Every finding on record at Gramercy Court

Based on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Resident 1, Resident 3, and Resident 4) were free from abuse, when:Resident 2 hit Resident 1 on the back of Resident 1's neck with his handResident 4 hit Resident 3 and Resident 3 hit Resident 4 backThese failures resulted in Residents 1, 3, and 4 not being free from abuse and had the potential for Resident 1 to be seriously harmed and to negatively impact Resident's 1, 3 and 4's highest practicable physical, mental, and psychosocial well-being.1. During a review of Resident 1's clinical record, Resident 1 was admitted in December 2025 with diagnosis that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 6/24/26, Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 1 was cognitively intact.During a review of Resident 2's clinical record, Resident 2 was admitted in April 2024 with diagnosis that included schizoaffective disorder, depression (mental health condition that causes a lasting feeling of sadness and a loss of interest in things you normally enjoy), and vascular dementia (a decline in thinking and memory skills caused by reduced blood flow to the brain).During a review of Resident 2's MDS, dated [DATE], Resident 2 had a BIMS score of 3 out of 15 which indicated Resident 2's cognition was severely impaired.During an interview on 8/24/26 at 10:45 a.m. with Resident 1, Resident 1 stated that Resident 2 hit her on the back of the neck.During a concurrent review of Resident 1's situation, background, and response (SBAR) communication form, dated 7/5/26, and Interdisciplinary Teams (IDT)note, dated 7/6/25, the SBAR indicated that Resident 2 punched Resident 1 in the back of the neck.Resident 1 was noted as having redness to the back of the neck. The IDT indicated Resident 2 swung his hand making contact with the back of Resident 1's head and neck.A review of Resident 2's care plan (CP), initiated 12/8/25, indicated Resident 2 was at risk of alteration in behavior related to a history of physical/verbal aggression towards others. secondary to schizophrenia. The CP indicated the goal was for Resident 2 not to harm others.2. During a review of Resident 4's clinical record, Resident 4 was admitted in June 2024 with diagnosis that included schizoaffective disorder, depression, and post-traumatic stress disorder (PTSD- PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event).During a review of Resident 4's MDS, dated [DATE], Resident 4 had a BIMS score of 14 out of 15 which indicated Resident 4's was cognitively intact.During a review of Resident 3's clinical record, Resident 3 was admitted in July 2022 with diagnosis that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance or lack of energy supply in the blood).During a review of Resident 3's MDS, dated [DATE], Resident 3 had a BIMS score of 5 out of 15 which indicated Resident 3's cognition was severely impaired.During an interview on 8/24/26 at 12:28 p.m. with Licensed Nurse (LN) 1, LN 1 stated she witnessed Resident 4 hit Resident 3's arm with a closed fist and Resident 3 hit Resident 4 back with a closed fist on the arm. LN 1 stated the incident could have been prevented when they were observed in the doorway.During a review of Resident 4's progress note written by LN 3, dated 8/7/26, the note indicated, .Upon interview with resident 4, Resident 4 stated she was hearing voices and experiencing delusions and hallucinations and thought Resident 3 was going to hit her so she hit her first.During an interview on 8/24/26 at 2:35 p.m. with the Administrator (ADM), the ADM stated, The expectation is that all preventable abuse be prevented. We do not want any of our residents to be victims of abuse. If there is any witnessed or physical evidence of abuse, then the facility did not keep the resident free from abuse.During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights dated February 2021, the P&P indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include. be free from abuse.During a review of the facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021, the P&P indicated, Residents have the right to be free from abuse. Implement measures to address factors that may lead to abusive situation.

Based on interview and record review, the facility failed to protect the resident's right to be free from abuse for one of three sampled residents (Resident 2) when Resident 1 hit Resident 2's face with his hand. This failure resulted in Resident 2 not being free from abuse and had the potential to negatively impact Resident 2's highest practicable physical, mental, and psychosocial well-being. Findings: A review of Resident 2's clinical record indicated Resident 2 was admitted in December 2025 with diagnoses that included schizophrenia (a mental health condition that affects thinking, emotions and behavior). A review of Resident 2's Behavioral Health Note dated 6/6/26 at 8:35 p.m. indicated at approximately 7 p.m. Resident 1 became suddenly agitated during a scheduled smoke break and, without known triggers, struck Resident 2 with a closed hand. Resident 2 was immediately assessed and showed no redness, swelling, bruising, or other visible injuries and denied pain or discomfort. During a review of Resident 2's Change in Condition Note dated 6/7/26 at 1:33 a.m., Resident 2 later reported a mild headache rated 2/10. Tylenol was administered, providing effective relief as ordered. Review of Resident 2's IDT Note dated 6/8/26 at 10:30 a.m., indicated that during another scheduled smoke break, Resident 1 became upset after believing Resident 2 was making faces toward him. Resident 1 then made physical contact with Resident 2's face with his hand. During an interview with Resident 2 on 6/25/26 at 2:57 p.m., Resident 2 stated that Resident 1 hit him in the face and it hurt.During a telephone interview on 6/29/26 at 2:24 p.m. with Assistant Director of Nursing (ADON), the ADON stated the expectation was all residents should be free from any forms of abuse. A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/2021, indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse . protect residents from abuse.by anyone including. other residents .

Based on observation, interview, and record review, the facility failed to ensure five of seven sampled residents (Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) were free from abuse, when: 1. Resident 2 threw a cup of coffee onto Resident 3;2. Resident 1 pushed his walker into the back of Resident 4's legs;3. Resident 1 put his lit cigarette butt on Resident 5's face;4. Resident 1 hit Resident 2's face with his fist; and5. Resident 7 hit Resident 6 in the back of the head with his hand. These failures had the potential to negatively impact Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6's highest practicable physical, mental, and psychosocial well-being.Findings: 1. A review of an admission record indicated Resident 2 was admitted to the facility with a diagnosis of schizophrenia (a serious mental health condition that affects how people think, feel, and behave and includes delusions or hallucinations). A review of Resident 2's Minimum Data Set (MDS, an assessment tool), dated 3/2/26, indicated Resident 2's Brief Interview of Mental Status (BIMS) score was three out of 15 with severe cognitive impairment. A review of Resident 2's Care Plan (CP), revised 1/16/26, indicated Resident 2 was at risk for behavioral disturbances related to history of physical aggression due to schizophrenia. A review of an admission record indicated Resident 3 was admitted to the facility with diagnoses including schizoaffective disorder (a chronic mental health condition combining the symptoms of schizophrenia such as hallucinations or delusions with a mood disorder), borderline personality disorder (a mental health condition characterized by profound difficulty regulating emotions), and anxiety disorder (a group of mental health conditions characterized by persistent, excessive, and uncontrollable fear or worry that is out of proportion to the actual situation). A review of Resident 3's MDS, dated [DATE], indicated a BIMS score of 15 out of 15 with intact cognition. A review of Resident 3's Behavioral Health Note, dated 4/7/26, indicated at approximately 9:45 a.m. on 4/7/26 Resident 3 was standing conversing with another resident when he was questioned by Resident 2 regarding staring. The note further indicated Resident 2 became agitated and threw coffee onto Resident 3. During an interview on 5/26/26 at 12:06 p.m. with Resident 3, Resident 3 stated he was in the dining hall talking to another resident when Resident 2 came up to him and asked him why he was staring at him. Resident 3 further stated Resident 2 held a cup filled with coffee in his hand, then Resident 2 threw the contents of the cup towards him and the coffee landed on his face, neck, and clothing. During an interview on 5/26/26 at 9:46 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated she witnessed Resident 2 taking the cup of coffee he was holding and throwing it towards Resident 3. CNA 2 further stated Resident 3 became upset and grabbed a nearby chair and pushed it towards Resident 2. During an interview on 5/26/26 at 11:48 a.m. with Mental Health Worker (MHW) 2, MHW 2 stated he saw Resident 2 with a cup of coffee in his hand when Resident 2 threw it towards Resident 3. MHW 2 further stated Resident 3 got a chair and pushed it towards Resident 2's body. 2. A review of an admission record indicated Resident 1 was admitted to the facility with diagnoses including schizoaffective disorder and personal history of traumatic brain injury (any past physical damage to the brain caused by an external force). A review of Resident 1's MDS, dated [DATE], indicated a BIMS score of 14 out of 15 with intact cognition. A review of an admission record indicated Resident 4 was admitted to the facility with diagnoses including schizophrenia, dementia (an umbrella term for a decline in mental abilities severe enough to interfere with daily life), and depression (mood disorder that causes persistent feeling of sadness and loss of interest). A review of Resident 4's MDS, dated [DATE], indicated a BIMS score of five out of 15 with severe cognitive impairment. A review of Resident 4's Health Status Note, dated 4/20/26, indicated on 4/20/26 at 12:30 a.m. Resident 4 was walking towards his room when Resident 1 followed him and pushed his walker forward and made contact with the back of Resident 4's legs. A review of Resident 1's Behavioral Health Note, dated 4/20/26, indicated Resident 1 pushed his walker in the direction of Resident 4, and the walker made physical contact with the back of Resident 4's legs. The note further indicated Resident 1 was verbally aggressive when checked on by staff in his room after the incident and shouted to be left alone. During an interview on 6/2/26 at 11:25 a.m. with CNA 4, CNA 4 stated Resident 1 and Resident 4 were both walking in the hallway, and Resident 1 was walking behind Resident 4 using his walker. CNA 4 further stated she saw Resident 1 intentionally pushing his walker forward into the back of Resident 4's legs. CNA 4 also stated Resident 1 had often showed aggressive behaviors towards other residents. 3. A review of an admission record indicated Resident 5 was admitted to the facility with diagnoses including schizoaffective disorder, anxiety disorder, and depression. A review of Resident 5's MDS, dated [DATE], indicated a BIMS score of 14 out of 15 with intact cognition. A review of Resident 1's Interdisciplinary (IDT) Note, dated 4/28/26, indicated on 4/25/26 at approximately 4 p.m. Resident 1 was observed ambulating toward the cigarette disposal area, and without any apparent trigger turned and made contact with Resident 5's face with a cigarette butt. During an observation 5/26/26 at 11:42 a.m. in the hallway outside Resident 5's room, Resident 5 was observed with a small dark scar under his right eye. During an interview on 5/26/26 at 11:42 a.m. with Resident 5, Resident 5 stated he was sitting outside in the smoking area when Resident 1 abruptly came towards him and put his lit cigarette butt on Resident 5's face under his right eye. Resident 5 further stated he felt heat and a burning sensation. During an interview on 5/26/26 at 8:43 a.m. with CNA 1, CNA 1 stated he was outside for a staff monitored smoke break at approximately 4 p.m. and observed Resident 5 sitting down. CNA 1 further stated he then observed Resident 1 walking towards Resident 5's direction and abruptly putting his cigarette butt onto Resident 5's face. During an interview on 5/27/26 at 11:35 a.m. with MHW 1, MHW 1 stated residents were out smoking when he observed Resident 1 walking towards the cigarette disposal, then intentionally moving his walker towards Resident 5 and pressing his cigarette butt onto Resident 5's face under his right eye. 4. A review of Resident 2's Health Status Note, dated 4/25/26, indicated at approximately 3 p.m., two staff members reported that Resident 2 was the victim of peer-to-peer physical altercation and sustained physical contact to the cheek when Resident 1 struck Resident 2 with a hand while both were lined up waiting for a smoke break. A review of Resident 2's IDT Note, dated 4/28/26, indicated on 4/25/26 at approximately 3:30 p.m., Resident 1 made physical contact with Resident 2's cheek using his hand while both were in close proximity to each other waiting for the smoke break. During an interview on 5/26/26 at 8:42 a.m. with CNA 1, CNA 1 stated he was standing in the hallway when he saw Resident 1 and Resident 2 in line next to each other to go outside for a smoke break. CNA 1 further stated he saw Resident 1 abruptly standing from his sitting walker and punching Resident 2 in the face with his right fist. During an interview on 5/27/26 at 11:37 a.m. with MHW 1, MHW 1 stated he was standing with CNA 1 when he saw Resident 1 standing from his sitting walker, then swinging his right fist towards Resident 2's face and hitting Resident 2's cheek. MHW 1 further stated this incident occurred right before the incident with the cigarette butt happened. 5. A review of an admission record indicated Resident 7 was admitted to the facility with diagnoses including schizophrenia, bipolar disorder (a lifelong mental health condition that causes extreme emotional highs and lows), depression, and pervasive developmental disorder (now known as autism spectrum disorder, a lifelong neurological and developmental condition that affects how a person communicates, interacts, behaves, and learns). A review of Resident 7's MDS, dated [DATE], indicated a BIMS score of zero out of 15 indicating Resident 7 was unable to participate in the BIMS assessment due to severe cognitive impairment. A review of an admission record indicated Resident 6 was admitted to the facility with diagnoses including schizoaffective disorder and bipolar disorder. A review of Resident 6's MDS, dated [DATE], indicated a BIMS score of 14 out of 15 with intact cognition. A review of Resident 6's IDT Note, dated 4/30/26, indicated Resident 6 was involved in a peer-to-peer altercation on 4/29/26 at approximately 9:30 p.m. when he was approached from behind by a peer (Resident 7) and was struck on the back of the head. The note also indicated Resident 6 expressed concern about safety within the facility and indicated discomfort around the involved peer. The note further indicated Resident 6 reported that Resident 7 was observed standing outside his room earlier, which caused distress. During an interview on 5/26/26 at 12:22 p.m. with Resident 6, Resident 6 stated he was waiting in line for snacks in the dining hall when Resident 7 came and hit him in the back of his head with a fist and ran away. During an interview on 5/27/26 at 10:02 a.m. with Licensed Nurse (LN) 2, LN 2 stated he saw Resident 6 in the dining room standing in line during snack time when Resident 7 run up behind Resident 6 and hit him in the back of the head with his hand. LN 2 further stated Resident 7 started yelling at Resident 6 until they were both separated. During an interview on 5/27/26 at 11:15 a.m. with Assistant Director of Nursing (ADON), ADON stated the expectation was all residents should be free from any forms of abuse. During an interview on 5/27/26 at 11:20 a.m. with Behavior Health Nurse Director (BHNP), BHNP stated any type of abuse should not have occurred and all residents should have been kept safe. A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/2021, indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse . protect residents from abuse by anyone including other residents .

