2022, the care plan indicated, Resident 1 was at risk for elopement, for leaving safe area without authorization, related to mental illness (a wide range of conditions that affect mood, thinking, and behavior). The care plan's interventions included monitoring Resident 1, an IDT for elopement risk, administer medication as ordered, redirecting the resident to alternatives, and provide 1:1, if needed. During an interview on 5/4/2022 at 3:35 p.m., LVN 2 stated she was not aware of Resident 1's elopement risk or care plan. LVN 2 stated the purpose of a care plan was to direct the care of each resident. A concurrent interview and record review of Resident 1's clinical record, on 4/27/2022, at 12:45 p.m., the MDS nurse and Infection Prevention Nurse ([IP] licensed nurse in-charge of infection prevention in the facility) were conducted. The MDS nurse stated Resident 1's Elopement Assessment was last completed on 3/18/2022. The MDS nurse stated when Resident 1 was readmitted on [DATE], an elopement assessment was not done. The MDS nurse and IP stated the admitting nurse oversaw completing an elopement/wander assessment with each admission, whether it was an initial admission or a re-admission. The MDS nurse and IP also stated that there was no IDT meeting documentation for elopement and per Resident 1's care plan, one should have been conducted. The MDS nurse stated it was her responsibility along with the DON to ensure IDT meetings were conducted and care plans updated accordingly. During an observation on 4/27/2022, at 2:10 p.m., the back door of the assisted living facility to the assisted living was approximately one hundred twenty-five (125) feet ([ft] unit of measurement) to the corner of a high traffic street. During an interview on 5/4/2022 at 3:04 p.m., CNA 1 stated Resident 1 was not on 1:1 monitoring. CNA 1 stated she had never heard of any required documentation for Resident 1's whereabouts monitoring and had never completed one. During an interview on 5/2/2022 at 12:40 p.m., the Social Services Director (SSD) stated an elopement prevention IDT meeting was not done for Resident 1. The SSD stated the facility was at fault for not taking the corrective action for Resident 1's elopement including not calling 911, initiating Code Lockdown, and following Resident 1's care plan titled at risk for elopement. The SSD stated the facility placed Resident 1 at risk for a serious health issueS and possibly death by not supervising the resident and letting Resident 1 go out to dangerous surrounding areas of the facility. During an interview on 5/4/2022, at 3:35 p.m., LVN 2 stated she was not aware Resident 1 was missing until LVN 3 told her on 4/26/22 around 8a.m. LVN 2 stated the last time she saw Resident 1 was on 4/25/2022 around 8 p.m. when she gave Resident 1 evening medication at 9 p.m. LVN 2 did not provide a response on why Code Green Lockdown was not called. LVN 2 stated that it was important to call a Code Green Lockdown to notify staff that Resident 1 was nowhere to be found and to start searching for the resident. During a review of the facility's undated policy and procedure (P/P) titled, Care of Wandering Residents, the P/P indicated the purpose of the policy was to protect wandering residents from injury, continuously reorienting residents to their rooms, and monitoring residents' locations with visual checks as needed. During a review of the facility's undated P/P titled, The Resident Care Plan, the P/P indicated the objective was to promote continuity of resident care. The P/P indicated the care plan was a communication instrument between nurses and other disciplines, contained information for all nurses concerning nursing approach and problem solving, and the staff were responsible to meet the above goals. During a review of the facility's undated P/P titled, Documentation in Medical Record, the P/P indicated all pertinent information concerning the resident shall be documented in the resident's medical record. The P/P indicated all CNAs involved in residents' care shall document daily on the CNA flowsheets and notify charge nurses of any changes in residents' condition.