Based on interviews, and record review, the facility failed to protect one of five sampled residents' (Resident 1) right to be free from physical abuse by another resident when Resident 2 punched Resident 1 in the face. This failure had the potential to cause physical and mental harm to Resident 1.Findings:Resident 1 was admitted to the facility in February of 2026 with diagnoses that included schizoaffective disorder (a chronic mental health condition characterized by a combination of schizophrenia symptoms and a mood disorder).A review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool used in nursing homes), dated 2/26/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident 1 was cognitively intact.Resident 2 was admitted to the facility in December of 2025 with diagnoses that included schizophrenia (a mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior).A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had a BIMS score of 13, indicating Resident 2 was cognitively intact. A review of Resident 2's, Behavioral Health Note, dated 2/23/26, indicated, At approximately 0405am [4:05 a.m.] on 2/23/26, this resident [Resident 2] entered a female peer's bedroom [Resident 1's room]. Per [Resident 1], he entered my room, 2 feet in, and he stood there staring. I [Resident 1] asked him [Resident 2] to leave and he just stood there staring. His peer [Resident 1] pushed him out and it was observed that this resident [Resident 2] swung his arm twice to the resident's [Resident 1] face.During an interview on 4/1/26 at 11:14 a.m. with Resident 1, Resident 1 indicated that, on 2/23/26, Resident 2 had entered her room without her permission, which prompted her to tell him to leave. Resident 1 indicated that after trying to get Resident 2 to leave her room, Resident 2 punched her in her face. During an interview on 4/1/26 at 11:47 a.m. with the Social Services Director (SSD), the SSD indicated that the Resident 2 punching Resident 1 in the face would be considered physical abuse. The SSD indicated she had interviewed Resident 1 after the incident and Resident 1 stated that she felt, shaken up.During an interview on 4/1/26 at 12:34 p.m. with Licensed Nurse 1 (LN 1), LN 1 confirmed she witnessed the incident on 2/23/26 between Resident 1 and Resident 2. LN 1 indicated she had been in the nursing station near the incident when she rushed over after hearing yelling. LN 1 indicated that she then witnessed Resident 2 punch Resident 1 in the mouth area twice. During a review of the facility's policy and procedures (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/21, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.These findings represent past noncompliance with this regulatory requirement. Observations, interviews and record review confirmed the residents were separated immediately, the residents were assessed, the residents' providers and responsible parties were notified, and both residents were put on 15-minute checks for 72 hours. Staff in-services on abuse were done. There was sufficient evidence that the facility corrected the violation as of 2/23/26, and no other occurrences of noncompliance were identified. At the time of the visit, the facility was in substantial compliance with this regulatory requirement, and therefore, this violation does not require a plan of correction.

Based on observation, interview and record review the facility failed to protect one of four sampled resident's (Resident 4) from abuse when Resident 3 threw a chair at Resident 4 who attempted to deflect the chair and sustained an injury.This failure resulted in slight pain and a minor fracture to the ring finger.Findings:Resident 3 was admitted to the facility in the winter of 2024 with diagnosis which included schizoaffective disorder (a chronic mental health condition combining symptoms of schizophrenia (hallucinations or delusions) with severe mood swings of mania and sometimes depression).During a review of Resident 3's Minimum Data Set (MDS, an assessment tool), dated 12/10/25, the MDS indicated Resident 4 was alert and oriented, able to make her needs known.During a review of Resident 3's care plan (CP) titled .At risk of becoming physically aggressive towards others.History of harm/assaultive behavior to others, Poor impulse control, fixated delusional thoughts, agitation., revised 12/18/25, the CP indicated Assess and anticipate resident's needs.Intervene before agitation escalates. Resident 4 was admitted to the facility in the winter of 2025 with diagnoses which included schizophrenia (a chronic, severe brain disorder that causes people to lose touch with reality, disrupting how they think, feel, and behave).During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 was alert and oriented, able to make her needs known.During a review of Resident 4's CP titled At risk for behavioral disturbances related to Hx [history] of assaultive behavior, schizophrenia, revised 1/15/26, the CP indicated .Provide secure & comfortable environment.During a review of Resident 3's nurses notes (NN), dated 2/4/26, the NN indicated Resident was involved in a behavioral incident in the dining room.Resident stood up, lifted the chair she has been sitting on, and threw it toward another resident [Resident 4].Resident stated she believed the other resident was going to hurt her brother, which prompted her reaction.During a review of Resident 4's social services note (SSN), undated, the SSN indicated, SS spoke with resident regarding and(sic) incident that occurred in the dining room while waiting for smoked (sic) break. Resident stated, I'm not sure (sic) she didn't say anything (sic) she didn't look mad (sic) she just stood up lifted the chair and turned and threw it (sic) I blocked it with my hand.During a review of Resident 4's Radiology Results Report (RRR), dated 2/6/26, the RRR indicated .Soft tissue swelling.Mild.fracture.During an interview on 2/24/26 at 1:13 p.m. with the Social Services Director (SSD) in the conference room about the incident on 2/4/26 which involved Resident 3 and Resident 4, the SSD stated, [Resident 3] has delusions at times and it seems to be family related.During a concurrent observation and interview on 2/24/26 at 1:57 p.m. with Resident 4 in the upper activity room, Resident 4 was observed to have a hard splint from the ring finger to the left elbow wrapped with gauze. She was asked about the incident on 2/4/26. Resident 4 stated, My ring finger got broken It doesn't hurt. It's just good if I stay away from [Resident 3].We were waiting for a smoke break .She stood and threw the chair toward me. I think it was intentional. I just stopped the chair as it came toward me. My hands hit the front of the chair. It's kind of heavy [Observed to have a metal frame with padded seats, back and armrests]. It could have been something I said to her, not then, but maybe before. She has a mental issue where .she'll flip on me. She'll start to blame me about something that I don't even know about .It's the first time she hurt me.During an interview on 2/25/26 at 10:02 a.m. Certified Nurses Assistant (CNA) 4, CNA 4 was asked to describe Resident 3 and said .[Resident 3] is unpredictable. It's not foreseeable. My experience with her is she has a quick shift in moods.When she's trying to sleep and other residents are loud in the hallway, she targets them. She'll start yelling and saying 'Stop trying to kill my daughter,' as an example.During a concurrent observation and interview on 2/25/26 at 10:32 a.m. with Resident 3 in the small dining room, Resident 3 had a slow, quiet demeanor and smiled when being questioned.She was asked about the incident on 2/4/26 and said, I threw the chair at [Resident 4]. It was heavy. She was right here.[at another table about 6 feet away]. I think she hurt her hand .During an interview on 2/25/26 at 11:47 a.m. with the MHW in the conference room, the MHW was asked to describe the incident on 2/4/26 and said, I was standing at the entry to the small dining room on [name of unit] so I could watch the residents inside the dining room and outside in the hall.Then I turned my head, for just a moment, to watch [residents passing through] the hallway and nurses station area. When I looked back towards the dining room, I saw [Resident 3] stand up, grab her chair and throw it at [Resident 4]. I.couldn't stop it because it all happened too fast.There was also a CNA behind me.[Resident 3] did not say anything. I didn't even notice them talking before this happened.During an interview on 2/25/26 at 12:30 p.m. with the Nurse Consultant (NC), the NC said, I know [Resident 4] was refusing care, didn't want them to look at it and didn't want medications. That might have been the reason for the delay in the Xray .During an interview on 2/25/26 at 12:14 p.m. with the Assistant Director of Nurses (ADON), the ADON was asked what her expectation was regarding abuse toward residents and stated, Our residents should be free from abuse.During a review of the facility policy and procedure (P&P), titled Abuse, Neglect, Exploitation and Misappropriation Prevention, revised 4/21, the P&P indicated, Residents have the right to be free from abuse.This includes.physical abuse.