Based on observation, interview, and record review, the facility failed to implement a resident's care plan and supervise one of three sampled residents (Resident 1) during a smoking break. These deficient practices resulted in Resident 1 suffering 10 percent (%) second and third degree [CONDITION(S)] to her right side of the face, head, neck, and ear. Findings: During a review of Resident 1's Admission Record (Face Sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses including paranoid [CONDITION(S)] (a serious mental illness that affects how a person thinks, feels, and behaves often including hallucinations, and delusions of persecution), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety (a cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal function are significantly impaired), and [CONDITION(S)] ([CONDITION(S)] - a chronic [CONDITION(S)] lung disease that causes obstructed airflow from the lungs). During a review of Resident 1's Minimum Data Set (MDS) a standardized assessment and care planning tool), dated 3/24/2021, the MDS indicated Resident 1's cognition was intact, and was able to make herself understand and understood others. The MDS indicated Resident 1 was totally dependent on a one-person physical assist for locomotion off unit (how the resident moves from areas in the facility) and had limited range of motion (ROM) of bilateral (both sides) upper and lower extremities. During a review of Resident 1's care plan titled, Smoking Supervision Assessment-Resident requires Supervision while Smoking, dated 4/11/2021, the care plan goals indicated Resident 1 would be able to smoke according to facility's policy and procedures (P/P) with precautions taken for resident's safety and safety of others. The staffs' interventions included to ensure resident would not smoke when oxygen was in use and supervise resident when smoking. During a review of the facility's Investigation of Incident/Accident Known/Unknow Origin, dated 6/11/2021, the report indicated on 6/11/2021 at 6:35 p.m., Resident 1 was on the patio for activity as usual, smoking under supervision when a staff noted smoke coming out from the resident's hair. The report indicated the staff immediately grabbed a blanket and put it around the resident to put the fire out. The report indicated Resident 1 was transferred to the general acute care hospital (GACH). During a review of Resident 1's GACH Social Services Forms, dated 6/12/2021, the form indicated Resident 1 arrived to the GACH for treatment of burn injuries sustained while smoking. The form indicated resident was wheelchair bound with hands contractures (a condition of shortening and hardening of muscles, tendons, leading to deformity and rigidity) and unable to transfer on her own. The form indicated Resident 1 stated a fell ow resident was assisting her lighting her cigarette when her hair/face caught on fire and the incident could have possible be intentional. During a concurrent observation of Resident 1 and interview, on 6/16/2021 at 1:57 p.m., Resident 1 was observed in the patio dozing off (falling asleep), Resident 1's entire right side of the face, going beyond the hairline and into her scalp, right ear, and neck were observed to be scabbed over. Resident 1 stated she burned her face while smoking. During an interview on 6/16/2021 at 2:20 p.m., Licensed Vocational Nurse (LVN 1) stated he had knowledge of the incident but had not been present. LVN 1 stated he was told Resident 1 had gotten a hold of a lighter and caught herself on fire while lighting a cigarette. LVN 1 stated residents were not allowed to carry lighters. During a phone interview on 6/23/2021 at 10:01 a.m. the GACH's Social Services Worker (SSW), SSW stated Resident 1 had reported to him a fell ow resident had assisted her with lighting her cigarette with a lighter and caught her hair on fire. SSW stated Resident 1 indicated to HSW she felt the incident was intentional and the other resident might still have the lighter. During a phone interview on 6/23/2021 at 8:50 a.m., LVN 2 stated she was the charge nurse for the ANNEX (area of the facility where the incident occurred) the night of the incident and Certified Nursing Assistant (CNA 1) was the one who witnessed the incident and assisted putting the fire out from Resident 1's hair. LVN 2 stated CNA 1 was the only person on the patio during the incident. During a phone interview on 7/9/2021 at 1:02 p.m. CNA 1 stated he was the only staff member outside at the time of the incident because he was outside at his locker getting his belongings ready to go home and was not assigned to monitor the patio area. CNA 1 stated he did not witness the incident, he just looked over and saw Resident 1's hair on fire and immediately went to assist Resident 1 by putting the fire out. CNA 1 stated sometimes residents get a hold of lighters and he was not sure how. CNA 1 stated no other staff was present supervising the residents while smoking, he was out there getting ready to go home. During a review of the facility's undated P/P titled, Smoking Policy and Procedure, the P/P indicated the designated smoking areas would be under supervision, as needed per Smoking Assessment, by facility staff. During a review of the facility's P/P titled, Smoking Policy, revised on 5/1/2014 indicated all cigarettes, lighters and matches will be kept locked in the Activity Director's (AD's) room, and residents were not allowed to keep them in their possession for safety purposes.

Based on interview and record review, the facility failed to follow its policy and ensure a resident received the necessary care and services to alleviate pain and anxiety for one of three sampled residents (Resident 1). Resident 1, who was newly admitted , had recent discharge orders from the hospital for medication to control back pain and anxiety, but did not receive pain medications and was in severe pain with increased anxiety for three (3) days without the ability to sleep. This deficient practice resulted in Resident 1 having uncontrollable pain and discomfort for three days (10/29-10/31/18) with the inability to sleep and increased anxiety. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE] from a general acute care hospital (GACH) with [DIAGNOSES REDACTED]. A review of the GACH's history and physical (H/P), dated 10/23/18, indicated Resident 1 had chronic back pain and anxiety. The GACH's discharge reconciliation orders indicated for Resident 1 to receive [MEDICATION NAME] 10 milligram (mg)/325mg one tab by mouth (PO) every 6 hours for severe pain on a pain scale from 7-10 (10 being the worse). A review of a Nursing Admission Progress note, dated 10/29/18 and timed at 7 p.m., indicated that Resident 1 was admitted to the facility from an acute care hospital with medical [DIAGNOSES REDACTED]. A Nursing Note, dated 10/30/18 and timed at 10 a.m., indicated, MD (physician) gave order for PT (physical therapy) for [DIAGNOSES REDACTED]. The Nursing Note, dated 10/30/18 and timed at 3 p.m., indicated left message for doctor regarding the resident's complaint of anxiety and pain .awaiting reply back . There were no further entries regarding Resident 1's pain and anxiety. A review of a Nursing Note, dated 10/31/18 and timed at 9:30 a.m., indicated Resident 1 complained of severe pain and verbalized Tylenol was ineffective for his low back pain, and the physician gave a new order for [MEDICATION NAME] 5/325mg one tab PO every 6 hours as needed for severe pain (of 8-10). A Nursing Note, dated 10/31/18 and timed at 1:30 p.m., indicated Called pharmacy to get one dose of [MEDICATION NAME] from the E-kit (emergency medication kit), but still waiting for the physician's authorization for the [MEDICATION NAME] medication. A Nursing Note, dated 10/31/18 and timed at 4:30 p.m., indicated Spoke with pharmacy regarding authorization for [MEDICATION NAME] medication and the MD made aware. [MEDICATION NAME] 5/325mg 1 tab PO one dose taken from E-kit and given to Resident 1. A review of the physician's admission orders [REDACTED]. There was no medication ordered for Resident 1's severe pain. A review of a Medication Administration Record [REDACTED] A review of Resident 1's care plans, dated 10/29/18, did not address the resident's low back pain or anxiety. A review of facility's Emergency Kit (E-Kit) Inventory List indicated there was six (6) [MEDICATION NAME] 5mg/[MEDICATION NAME] 325 mg tablets ([MEDICATION NAME]) in the E-kit. A review of the facility's policy and procedure, undated and titled, Emergency Medication Kits . indicated the following, If the E-Kit contains the emergency medications ordered by the physician, the emergency medication(s) will be administered as ordered by the physician. On 10/31/18 at 1:50 p.m., during a concurrent interview and observation, Resident 1 was observed telling a licensed vocational nurse (LVN 1) that he was still in pain and having lots of uncontrolled anxiety and did not know what else he could do to manage without his medications. Resident 1 stated, How much longer I have to wait .It's already been two days . At 1:59 p.m., on 10/31/18, during an interview and record review, LVN 1 stated that she had called both Resident 1's admitting physician and the pharmacy in attempt to obtain Resident 1's pain medication, but was unsuccessful. LVN 1 stated that the pharmacy did not authorize the use of the E-Kit medication ([MEDICATION NAME]) because Physician 1 did not either sign, or order the medication and give a verbal authorization to Pharmacist 1 to dispense the [MEDICATION NAME]. LVN 1 stated that she called Physician 1 at 9:30 a.m., on 10/31/18 to obtain the new order for the pain medication [MEDICATION NAME] 5mg/[MEDICATION NAME] 325 mg, and notified pharmacy of the new order as well. LVN 1 also stated she placed a follow-up telephone call to Pharmacist 1 at 1:30 p.m., on 10/31/18, but was still denied access to use the [MEDICATION NAME] in the E-Kit, because Physician1 had not either signed or called the pharmacy to verbally authorize the order(s). During a telephone interview on 10/31/18 at 2:40 p.m., Pharmacist 1 stated she could not approve the facility's use of the E-Kit's medication for Resident 1's pain without the physician's signature on the order and the pharmacy's authorization form. Pharmacist 1 stated that the physician could authorize the medication order either with verbal over the telephone and/or by signature on the written form. Pharmacist1 reported that Physician1 had not returned the telephone call requesting authorization and that was the reason that the medication was not delivered, or approved for E-Kit removal. On 10/31/18 at 3:05 p.m., during an interview, Resident 1 stated .yesterday my pain (level) was at 10/10 . I was begging for medication for pain .I've been respectful and nice, I just can't take it any more . Resident 1 also stated that his anxiety level was uncontrolled (also at level 10/10) and that it made him feel like he could not relax around people. Resident 1 described what he felt as .I'm having panic attacks, it makes me feel like I want to grab another person, but that's not who I am, I'm a beautiful person .I'm trying real hard . Resident 1 also reported that he could not sleep and had been up since was admitted to the facility. During a telephone interview on 10/31/18 at 3:10 p.m., Physician 1 stated he was concerned about Resident 1's substance abuse history and did not prescribe the pain medication [MEDICATION NAME] when the resident was admitted . Physician 1 stated that he now realized that Resident 1's pain was severe and will order the [MEDICATION NAME]. Physician 1 confirmed knowledge that he was aware that Resident 1 had a medical history that included chronic low back pain and anxiety with frequent psychiatric hospitalization s related to anxiety and [MEDICAL CONDITION] (thoughts of suicide). Physician 1 stated that his plan now for Resident 1 was to immediately authorize the pain medication [MEDICATION NAME] for his severe pain, obtain a Psychiatric Evaluation for the resident's anxiety and agitation, and to perform an H/ P tomorrow (11/1/18) as is his practice to see new residents within 72 hours of admission. On 11/1/18 at 8:15 a.m., during a subsequent interview, Resident 1 verbalized, I finally got some sleep last night. I was afraid I was going to grab my roommate .I was so concerned, I didn't understand what was happening .I was in so much pain .