Based on interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for four of 11 sampled residents (Resident 1, Resident 4, Resident 5, and Resident 7), when:1. Resident 2 slapped Resident 1 in the back of the head; 2. Resident 3 hit Resident 4 in the face;3. Resident 4 slapped Resident 5 in the face; and4. Resident 6 pushed Resident 7.This failure caused Resident 1 to feel upset, Resident 4 to feel afraid, Resident 5 to have a cut lip, and Resident 7 to have leg pain. Findings:1.Resident 1 was admitted to the facility early 2024 with diagnosis which included Schizophrenia (a chronic, severe mental disorder that affects how a person thinks, feels, and behaves), major depression, and anxiety disorder.During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 1/26, the MDS showed a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 10/15 which indicated moderate cognitive impairment.Resident 2 was admitted to the facility early 2024 with diagnosis which included Schizophrenia and memory loss.During a review of Resident 2's MDS dated 11/25, the MDS showed a BIMS score of 3/15 which indicated severe cognitive impairment.During a review of Resident 1's Progress Notes (PN) dated 1/19/26, the PN indicated, On 01/19/2026 at approximately 0630 [6:30 a.m.] CNA [Certified Nursing Assistant] witnessed [Resident 2] open handedly slap [Resident 1] on the back of his head.During an interview on 2/4/26 at 2:06 p.m. with Resident 1, Resident 1 stated he was smacked on the back of the head by another resident and the incident upset him.During an interview on 2/4/16 at 2:16 p.m. with CNA 1, CNA 1 stated she witnessed Resident 2 open hand hit Resident 1 on the back of the head.2. Resident 3 admitted to the facility in late 2025 with diagnosis which included Schizophrenia.During a review of Resident 3's MDS dated 12/25, the MDS showed a BIMS score of 13/15 which indicated intact cognition.Resident 4 was admitted to the facility in late 2025 with diagnosis which included Schizophrenia, and need for assistance with personal care.During a review of Resident 4's MDS dated 1/26, the MDS showed a BIMS score of 12/15 which indicated moderately impaired cognition.During a review of Resident 3's PN dated 1/15/26, the PN indicated, At approximately 1915 [7:15 p.m.], [Resident 3] was observed by a CNA striking his roommate [Resident 4].[Resident 3] appeared highly psychotic, was unable to follow directions, and displayed aggressive behavior toward staff.During an interview on 2/5/26 at 1:20 p.m. with Resident 4, Resident 4 stated he was in bed and his roommate [Resident 4], started punching me in the face. Resident 4 stated he felt scared after the incident.During an interview on 2/5/26 at 3:11 p.m. with CNA 2, CNA 2 stated he saw Resident 3 lying in bed and trying to defend himself from Resident 4, I saw a few punches.3. Resident 5 was admitted to the facility in late 2025 with diagnosis which included Schizophrenia and need for assistance with personal care.During a review of Resident 5's MDS dated 12/25, the MDS showed a BIMS score of 13/15 which indicated intact cognition.During a review of Resident 5's PN dated 1/18/26, the PN indicated, At approximately 1243 [12:43 p.m.], [Resident 5] entered the room of [Resident 4].[Resident 4] struck [Resident 5] in the face.A mild tear and slight bleeding was noted on [Resident 5's] lip.During an interview on 2/5/26 at 1:20 p.m. with Resident 4 in his bedroom, Resident 4 confirmed he hit Resident 5 in the face, I hit him on his lip.4. Resident 6 was admitted to the facility in late 2025 with diagnosis which included Schizophrenia, restlessness and agitation.During a review of Resident 6's MDS dated 10/25, the MDS showed a BIMS score of 6/15 which indicated severe cognitive impairment.Resident 7 was admitted to the facility in early 2024 with diagnosis which included Schizophrenia, difficulty walking, memory problems and chronic pain syndromeDuring a review of Resident 7's MDS dated 12/25, the MDS showed a BIMS score of 10/15 which indicated moderate cognitive impairment.During a review of Resident 6's PN dated 1/19/26, the PN indicated, .[Resident 6] and his peer got into a verbal altercation that lead (sic) to this resident pushing his peer [Resident 7].During an interview on 2/4/26 at 2:36p.m. with Resident 7, Resident 7 stated he remembered Resident 6 pushed him on the shoulders and he fell to the ground. Resident 7 stated the fall caused his back and leg to hurt.During an interview on 2/5/26 at 11:47 a.m. with CNA 3, CNA 3 stated she witnessed Resident 6 intentionally push Resident 7 which caused him to fall to the floor.During an interview on 2/5/26 at 2:56 p.m. with the Director of Nursing (DON), the DON stated her expectations were for all residents to be free from abuse and to be safe in the facility.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation- Prevention Program, dated 4/21, the P&P indicated, Residents have the right to be free from abuse, neglect.Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including.other residents.

Based on observation, interview and record review, the facility failed to protect the right to be free from physical abuse for three of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4), when: 1. On 12/13/25, Resident 1 spat at Resident 2 in the hallway;2. On 12/24/25 in the dining room, Resident 1 slapped Resident 3 on the back of the head; and3. On 12/26/25 in the dining room, Resident 1 slapped Resident 4 on the face. This failure compromised the residents' ability to maintain their highest practicable physical, emotional and psychological well-being.Findings: 1. During a review of Resident 1's admission Record (AR), dated 1/8/26 (print date), the AR indicated Resident 1 was admitted to the facility in December of 2025 with diagnoses which included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and age-related cognitive (process of acquiring knowledge and understanding through thought process) decline. During a review of Resident 1's progress note (PN), dated 12/13/25, the PN indicated, At 1600 [4 p.m.] [Resident 1] was standing in the hallway using a walker. [Resident 2] was positioned in front of [Resident 1] and speaking loudly to himself.[Resident 1] became upset by the behavior and spat on [Resident 2]. During a review of Resident 2's AR, dated 1/8/26, the AR indicated Resident 2 was admitted to the facility in May of 2025 with diagnoses that included schizoaffective disorder and depression (a mood disorder causing persistent sadness, loss of interest). During a concurrent observation and interview on 1/7/26 at 12:43 p.m. with Resident 2, Resident 2 was observed walking and talking in the hallway. When asked if he had been involved in any altercation with other residents, Resident 2 stated, It was about a month ago when he spit on me. When asked if he felt safe in the facility, Resident 2 stated, I'm more worried about the staff here. During a phone interview on 1/8/26 at 9:04 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 confirmed he witnessed the incident on 12/13/25 between Resident 1 and Resident 2 as they met in the hallway and Resident 1 spat at Resident 2. CNA 1 further stated that when staff intervened, Resident 2 was questioning why Resident 1 spat at him, and Resident 2 remained silent and looked stunned. 2. During a review of Resident 3's AR, dated 1/9/26, the AR indicated that Resident 3 was admitted to the facility in April of 2024 with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought) and dementia (a progressive state of decline in mental abilities due to reduced blood flow to the brain). During a review of Resident 3's PN, dated 12/24/25, the PN indicated, [Resident 1 was observed standing from his wheelchair and approaching another resident table where [Resident 3] who was seated and drinking coffee. [Resident 1] subsequently stood up and then slapped [Resident 3] on the back of his head. During a concurrent observation and interview on 1/7/26 at 12:56 p.m. with Resident 3, Resident 3 was not answering questions clearly, mumbled and difficult to understand. When asked if he was involved with any altercations with other residents, Resident 3 stated, I was hit on the back of head by some guy. I don't remember exactly when. During an interview on 1/8/26 at 11:09 a.m. with the Social Services Assistant (SSA), the SSA stated that on 12/24/25 at around 9 a.m., he saw how Resident 1 hit Resident 3 on the back of the head with an audible sound when both residents were by the shared table in the dining room. The SSA further stated that Resident 3 looked shocked and confused, and Resident 1 stated that he slapped Resident 3 because he was looking at him in a weird way. 3. During a review of Resident 4's AR, dated 1/8/26, the AR indicated that Resident 4 was re-admitted to the facility in March of 2024 with diagnoses that included schizoaffective disorder and posttraumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). During a review of Resident 4's PN, dated 12/26/25, the PN indicated, .[Resident 4] was just sitting close to the nurse station attending the group, when [Resident 1] walked towards [Resident 4] sat down next to her and suddenly lay his hand on her and landed on her R [right] side face. Resident were separated right away. During a concurrent observation and interview on 1/7/26 at 2:41 p.m. with Resident 4, Resident 4 walked from the dining room to her room. When asked what her name was, Resident 4 introduced himself with a different name. When asked if she was involved in altercations with other residents, Resident 4 was not able to elicit an appropriate response and recanted a story not related to the question. When asked if she was safe in the facility, Resident 4 stated, I'm afraid that there will be fire.The man in the bathroom slapped me, he didn't do it, it's my word against everybody else. During an interview on 1/7/26 at 4:50 p.m. with Licensed Nurse 1 (LN 1), LN 1 stated that on 12/26/25, she saw how Resident 4 was sitting by the nurse's station, and Resident 1 approached Resident 4 and slapped her on the face with an audible slap sound. LN 1 further stated that Resident 4 cried and said that Resident 1 slapped her. During an interview on 1/8/26 at 3:04 p.m. with the Director of Nursing (DON), the DON confirmed that the incident on 12/13/25 between Resident 1 and Resident 2, the incident on 12/24/25 between Resident 1 and Resident 3, and the incident on12/26/25 between Resident 1 and Resident 4 were witnessed and constituted physical abuse. The DON further stated that she expected facility residents to be free from physical and verbal abuse. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/2021, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse.

Based on observation, interview, and record review, the facility failed to ensure food storage and preparation, in accordance with professional standards for food service safety, was provided to residents in a census of 101, when: 1. Floors, rolling racks, equipment, pots/pans, grill/stove panel, refrigerator doors, water pitcher preparation area, garbage cans, can opener, and towels were found unclean and unsanitary; 2. Food, and staff's personal food and drink, items were found in refrigerators and in the dry storage room, opened, not labeled, not securely covered, dented, and expired; and 3. Kitchen staff did not know how to explain or demonstrate the proper procedures for testing sanitizing solutions, and expired test strips were being used. These failures had the potential to cause food-borne illnesses in a vulnerable population. 1. During a concurrent observation and interview on 12/2/25 beginning at 8 a.m. in the kitchen with the Certified Dietary Manager (CDM), the CDM confirmed the kitchen area and equipment were uncleaned and unsanitary. The CDM acknowledged and verified the following:a. The kitchen floors had food stains and debris in corners; b. The grill stove panel, rolling cart racks with holding trays, and refrigerator doors were smeared with a white substance; c. The refrigerator doors were smeared with a black particle substance; d. A blue plastic garbage can, with food debris around the bottom and white brown streaks on the outside of can, near the food preparation area; e. Pots and pans, with food crumbs and brown white stains, on a fixed rack near the grill oven; f. A rolling white container with no lid, with Kitchen Rags written in black marker on the side, was found over filled with towels and a mop head that was grease stained and smelled musty, in the dry food storage room; g. The stainless-steel preparation area, for coffee, tea and water pitchers, was found with dried white streaks and brown stains leading to floor, and the shelf area underneath had a large dried dark brown stain; andh. The dishwasher was found with thick residue along panel near the motor mechanism. The CDM stated there was no weekly cleaning log sheet identifying staff duties. The CDM provided an In Service Compliance Training Record, for towels, staff signatures dated 10/2025, with topic: yellow dirty towel bin must now be stored in dry storage. No exception. The CDM stated expectations were for staff to keep kitchen areas, and all items used, clean and in sanitary conditions. The CDM stated it was important to prevent food-borne illnesses and avoid cross contamination. During a concurrent observation and interview on 12/4/25 at 9:15 a.m. in kitchen with the CDM, the CDM confirmed the can opener was found with chipped metal shavings on tip, and dried dark food particles with strands of hair on shaft holder. The CDM stated the expectation was for the can opener to be kept clean and free from defect. The CDM stated it was important to prevent metal flakes from getting into food, which could cause harm to residents. During a review of the facility's policy and procedure (P&P) titled, General Sanitation of Kitchen, dated 5/2017, the P&P stipulated, Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. During a review of the facility's P&P titled, Kitchen Cloths, dated 2017, the P&P stipulated, Kitchen cloths will be clean.2.soiled cloths will be sent to the laundry and replaced with clean cloths.3. Recyclable kitchen cloths will be laundered separately.They will be dried, folded . During a review of the facility's P&P titled, Cleaning and Disinfection of Environmental Surfaces, revised 8/2019, the P&P stipulated, .13. Mop heads.will be decontaminated regularly.dried.daily. During a review of the facility's P&P titled, Sanitization, revised 11/2022, the P&P stipulated, .2. All.equipment are kept clean, maintained in good repair and are free from.corrosions. 2. During a concurrent observation and interview on 12/2/25 beginning at 8 a.m. in the kitchen with the CDM, the CDM confirmed food items were not properly stored and labeled. The CDM verified and acknowledged the following:a. A food item of potato salad was found, in a clear plastic container, loosely covered with plastic wrap, with no open date label, and an expired date 11/21/25 written on a label in black marker, in the walk-in refrigerator;b. Three staffs' personal drinks were found in the residents' refrigerator on the second shelf; c. A caramel sauce bottle was found, opened with no date with white sticky substance leaked from top of the opening, on a shelf in the dry food storage room; d. An unidentified food item was found moldy, wrapped in clear plastic and foil wrap, on an opened box identified as tartar sauce, on a shelf in the dry food storage room, next to staff standing lockers for personal items; ande. A dented zero sugar cola can was found on bottom shelf of residents' refrigerator. The CDM stated the unidentified food item belonged to one of the kitchen staff. The CDM indicated the expectations for staff, were: to throw away expired food items; to use the bottom shelf of residents' refrigerator, or to use staff refrigerators on the nursing units, for personal food and drink items; not to eat personal food items in the dry food storage room; to label food items when opened with a date and kept clean. The CDM stated that it was important to prevent food-borne illnesses, cross contamination, and pests. During a review of the facility's P&P titled, Dry Storage Areas, dated 2017, the P&P stipulated, Dry storage areas will be kept in a condition which protects stored foods from infestation.4. Leaking or severely dented cans and spoiled foods should be disposed of promptly to prevent contamination of other foods. During a review of the facility's P&P titled, Food Receiving and Storage, dated 2001, the P&P stipulated, Dry Food Storage.7. Foods may not be stored: a. in locker rooms.Refrigerated/Frozen Storage 1. All foods stored in the refrigerator.are covered, labeled and dated ( use by date). A policy for kitchen staff personal food items was requested from the CDM but was unable to provide. 3. During a concurrent observation and interview on 12/2/25 at 9:10 a.m. in the kitchen with Dietary Aide 1 (DA 1), DA 1 was asked to explain and demonstrate how to test the sanitizer solution during final rinse of the dishwasher machine. DA 1 opened the left side door of the dishwasher and pulled the clean dishes rack onto the platform. DA 1 removed a test strip from a chlorine test paper bottle, swiped the strip across a clean, wet plate cover, held it next to the test strip bottle, and stated the result did not read 50-100 parts per million (ppm, a unit of concentration or ratio measuring contaminants or elements in water). DA 1 acknowledged the test strip yellow color result was not the recommended manufacturer's blue color. DA 1 requested the assistance of DA 2 to help explain the differences in color results. DA 2 and the CDM retrieved, and used, a different company's test strip, manufactured to test quaternary (QUAT) solution (a disinfectant cleaner and deodorizer that is effective against certain germs), which did not result in the 100 ppm being documented by staff on the Temperature/Sanitizer Record sheet. The kitchen staff confirmed both chlorine test paper bottles had an expiration date of 09/25. the CDM said staff had not had return demonstration education on how to test for dishwasher chlorine sanitizing solution, or for QUAT solution. The CDM stated it was important for staff to know how to test sanitizing solutions to ensure proper contact of solution on dishes and surfaces to prevent food-borne illnesses. During a concurrent observation and interview on 12/3/25 at 9 a.m. in kitchen with the [NAME] and the CDM, the [NAME] was asked to explain and demonstrate how to test the QUAT sanitizer solution. The [NAME] indicated there was no QUAT solution test form to document the results. The [NAME] stated the QUAT solution in the red bucket was changed every two hours if dirty. The [NAME] acknowledged it was important to maintain solution within range to protect and keep the residents safe. The CDM confirmed there was no form to document QUAT test results. The CDM stated it was important staff had a QUAT solution test result form to ensure solution was maintained within range to prevent cross contamination. During an interview on 12/5/25 at 7:30 a.m. with the Administrator (ADM) and the Administrator-in-Training (AIT), the ADM indicated his expectation was for kitchen staff to maintain cleanliness, to follow protocols, to prepare food with correct temperatures and residents' preferences. The ADM stated kitchen protocols were important to avoid food-borne illnesses in a vulnerable population. During a review of the facility's P&P titled, General Sanitation of Kitchen, dated 5/2017, the P&P stipulated, .4. Method and materials.to be used for.sanitizing will be written for each task.5. Employees will be trained on how to perform cleaning tasks. During a review of the FDA Food Code 2022, the food code indicated, Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.The hazards associated with the particular foods that are prepared, stored, or served.The type of operation including the methods and extent of food storage, preparation, and service.The number of people served.Whether the population served is highly susceptible population.

Based on observation, interview and record review, the facility failed to ensure accurate handling, storage, disposal, and documentation of controlled medications (medications with high potential for abuse or addiction) were provided for residents in a census of 101, when:1. There was no efficient system in place to accurately document and secure disposed controlled medications when two stored bags containing controlled substances were easily retrievable; and 2. There was no accurate documentation on controlled medication for Resident 98, when the administration date was missing, and two bottles of controlled substances were documented on only one controlled drug record with a discrepancy on the remaining quantity of the medication.These failures had the potential for drug diversion (theft for personal use or illegal sale), and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions.1.During a concurrent observation and interview on 12/2/25 at 8:50 a.m. with Licensed Nurse (LN) 3 at the facility medication cart C1 (C1), LN 3 confirmed there was a bag that contained multiple uncrushed controlled drugs within small plastic bags stapled to folded control drug records located inside the drawer of C1. LN 3 stated the half pills inside the bags were considered disposed of inside the cart into the bag after being verified by two nurses. During a concurrent observation and interview on 12/02/25 4:16 p.m. with LN 4 at the facility medication cart W1 (W1), LN 4 confirmed there was a bag that contained multiple uncrushed controlled drugs within small plastic bags stapled to folded control drug records located inside the drawer of W1. LN 4 stated the expectation was for nursing staff to make a copy of the controlled drug record, place the controlled drug into a small plastic bag uncrushed and staple it to a copy of the controlled drug record. LN 4 further stated she was expected to sign the controlled drug record that contained the stapled uncrushed controlled drug with two nurses, fold it up, then place it inside a larger plastic bag with the remaining discontinued controlled drugs until the DON (Director of Nursing) picked up to destroy the controlled substances with the pharmacist. LN 4 confirmed there was no controlled drug destruction at the medication carts, and no controlled drugs were placed in any unretrievable medication bins. During a concurrent observation and interview on 12/4/25 at 8:49 a.m. with LN 2 at W1, LN 2 confirmed there was a bag that held multiple uncrushed controlled drugs within small plastic bags stapled to folded control drug records located inside the drawer of W1. LN 2 confirmed there were uncrushed controlled drugs held in drawer for over a week. LN 2 stated the expectation was for staff to keep discontinued uncrushed controlled medications that were half pills inside the small plastic bags then stapled to a folded controlled paper which was placed in a larger bag with other held controlled substances and picked up weekly by the DON. LN 2 stated the reason to properly destroy controlled substances was for the safety of residents and to make sure diversion was avoided, and that best practice to immediately dispose of narcotics so they were not easily accessible or retrievable. During an interview on 12/4/25 at 1:40 p.m. with the DON, the DON stated the expectation was for a discontinued controlled substance to not be stored for no more than three days and that one month was not acceptable. The DON stated, It does not always happen how it was supposed to. The DON stated If staff destroyed controlled substances on the cart the medication was placed in plastic after crushing, attached to the count sheet and turned to the DON. The DON stated she expected staff to bring the count sheets and stored controlled substances to the office or be destroyed in the medication room destruction bin, so controlled drugs were safe, unretrievable in containers to avoid diversion. During a review of the facility's policy and procedure (P&P) titled, Controlled Substances, dated 2001, the P&P indicated, 6.when a resident.receives a partial tablet (or it is not given) the medication is destroyed.The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule 11-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). Dispensing and Reconciling Controlled Substances: 9. Disposal methods are used to prevent diversion and/or accidental exposure to controlled or hazardous substances. 2. During a review of Resident 98's admission Record (AR), dated 12/5/25, the AR indicated Resident 98 was readmitted to the facility Fall of 2025 with diagnosis which included malignant kidney neoplasm (kidney cancer), palliative care (specialized medical care that helps people managing symptoms like pain), and rheumatoid arthritis (disease that causes pain and stiffness in hands, wrist and joints). During a review of Resident 98's Order Summary Report [OSR], dated 12/5/25, the OSR indicated, Hydromorphone [pain medication] Give 3 ml by mouth every 3 hours for Pain management. During a review of Resident 98's Shipping Manifest [controlled substance delivery receipt form), dated 11/30/25, the manifest indicated a 60 mL of hydromorphone 5 mg/mL was received for Resident 98. During a review of Resident 98's Medication Administration Record (MAR) for November 2025 and December 2025, the MAR indicated a total of 19 ml of hydromorphone remained after the medication administration. During a concurrent interview and record review on 12/4/25 at 4:22 p.m. with the DON, Resident 98's Controlled Drug Record Liquids, multidose (CDR), dated 11/30/25, was reviewed. Resident 98's CDR indicated one missed administration time for a 2 ml administration of hydromorphone on 12/2/25 and that 19 mL of hydromorphone remained to be wasted. The DON held Resident 98's bottle of hydromorphone at eye level and confirmed Resident 98's bottle of hydromorphone contained 30 mL of hydromorphone instead of 19 ml. The DON stated controlled drug records were expected to be completed and should be easily read and reconcilable. The DON acknowledged the discrepancy and stated she expected the remaining medication volume in the bottle to match the count sheet volume for resident safety and to avoid drug diversion. During a review of the facility's policy and procedure titled, Controlled Substances, date 2001, indicated, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule 11-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) .Dispensing and Reconciling Controlled Substances: 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count .Handling Controlled Substances 3. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion . Handling Controlled Substances. This record contains: j. time of administration.

Based on observation, interview, and record review, the facility failed to maintain comfortable room temperatures for three out of 28 sampled residents (Resident 61, Resident 62, and Resident 120) when:Resident 62's and Resident 120's shared room temperature was below 71 F (degrees Fahrenheit); and Resident 61's room temperature was below 71 F.These failures resulted to Resident 61, Resident 62, and Resident 120 verbalizing that their rooms were cold and very uncomfortable.Findings: 1. During a review of Resident 62's admission Record (AR), dated 12/5/25, the AR indicated Resident 62 was readmitted to the facility in November of 2025 with diagnoses which included epilepsy (a brain disorder causing recurrent seizures due to abnormal electrical activity) and the need for assistance with personal care. During a review of Resident 62's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 11/24/25, the MDS indicated, Resident 62 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 9 out of 15 suggestive of moderate cognitive impairment. During a review of Resident 120's AR, dated 12/5/25, the AR indicated Resident 120 was readmitted to the facility in November of 2025 with diagnoses which included metabolic encephalopathy (a type of brain dysfunction) and the need for assistance with personal care. During a review of the Resident 120's MDS, dated [DATE], the MDS indicated Resident 120 had a BIMS score of 13, suggestive of intact cognition. During a concurrent observation and interview on 12/2/25 at 11:49 a.m. with Resident 62 in his room, Resident 62 sat on a wheelchair next to his bed, dressed in a hoodie (a hooded sweatshirt, jacket, or other top). The in-room thermometer located on the wall displayed a temperature of 69 degrees F. Resident 62 stated that his room was too cold, around 68 to 69 degrees F, and he gets cold all the time and had to wear warm clothing. Resident 62 further stated that he preferred the room temperature around 72 degrees F. During a concurrent observation and interview on 12/2/25 at 11:58 a.m. with Resident 120 (Resident 62's roommate) in his room, Resident 120 sat on a wheelchair next to his bed, dressed in a shirt and pants, and stated that he felt cold and the room was running cold since he was admitted to the facility. Resident 120 also stated that two workers were in the room yesterday who tried to fix a heater or thermostat issue. During a concurrent observation, interview, and record review on 12/4/25 at 8:55 a.m. with the Environmental Services Specialist (ESS) and the Maintenance Assistant (MA) in Resident 62's and Resident 120's room, the in-room thermometer displayed 67 degrees F. The MA used hand-held thermometer to measure several surfaces in the room: the wall measured 68.5 degrees F and the ceiling measured 69 degrees F. The ESS stated that temperature issues were reported to the maintenance staff via the communication logbook, and the issues get addressed in a timely manner. The ESS walked over to the nurse's station and showed the logbook. The logbook sheet for December of 2025 indicated that Resident 62's and Resident 120's room was reported to be too cold on 12/1/25 and too hot on 12/3/25. The ESS confirmed that there were no room specific temperature monitoring and documentation following attempted temperature adjustments for the room on 12/1/25 and 12/3/25. The ESS further stated that the facility should maintain a temperature between 71 and 81 degrees F. 2. During a review of Resident 61's AR, dated 12/5/25, the AR indicated, Resident 61 was admitted to the facility in May of 2025 with diagnoses which included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and needed for assistance with personal care. During a review of Resident 61's MDS, dated [DATE], the MDS indicated Resident 61 had a BIMS score of 10 out of 15 suggestive of moderate cognitive impairment. During a concurrent observation and interview on 12/2/25 at 8:30 a.m. with Resident 61, Resident 61 walked from his room into the hallway with two blankets over his shoulders. Resident 61 stated he was very uncomfortable because of the temperature of the facility and his room was cold. During an interview on 12/4/25 at 8:49 a.m. with Licensed Nurse 2 (LN 2), LN 2 stated when a resident was uncomfortable from a cold room, she expected maintenance to follow up to make sure the resident's room was at a comfortable temperature. During a concurrent observation, interview, and record review on 12/5/25 at 8:30 a.m. with the ESS in Resident 61's room, the ESS used a hand-held thermometer to measure the temperature of Resident 61's room. Resident 61's room measured 64.5 degrees F. The ESS stated the residents' rooms should be set at the comfortable level requested by the resident, and the facility should maintain a temperature between 71 and 81 degrees F for the comfort of the residents. During a concurrent observation and interview in Resident 61's room, on 12/5/25 at 8:40 a.m. with Resident 61, Resident 61 was observed with hands in his pockets, wearing a thick sweater, long sleeve shirt and long pants on. Resident 61 stated he was uncomfortable and stated, I have lived on the streets for years and I am used to the cold, but here [his room and facility] is very cold. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised 2/2021, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment.The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include.comfortable and safe temperatures (71 degrees F - 81 degrees F).

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of four sampled resident (Resident 1), when Resident 2 pushed Resident 1 which caused a fall to the floor. This failure resulted in an injury to Resident 1's left leg.Findings:Resident 1 was admitted to the facility in mid-2025 with diagnosis which included anxiety disorder, dementia, history of falls, and a mental health condition where a person has hallucinations, delusions and mood swings.During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 6/16/25, the MDS showed a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 14/15 which indicated intact cognition.Resident 2 was admitted to the facility in late 2024 with diagnosis which included anxiety disorder, intellectual disabilities, and a mental health condition where a person has hallucinations, delusions and mood swings.During a review of Resident 2's MDS dated [DATE], the MDS showed a BIMS score of 12/15 which indicated moderate cognitive impairment.During a review of Resident 1's Progress Note (PN) Type: Change in Condition, dated 8/31/25 at 7:25 p.m. the PN indicated, At approximately 1:15 PM [Resident 1] was observed walking in the hallway.[Resident 2] who was seated suddenly stood up without warning and pushed the (sic) [Resident 1], [Resident 1] fell onto her left side.she [Resident 1] was noted to have limited mobility in the left leg and hip.received result of the x-ray: conclusion Intertrochanteric fracture varus deformity [break in the upper part of the femur near the hip].During an interview on 9/17/25 at 9:57 a.m. with Resident 2 in her bedroom, Resident 2 confirmed she had pushed Resident 1, Yes, I just pushed her.I got tired of hearing her voice, so I just pushed her and told her to be quiet.During an interview on 9/17/25 at 10:08 a.m. with Licensed Nurse (LN 1), LN 1 stated he was following behind Resident 1 as she walked past Resident 2, Resident 2 stood up and pushed Resident 1 with both hands. Resident 1 fell on the ground landing on her left hip/leg and could not move her left foot. LN 1 stated when the facility received the x-ray results for Resident 1, she was transferred to the hospital for a left hip fracture.During an interview on 9/17/25 at 12:38 p.m. with the Director of Nursing (DON), the DON confirmed Resident 2 pushed Resident 1 which caused her to fall to the floor and resulted in a left hip fracture. The DON stated all residents have the right to be free from abuse.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation- Program, dated 4/21, the P&P indicated, Residents have the right to be free from abuse.This includes but is not limited to.physical abuse.Protect resident from abuse.by anyone including but not necessarily limited to.other residents.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of four sampled resident (Resident 1), when Resident 1 was punched in the face by Resident 2. This failure caused injury to Resident 1's lip.Resident 1 was admitted to the facility early 2024 with diagnosis which included a mental health disorder marked by hallucinations and delusions, anxiety, impulse disorder, and mood disorder.During a review of Resident 1's Order Summary Report [OSR], order date 3/11/24, the OSR indicated, Resident is Incapable Of Understanding Rights, Responsibilities, And Informed Consent.Resident 2 was admitted to the facility mid 2025 with diagnosis which included a mental health disorder marked by hallucinations, delusions and extreme mood swings.During a review of Resident 2's OSR, order date 5/14/25, the OSR indicated, Resident is Incapable Of Understanding Rights, Responsibilities, And Informed Consent.During a review of Resident 2's Progress Notes (PN) Type: Verbal Altercation, dated 8/3/25 at 5:45 p.m., the PN indicated, Resident [Resident 2] was standing yelling towards [Resident 1] LN [licensed nurse] spoke with resident [Resident 2] regarding his current behavior towards [Resident 1], [Resident 2] continue (sic) to be racially preoccupied and experiencing delusional thoughts.During a review of Resident 1's PN Type: Health Status Note, dated 8/3/25 at 11:36 p.m., the PN indicated, .At [7:57 p.m.].found [Resident 1] staggering from the floor.other [staff] stayed with [Resident 2] who continued yelling profanities.Patient [Resident 1] was noted with bleeding from the right lower lip and scratches to left forearm and redness to the right hand knuckles. Right arm was observed shaking.During a review of Resident 2's PN Type: Physical Altercation, dated 8/4/25 at 12:27 a.m., the PN indicated, .[Resident 2] was asked by LN what happened and how did [Resident 1] lip began bleeding. [Resident 2] stated .[Resident 1] began pissing me off my using his mind.I began hitting him and continued hitting him until he dropped on the floor.During a review of Resident 2's Care Plan Report [CP], dated 8/3/25, the CP indicated, Resident has abusive behavioral symptoms as evidenced by punching another resident in the face.During an interview on 8/6/25 at 9:51 a.m. with Resident 2, Resident 2 was asked about the altercation with Resident 1. Resident 2 stated he punched Resident 1 in the face, .I was punching him [Resident 1] just like [NAME] in the face.During an interview on 8/6/25 at 3:19 p.m. with the Director of Nursing (DON), the DON confirmed the incident occurred, and stated all residents had the right to be free from abuse.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation- Program, dated 4/21, the P&P indicated, Residents have the right to be free from abuse.This includes but is not limited to.physical abuse.Protect resident from abuse.by anyone including but not necessarily limited to.other residents.

Based on observations, interviews, and record reviews, the facility failed to protect one of five sampled residents (Resident 1) from abuse when Resident 2 slapped Resident 1 on the left cheek. This failure resulted in Resident 1 experiencing feelings of unsafety, disrespect and physical pain.Findings:Review of Resident 1's admission Records indicated Resident 1 was admitted in Summer of 2024 with diagnoses which included a mental health condition that affected how people think, feel and behave and Type 2 Diabetes. A review of Resident 1's Brief Interview for Mental Status (BIMS), dated 6/2/25, the BIMS indicated Resident 1 had a score of 12 out of 15 which indicated Resident 1 had a moderate cognitive impairment.A review of Resident 1's Interdisciplinary Team (IDT) Note dated 7/14/25 indicated, At approximately 1540 [3:40 p.m.] on 7/13/25, MHW [Mental Health Worker] reported they had heard a slapping sound and saw this resident's [Resident 1] peer strike him on the left side of the face.Resident [Resident 1] stated. I backed my wheelchair up to turn around to go out the door then I accidentally ran over peer's [Resident 2] foot. He [Resident 2] then slapped me instantly on the left side of my face. It began to hurt and sting, my pain is about 8/10.A review of Resident 1's Health Status [HS] Note dated 7/13/25 indicated, MHW 2 reports that he was escorting visitors of 709 to Patio 3 when he witnessed 720B [Resident 2] slap 721B [Resident 1] in the face.During an interview on 7/17/25 at 1:46 p.m., with Resident 1, Resident 1 stated, I was sitting on my wheelchair and the [NAME] was there, I rolled back and rolled over his foot. He yelled then he slapped me on my face. He was close to me. Resident 1 stated that he felt unsafe and disrespected by Resident 2 at the time of the event. Resident 1 also reported that his left cheek was in pain at that time. During an interview on 7/17/25 at 1:20 p.m., with MHW, MHW confirmed he witnessed Resident 2 slapped Resident 1 on his left cheek and stated, It was loud and it's like the ones from the slapping competition. He added it was loud enough that the whole unit heard when Resident 2 slapped Resident 1's face. MHW also stated, He was holding his face, and it looks like he was hurt.During an interview with the Director of Nursing (DON) on 7/17/25 at 11:25 a.m., The DON confirmed that incident between Resident 1 and Resident 2 was witnessed by staff during the residents smoke break. The DON stated, That incident should have not happened because we have staff there. The DON also confirmed that the incident involving Resident 1 and Resident 2 was a safety concern and that the residents safety and supervision was a facility priority.During a review of the facility policy and procedures (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021, the P&P indicated, Residents have the right to be free from abuse.This includes.physical abuse.Protect residents from abuse.by anyone including. other residents.During a review of the facility P&P titled, Resident-to-Resident Altercations dated September 2022, the P&P indicated, All altercations including those that may represent resident-to-resident abuse.Behaviors that may provoke a reaction by residents or others includes.physical aggressive behavior, such as hitting, kicking, grabbing, scratching.

Based on interview and record review, the facility failed to protect the resident's right to be free from abuse for one of three sampled residents (Resident 1) when Resident 2 pushed Resident 1 and hitting Resident 1's head into a wall which resulted in Resident 1 sustaining a skin tear. This failure resulted in Resident 1 not free from abuse by Resident 2. Findings: Review of Resident's 1 Admission Record indicated Resident 1 was admitted [DATE] with diagnoses including schizoaffective disorder, bipolar type (a mental illness that is characterized by disturbances in thought and mood swings that range from the lows of depression to elevated periods of emotional highs). Review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 5/14/25, indicated Resident 1 was cognitively intact. Review of facility dcoument titled Health Status Note, for Resident 1 dated 5/18/25, indicated, Resident [1] was assaulted by another resident [2] attempting to break up a fight . Review of Interdisciplinary Team (IDT) Note, dated 5/19/25, indicated, on 5/17/25, resident [1] was assaulted by another resident [2] when attempting to break up a fight. Resident [1] stated . [Resident 2] was hitting the staff and holding her down. The other staff wasn't doing anything, so I [Resident 1] got up to help her . we started fighting and he [Resident 2] hit my head against the wall. upon assessment resident [1] was noted with a bump to his head. Resident [1] also sustained a skin care tear on his right elbow with minimal bleeding resident [1] was transferred to UCD . due to complaints of headaches, nausea, and dizziness . Review of Resident 2's Admission Record indicated Resident 2 was admitted [DATE] with diagnoses including Schizophrenia, Unspecified (a mental illness that is characterized by disturbances in thought) and Depression, unspecified (a mental illness low self esteem and loss of interest in normally enjoyed activities). Review of Resident 2's MDS, dated [DATE] indicated Resident 2 had severely impaired cognition. Review of facility dcoument titled Health Status Note, for Resident 2 dated 5/18/25, indicated, Resident [2] assualt staff and resident [1] . During an interview on 5/28/25 at 1:19 p.m., with Mental Health Worker (MHW), the MHW worker stated she was on Patio 2 leading an exercise group and Resident 2 requested a song. Resident 2 got mad when he was told to wait his turn. Resident 2 proceeded to hold the mental health worker down between the chair and the table and spit on her face. Resident 1 pulled Resident 2 off the MHW. Resident 2 then pushed Resident 1 up against a wall and his head into the wall. During an interview on 5/28/25 at 2:03 p.m. with the Director of Nursing (DON), the DON stated that all residents should be free from physical abuse in the facility. Review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021, the P&P .Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation . Protect residents from abuse . by anyone including but not necessarily limited to . other residents.

Based on observation, interview, and record review, the facility failed to maintain a safe environment for one of 35 sampled residents (Resident 1), when Resident 1 eloped (left the facility unsupervised without prior authorization) through an unsecured exit gate. This failure decreased the facility's potential to maintain residents' safety and prevent accidents. Findings: A review of an admission record indicated Resident 1 was admitted to the facility in November 2024 with a diagnosis of bipolar schizoaffective disorder (causes mood swings that range from the lows of depression to elevated periods of emotional highs and a mental illness that is characterized by disturbances in thought). A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 2/26/25, indicated Resident 1's Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 14 out of 15 with good memory and judgement. During an interview on 4/21/25 at 1:30 p.m. with Licensed Nurse 1 (LN 1), LN 1 stated Resident 1 eloped from the facility on 4/20/25 at approximately 2:30 p.m. when he was outside on the basketball court patio with other residents. LN 1 further stated staff on the patio noticed Resident 1 was missing; a search was conducted, and Resident 1 was not found. During an interview on 4/21/25 at 1:40 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 was outside on the basketball court with a group of residents. CNA 1 further stated she was told Resident 1 was missing, so she participated in the facility's search and Resident 1 was not found. During a concurrent observation and interview on 4/21/25 at 1:55 p.m. with LN 1, LN 1 walked out of the facility to the first patio area. The patio area was secured with a keypad and had gates locked with a working alarm speaker box. LN 1 unlocked the gate and exited to the basketball patio. The basketball patio had two exit doors. Both exit doors had non-functioning security keypads, a sign indicating push until alarm sounds door can be open in 15 seconds, and no alarm speaker boxes. Both exit doors were unlocked, opened easily without using the push bar, and led towards the open parking lot area. No audible alarm was heard when doors were opened, and both doors did not automatically and securely close when released. LN 1 confirmed the observations and stated the basketball patio area was undergoing some renovations, both exit gates should have been secured and had a working alarm to prevent residents from leaving. LN 1 further stated the alarm should have worked otherwise residents could easily go through the door without a warning, leave the facility and possibly get injured. During an interview on 4/21/25 at 2:06 p.m. with the Director of Nursing (DON), DON confirmed the exit gates on the basketball patio were unlocked, not secured and did not have working alarms. DON stated the basketball patio was not to be used for residents until renovations were complete. DON further stated her expectation was residents were not to go out to the secondary patio until the renovations were complete and the unlocked gates could potentially allow residents to elope from the facility which might put them at risk of injury. A review of the facility's policy titled, Behavioral Health Elopement, dated May 2022, indicated, This situation represents a risk to the residents health and safety and places the resident at risk . A review of the facility's undated policy titled, Behavior Intervention Protocol: Exit Seeking, indicated, Ensure doors, windows, and other locking mechanisms are always working.

Based on observation, interview, and record review, the facility failed to ensure medications were stored properly for a census of 107, when: 1. Staff stored personal belongings inside Hall C medication room; 2. Expired medications were found in two medication carts; 3. Two multi-dose liquid protein bottles without open dates and an expired inhaler were found in one medication cart; 4. Medication was left at Resident 404's bedside table; and 5. Treatment cart was left unlocked. These failures decreased the facility's potential to safely store medications. Findings: 1. During a concurrent observation and interview on 12/4/24 at 10:42 a.m. with Licensed Nurse 6 (LN 6), Hall C medication room was observed. LN 6 confirmed a lunch box, a water bottle, three jackets and a bag were found inside the medication room and stated these were her belongings and she placed them in the medication room. 2. During a concurrent observation and interview on 12/4/24 at 11:28 a.m. with LN 6, Hall C medication cart-1 was observed. 31 expired and discontinued pills of carvedilol (a medication used to treat high blood pressure) 12.5 milligrams (mg; a unit of measure) each in a bubble pack were found behind the bottom drawer of the medication cart. LN 6 stated expired and discontinued medications should not be stored in the medication cart. During a concurrent observation and interview on 12/4/24 at 11:53 a.m. with LN 7, W Hall medication cart-2 was observed. Two bubble packs with three pills in each were found behind the bottom drawer of the medication cart with old, partially ripped, and unreadable labels on them. LN 7 could not identify the name of medications and residents on both bubble packs. LN 7 agreed unidentifiable medications should not be stored in the medication cart. 3. During a concurrent observation and interview on 12/4/24 at 12:18 p.m. with LN 8, W Hall medication cart-1 was observed. Two multi-dose bottles of liquid protein with no open dates and one expired albuterol sulfate inhaler (a medication that relaxes the muscles of the airways and improves breathing) were found. Both bottles of liquid protein were found opened and partially used with no open dates marked as instructed in the manufacturer's labels on the bottles. LN 8 agreed both bottles should have been marked with an open date when opened and stated she did not know when the bottles were opened. LN 8 also agreed the albuterol sulfate inhaler was marked with an open date 1/4/24 and expired on 2/4/24 (30 days after opening it) and stated expired medications should not be stored in the medication cart. 4. During a concurrent observation, interview, and record review on 12/2/24 at 4:28 p.m. with Resident 404 and LN 2, an unlabeled tube of menthol (pain relieving gel) was observed on the bedside table for Resident 404. Resident 404 stated the ointment was her medication from home. LN 2 reviewed Resident 404's physician's order of menthol ointment and confirmed physician ordered the menthol ointment for Resident 404. LN 2 also confirmed there was no order for self-administration and/or to be left at the bedside. LN 2 stated all residents' medications including home medications should be locked in the medication cart for safe use of medications. During an interview on 12/4/24 at 4:45 p.m. with the Director of Nursing (DON), DON stated LN 6 should have not stored her personal belongings in C. hall medication room to prevent cross contamination, nurses should have checked their medication carts every day and every shift to remove all expired and discontinued medications for safe use of medications, and multi-dose bottles of liquid protein should have been marked with open dates upon opening as instructed in manufacturer's labels on the bottles. DON also stated undated liquid protein should not be used, should have been disposed for residents' safety, and nurses should have not left the pain relieving ointment at Resident 404's bedside until the physician ordered that and the resident was assessed for self-administration. A review of the facility's policy titled, Medication Labeling and Storage, revised February 2023, indicated, . The nursing staff is responsible for maintaining medication storage areas in a clean, safe, and sanitary manner . If the facility has discontinued, outdated, or deteriorated medications . the dispensing pharmacy is contacted for instructions . or destroying these items . Medications or biologicals are locked when not in use . A review of the facility's policy titled, Medication Brought to the facility by Resident/family, dated April 2007, indicated, . Medications will be kept in the med cart unless evaluated to be safe to be kept at bedside and approved by physician . 5. During a concurrent observation and interview on 12/5/24 at 11:40 a.m. in the hallway, the treatment cart was left unlocked and unattended for 10 minutes while the Treatment Nurse (TN) was in the resident's room providing wound care, with door closed. TN confirmed the treatment cart should have been locked while providing care in the room and stated the unlocked treatment cart would create an opportunity for staff or residents to obtain the medications. A review of the facility's policy titled, Medication Labeling and Storage, dated 2001, indicated, The facility stores all medications and biological in locked compartment .

Based on interview and record review, the facility failed to ensure a discharge Minimum Data Set (MDS-a federally mandated resident assessment tool) was completed in accordance with the regulatory timeframe required for one of 30 sampled residents (Resident 76), when Resident 76's discharge assessment was not submitted within 14 calendar days of discharge. This failure decreased the facility's potential to complete residents' assessments in a timely manner. Findings: A review of Resident 76's Admission Record, indicated he was admitted to the facility on [DATE] and discharged to the hospital on 7/15/24. During a concurrent interview and record review on 12/4/24 at 10 a.m. with the Business Office Consultant (BOC), the facility's census of July 2024 was reviewed. BOC confirmed Resident 76 was admitted in the first week of July and was discharged 13 days after admission. During a concurrent interview and record review on 12/4/24 at 10:20 a.m. with the MDS Coordinator (MDSC), Resident 76's Progress Notes and MDS Assessments were reviewed. MDSC confirmed Resident 76 was discharged to the hospital, did not return to the facility, and a discharge assessment was not completed. MDSC stated the discharge assessment should have been done and submitted within 14 calendar days according to the resident assessment instrument (RAI) manual. During a concurrent interview and record review on 12/5/24 at 8:30 a.m. with the Director of Nursing (DON), Resident 76's MDS Assessments were reviewed. DON stated Resident 76's discharge assessment should have been completed immediately after the resident was transferred to the hospital. DON further stated she expected the staff responsible for resident assessments to schedule, complete and submit assessments accurately and on time. A review of the facility's policy titled, MDS Completion and Submission Timeframes, revised 2017, stipulated, Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. A review of a document titled, Assessments for the RAI, dated 10/23, indicated MDS completion date for discharge assessment must be completed no later than the discharge date plus 14 calendar days.

Based on observation, interview, and record review, the facility failed to ensure a self-medication administration assessment was completed for one of 30 sampled residents (Resident 43), when Resident 43's medications were accessible and left stored on top of bedside table. This failure increased Resident 43's potential to unsafely self-administer medications. Findings: A review of Resident 43's Admission Record, indicated Resident 43 was admitted to the facility in January 2020 with a diagnosis of anxiety. A review of Resident 43's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 11/13/24, indicated Resident 43 had a brief interview for mental status (an assessment tool for cognitive status) scored 15 out of 15 with intact memory. During a concurrent observation and interview on 12/2/24 at 9:32 a.m. with Resident 43 inside her room, Resident 43 had a plastic container filled with multiple anti-fungal, anti-itching, and antibiotic creams in packets and tubes placed at bedside table. Resident 43 stated the nurse and certified nursing assistant gave her the medications so she could keep it at bedside when needed. During an interview on 12/2/24 at 11:08 a.m. with the Assistant Director of Nursing (ADON), ADON confirmed there were antibiotic, anti-fungal, and anti-itching cream medications at Resident 43's bedside and stated it should have been kept locked in the medication cart. During a concurrent interview and record review on 12/4/24 at 4:20 p.m. with Medical Record (MR), Resident 43's medical record was reviewed. MR confirmed there was no Self-Medication Administration Assessment for Resident 43. During a concurrent interview and record review on 12/5/24 at 8:54 a.m. with the Director of Nursing (DON), Resident 43's medical record was reviewed. DON confirmed there was no Self-Medication Administration Assessment for Resident 43 and stated medications should not be left at bedside because other residents could possibly get the medications when left unlocked. A review of the facility's policy titled, Self-Administration of Medications, dated 2/2021, indicated, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.

Based on interview and record review, the facility failed to ensure an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was obtained for the use of psychotherapeutic drug (a medication to control a resident's behavior) for one of 30 sampled residents (Resident 43), when Resident 43 was prescribed three psychotherapeutic drugs without an informed consent. This failure had the potential for Resident 43 to receive unnecessary medications. Findings: A review of Resident 43's Admission Record, indicated Resident 43 was admitted to the facility in January 2020 with a diagnosis of anxiety. A review of Resident 43's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 11/13/24, indicated Resident 43 had a brief interview for mental status (an assessment tool for cognitive status) scored 15 out of 15 with intact cognition. A review of Resident 43's Order Summary Report, dated 12/4/24, indicated orders for buspirone (an anti-anxiety medication) 20 milligrams (mg, a unit of measure) by mouth three times a day for anxiety disorder, duloxetine (anti-depression medication) delayed release 60 mg by mouth one time a day, and lorazepam (anti-anxiety medication) one mg by mouth every 12 hours as needed for anxiety manifested by restlessness and agitation until 12/6/24. A review of a facility's document titled, Consultant Pharmacist's Medication Regimen Review [MRR], dated 2/24 to 11/24, indicated there was no MRR for buspirone, duloxetine and lorazepam from 2/24 to 11/24. During a concurrent interview and record review on 12/5/24 at 9:42 a.m. with Medical Record (MR), Resident 43's medical record was reviewed. MR confirmed there were no informed consents for lorazepam, duloxetine, and buspirone. During an interview on 12/5/24 at 1:42 p.m. with the Assistant Director of Nursing (ADON) and Director of Nursing (DON), both DON and ADON stated an informed consent needed to be obtained every six months for psychotherapeutic drugs. A review of the facility's policy titled, Informed Consents, dated 11/2017, indicated, The use of psychotherapeutic drugs . shall be initiated when the facility is able to verify that the resident or resident representative has given informed consent. The policy further stipulated, The resident's physician shall obtain further informed consent when material circumstances or risk change and . medication increase if it is outside of the range the original informed consent was obtained.

Based on observation, interview, and record review, the facility failed to promote dignity for one of 30 sampled residents (Resident 27), when Resident 27 was wearing a gown while sitting in a wheelchair with her back and side of body exposed. This failure decreased the facility's potential to maintain residents' dignity and privacy. Findings: A review of Resident 27's Admission Record, indicated Resident 27 was admitted to the facility in January 2024 with a diagnosis of left hip fracture. A review of Resident 27's Minimum Data Set (MDS, an assessment tool), dated 10/22/24, indicated Resident 27 had a brief interview for mental status (an assessment tool for cognitive status) scored 12 out of 15 with moderate memory impairment. Resident 27 required substantial to maximal assistance (helper does more than half the effort) with dressing clothes. A review of Resident 27's [Activities of Daily Living] Self-Care Performance Deficit care plan, dated 7/18/24, indicated staff had to promote dignity by ensuring privacy during care . During an observation on 12/3/24 at 9:27 a.m., Resident 27 wheeled herself into the hallway while wearing one gown with her back exposed. Other residents and staff were walking in the hallway and staff did not cover Resident 27's back. During a concurrent observation and interview on 12/4/24 at 1:06 p.m. with Certified Nursing Assistant 2 (CNA 2) inside Resident 27's room, Resident 27's back and side of body were exposed while she was sitting in her wheelchair. Resident 27 was sitting by the door's entrance and other staff and residents were walking beside the room. CNA 2 confirmed Resident 27's back and side of body were exposed to the public and stated it should have been covered with another gown or shirt. During a concurrent observation and interview on 12/4/24 at 1:09 p.m. with CNA 3, CNA 3 confirmed Resident 27's back and side of body were exposed and stated it should have been covered by another gown. CNA 3 also stated Resident 27 would feel embarrassed if her back and side of body were exposed to staff and other residents. During an interview on 12/5/24 at 9:03 a.m. with the Director of Nursing (DON), DON stated Resident 27 would feel embarrassed when exposing her body and back and expected staff to provide a second gown to cover her. A review of the facility's policy titled, Dignity, dated 2/2021, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem.

Based on interview and record review, the facility failed to provide adequate supervision and assistance to prevent accidents for one of 23 sampled residents (Resident 23) when the resident was transferred and toileted with the assistance of 1 staff member. This failure resulted in Resident 23 sustaining a fracture. Findings: Resident 23 was admitted to the facility in late (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 23's clinical record included the following documents: A Minimum Data Set (MDS, an assessment tool), dated 8/9/19, indicated a Brief Interview for Mental Status (BIMS) score of 10 out of 15 points indicating moderate cognitive impairment. The MDS also indicated the resident required 2+ persons physical assist for transfer and toileting. A Nursing Fall Risk Review, dated 8/9/19, indicated the resident was at moderate risk for falls. A progress note, written by Licensed Nurse (LN) 7 and dated 10/16/19, indicated at 9:22 a.m. the resident was being transferred from the toilet to her wheelchair by a CNA (Certified Nursing Assistant) when she became weak and started to drop down. The note indicated the resident did not hit the floor, but her left leg twisted. A Change in Condition Evaluation, completed by LN 7 and dated 10/16/19, reflected the resident had acute onset pain in the left knee and ankle rated at an 8 out of 10 with 10 being the worst pain. A progress note, written by LN 7 and dated 10/16/19, indicated the resident's x-ray results showed an acute fracture to the distal femur and the resident was sent to a hospital. An IDT (Interdisciplinary Team) note, dated 10/17/19, indicated the resident hit her left knee on the wall when she started to fall, but was assisted back to the toilet and prevented from falling on the floor. The note indicated preventive measures prior to the event were, Assistance to and from the toilet, call light within reach and needs anticipated. A hospital Discharge Summary, dated 10/20/19, indicated the resident received surgery for [REDACTED]. A MDS, dated [DATE], described the resident as totally dependent for transfer with 2+ persons physical assist. The MDS also described the resident as totally dependent for toileting with 1 person physical assist. In an interview, on 11/5/19 at 10:35 a.m., Resident 23 stated the CNA helped her to the wheelchair and then to the bathroom. Resident 23 stated he lifted her up off of the toilet, but then let go and she could not stand up. He dropped me. Resident 23 stated she was in a lot of pain at the time. Resident 23 stated she used to be able to go to the toilet, but now she used a bed pan for toileting. In an interview, on 11/5/19 at 10:45 a.m., LN 7 stated the resident was a 2 person assist at the time of the fall. LN 7 stated CNA 4 told him about the fall and that he was transferring and toileting the resident by himself. In interviews on 11/5/19 at 4:07 p.m., the Minimum Data Set Coordinator (MDSC) and the Minimum Data Set Nurse (MDSN) stated the resident was extensive assistance at the time of the fall. The MDSN stated the resident was a 2 person assist for transfers and toileting. The MDSC and MDSN stated the resident was now totally dependent for transfers and toileting since returning from the hospital. In an interview, on 11/6/19 at 7 a.m., CNA 4 stated he was by himself at the time of the fall. CNA 4 stated he was transferring the resident off the toilet. CNA 4 stated the resident could normally stand while he was wiping her, but her left knee buckled and hit the wall. CNA 4 stated he was able to sit her back on the toilet and then went and got help. CNA 4 stated he was not really sure if the resident was a 1 or 2 person transfer at time of the fall, and he did not ask the nurse. In an interview, on 11/6/19 at 8:10 a.m., LN 7 stated CNA 4 should have known the resident was a 2 person assist because he had worked with her before. In an interview, on 11/7/19 at 11:11 a.m., the Director of Nursing (DON) acknowledged the 8/9/19 MDS indicated the resident was a 2 person assist for transfers and toileting, but stated sometimes Resident 23 had been a 1 or 2 person assist in the past depending on the day. The DON confirmed staff should have been using the highest level of assistance assessed for the resident when transferring and toileting as it would have been difficult for staff to adequately assess the resident each time before they transferred or toileted her. The DON confirmed the resident was now totally dependent for transfers and toileting since returning from the hospital.

Based on interview, and record review, the facility failed to prevent the development of an avoidable pressure ulcer when the initial pressure sore risk assessment did not reflect Resident 1's risk accurately, and no care plan was developed at the time of admission to address her risk for skin breakdown. This failure resulted in the development of an avoidable pressure ulcer to her right heel. Findings: Resident 1 was an [AGE] year old admitted to the facility on [DATE] for rehabilitation following right hip surgery. The clinical record for Resident 1 included a 9/21/12 pressure sore risk assessment. The assessment form indicated a score of 19 and above was considered "no risk". A score of 15-18 indicated "at risk". A score of 13-14 indicated "moderate risk". A score of "10-12" indicated "high risk", and a score of 9 or less signified "very high risk". The form included additional guidance directing the nurse to advance to the next level of risk in the presence of additional risk factors such as poor dietary intake of protein, and advanced age. Resident 1 had a score of "16", or "at risk" for developing a pressure sore. Despite her advanced age, the assessment was not revised (advanced as directed) to identify Resident 1's increased risk of developing a pressure sore. A review of the nursing care plans in Resident 1's clinical record revealed no care plan had been prepared at the time of the pressure sore risk assessment to address Resident 1's moderate risk of developing a pressure sore. There was no documented evidence the facility had developed a plan with interventions to prevent the development of a pressure sore. Review of a Nutritional Assessment, completed on 9/26/12, indicated Resident 1 had problems chewing. Under "Nutritional Problems" the assessment reflected that Resident 1 "Leaves 25% or more of food uneaten at most meals." The 9/28/12 Minimum Data Assessment (MDS) indicated Resident 1 had no pressure ulcers at the time she was admitted , although she was at risk of developing pressure ulcers. The MDS also indicated she could not freely move her legs, and she needed 2 or more staff to assist her with repositioning her body in bed and she had moderately impaired cognition. A review of the lab results in Resident 1's clinical record indicated she had an [MEDICATION NAME] level of 2.4 on 10/1/12. The lab report indicated the normal range for [MEDICATION NAME] levels is 3.4-5.0, and Resident 1's [MEDICATION NAME] was low. ([MEDICATION NAME] is a protein component of blood. A low [MEDICATION NAME] level is an indicator of poor nutrition and negatively impacts wound healing). The clinical record for Resident 1 contained a 10/7/12 pressure ulcer care plan indicating Resident 1 was at risk for developing a pressure ulcer. The care plan at this time did not include any specific interventions directing the staff to turn and reposition Resident 1 despite her poor ability to reposition herself. On 10/10/12 the pressure ulcer care plan had been modified to address the presence of an actual pressure ulcer to her right heel. On 10/15/12 the care plan was updated again to include the specific intervention of turning and repositioning the resident frequently and as needed. There was no care plan for pressure ulcer prevention prepared prior to 10/7/12. The clinical record for Resident 1 included the following progress notes: - On 10/10/12 a darkened area was discovered on the resident's right heel. - On 10/11/12 the wound was described as a 4.2 by 5.0 centimeter blood blister. - On 10/17/12 the progress note indicated the wound was discussed by "Risk management" that day. The note indicated "Resident has been immobile and on back from hospital and is unable to reposition without assist. She has severe dementia.....She was placed on (diet supplement) on admission due to a h(istory) of poor eating due to dementia." - On 10/22/12 the wound measured 4.5 by 7.5 centimeters, and was possibly a deep tissue injury (a breakdown of tissue beneath intact skin.) - On 10/29/12 the progress note indicated the wound measured 4.8 by 8.0 centimeters with little change, "a slow healing process." (A business card measures 5.0 by 9.0 centimeters). - On 11/26/12 the nurse noted that Physician 1 had removed the exterior of the blister exposing a 4.5 by 8.0 centimeter wound with a .1 centimeter depth. Eschar, (dead and black tissue) remained below the removed blister, preventing visual inspection of the full depth of the wound. Physician 1, a wound specialist, conducted a physical exam of the wound on 11/26/12. At that time the wound measured 4.5 by 8.0 centimeters. The physician indicated the sore was an unstageable, deep tissue pressure ulcer, and was completely covered with eschar (blackened dead skin). The 2010 Lippincott Manual of Nursing Practice indicates a Stage II pressure ulcer presents with a partial thickness skin loss. A Stage III pressure ulcer presents with a full thickness skin loss, but muscle or bone are not exposed, and a Stage IV pressure ulcer presents with full thickness skin loss and muscle or bone are visible. An unstageable wound presents with full thickness skin loss, but underlying tissue loss cannot be determined as the wound is covered with eschar or slough (Soft, light colored dead tissue, in the process of separating from the viable portions of the body). In an interview with the Minimum Data Set Coordinator on 1/31/12 at 12:45 p.m., she reported a pressure ulcer was unstageable when it could not be determined how deep the wound was if it was covered by eschar, but the presence of eschar indicated it was a Stage III or Stage IV wound. In an interview with Physician 1 on 2/5/12 at 9:10 a.m. he reported he had not been able to see the base of the wound to determine its stage. He also stated an unstageable pressure ulcer was rarely anything other than a Stage III or Stage IV wound. In telephone interviews with the Director of Nursing on 2/5/12 at approximately 10:30 a.m. and 2/5/12 she reported Resident 1 was admitted with known risk factors, such as poor nutrition and leg contractures (an inability to straighten the limbs). She reported nurses were expected to prepare a care plan within 24 hours of identifying actual or potential nursing needs, and the care plan should have included turning and repositioning the resident frequently and as needed. She reviewed the clinical record and reported the nursing staff had not prepared a care plan for pressure ulcer prevention at the time Resident 1 was admitted to the facility. She also verified the 10/7/12 pressure ulcer risk care plan did not include the repositioning instructions that had been added to the care plan on 10/15/12, after the pressure ulcer had been identified.