Every finding on record at Hollywood Premier Healthcare Center

Based on observation, interview, and record review, the facility failed to review, update, and/or revise a care plan for smoking interventions for one of three sampled residents (Resident 1) by failing to: -Ensure to update the smoking care plan with appropriate interventions and alternative interventions. On 5/10/2026 at 9:30 AM, Resident 1 was involved in a verbal and physical incident with Resident 2 and Resident 3 in the smoking patio at the facility. This failure resulted in Resident 1 not to follow the facility's smoking rules and had the potential not to address Resident 1's needs.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/22/2021 with diagnoses of schizophrenia (a severe, chronic brain disorder that disrupts how a person perceives reality), dementia (a decline in mental abilities severe enough to interfere with daily life), and major depressive disorder (mental health condition characterized by a persistent feeling of sadness, loss of interest, and lack of energy that severely disrupts daily life). During a review of Resident 1's Care Plan Report dated 5/23/2021, the Care Plan Report indicated Resident 1 refused to surrender smoking materials and shared cigarettes with other residents (unidentified). The Care Plan Report indicated the goals for the resident included not share cigarettes and to follow facility rules. The Care Plan Report indicated the interventions included to discourage family from providing smoking material. During a review of Resident 1's History and Physical examination (H&P) dated 7/14/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - Resident assessment tool) dated 4/28/2026, indicated Resident 1 had intact cognition, and had little interest or pleasure in participating in activities at the facility. The MDS indicated Resident 1 did not hallucinate (sensory experiences that appear real but are created by the person's mind), did not manifest physical, behavior symptoms, was not prescribed antipsychotic medications (used to control behavioral symptoms), and was not on antidepressant medications (used to reduce symptoms of depression). Resident 1 was independent with activities of daily living (ADLs, such as walking, dressing, locomotion, and personal hygiene). During a review of Resident 1's Social Services Progress Note dated 5/11/2026, the Social Services Progress Note indicated Resident 1 did not want to discuss or elaborate on the incident [on 5/10/2026 at 9:30 AM]. During a review of Resident 1's Care Conference notes dated 5/11/2026, the Care Conference notes indicated an Interdisciplinary Team (IDT- a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) meeting was held for Resident 1 to discuss Resident's 1 behavior. The Care Conference notes indicated Resident 1 explained that she (Resident 1) shared a cigarette with Resident 2, who then shared the cigarette with Resident 3. The Care Conference notes indicated Resident 1 believed Resident 3 took the cigarette from Resident 2 which lead to a misunderstanding of the situation. During a review of Physician's Orders for Resident 1, for the month of May 2026, indicated there were orders for the nurses to monitor, every shift, Resident 1 for manifestation of mood problems, physical, verbal, or other behavioral symptoms or to assess emotional state (such hostile, anger, calm, despondent, stress, pleasant, sad, fear, etc.). During an interview on 5/22/2026 at 10:15AM with Certified Nurse Assistant 1 (CNA1), CNA1 stated Resident 1 had many incidents related to not following the facility's rules about smoking. CNA 1 stated Resident 1 would share cigarettes with other residents despite knowing it was against the rules. During an interview on 5/22/2026 at 10:45AM with the Director of Staff and Development (DSD), the DSD stated that all staff (in general) at the facility completed training related to signs and symptoms of aggressive behavior and abuse. The DSD stated the staff (unidentified) monitored the smoking area during the incident on 5/10/2026 at 9:30 AM should have noticed Resident 1's increasingly aggressive behavior and redirected the situation. During an interview on 5/22/2026 at 11:15AM with Registered Nurse1 (RN 1), RN1 stated the entire interdisciplinary team had access to update care plans for Resident 1. RN 1 stated that care plans should be updated after any significant event. RN 1 stated that Resident 1's interventions were not appropriate for the resident. RN 1 stated that if interventions were appropriately revised then no incident would have occurred. During an interview on 5/22/2026 at 11:38AM with Activities Aide (AA 1), AA1 stated that she (AA1) was the staff present at the time of the incident on 5/22/26 at 11:38AM. AA 1 stated the smoking break was at 9AM and there were five people present at that time. AA 1 stated she (AA1) looked down at her smart watch to keep track of time, and that is when the incident occurred. AA 1 explained Resident 1's reaction was faster than a blink of the eye. AA 1 stated that if she had been looking at the residents before the incident occurred, she would have been able to intervene. During an interview on 5/22/2026 at 12:50PM.Director of Nursing (DON), stated that it is important to keep care plans updated because that is the best way to make sure there is no care deficit for the residents. The DON stated Interventions for Resident 1 were difficult to create because she chooses not to listen to staff and follow rules. The DON admits that Resident 1's care plan interventions have not been revised and updated to more appropriate interventions. During a review of the facility's policies and procedures tiled Smoking Policy Residents revised in April 2026, indicated the facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision or violates any item in this smoking policy. The policies and procedures indicated Residents are not permitted to give smoking items to other residents. During a review of the facility's policies and procedures titled Care Plans - Comprehensive, revised in April 2026, indicated an individualized care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The policies and procedures indicated assessments of residents are ongoing and care plans are revised as information about the change between the resident and the resident's condition change.

Based on observation and interview, the facility failed to maintain a sanitary and comfortable environment for two of four sampled residents (Residents 1 and 2).This deficient practice resulted in unclean resident room floors, presence of food debris, and conditions that could contribute to pest infestation, supporting the complainant's concern.During a review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of end stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life) and hemiplegia (loss of ability to move one side of the body).During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool), dated 12/26/2025, indicated, Resident 1 had intact cognitive skills for daily decision making. The MDS indicated Resident 1 required set up assistance for eating, partial assistance for oral hygiene, was dependent on staff for toileting, showering, upper and lower body dressing, and putting on/taking off footwear. Resident 1 required maximal assistance for personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed.During a review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnosis muscle weakness.During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool), dated 2/13/2026, indicated Resident 2 had intact cognitive skills for daily decision making. The MDS indicated Resident 2 required set up assistance for eating, partial assistance for oral hygiene, toileting, showering, upper and lower body dressing, and putting on/taking off footwear. Resident 2 required supervision to roll left and right, sit to lying, lying to sitting on side of bed.During a phone interview on 4/23/2026 at 9 AM, with Resident 1's Family Member (FM), the FM alleged the presence of roaches within the facility on two different dates, the last one being on 4/15/2026 in the facility lobby when she went to visit Resident 1. During the surveyor's investigation, no roaches were observed at the time of the visit. However, environmental observations identified conditions that could contribute to pest activity.During an observation on 4/23/2026 at 1:45 PM, Resident 1's room revealed brown stains and visible food particles on the floor, indicating inadequate and untimely housekeeping. The condition appeared to have been present beyond the current day. An open lid plastic urinal with yellow urine present was noted to be hanging from Resident 1's bed rail.During an interview on 4/23/2026 at 1:49 PM with Resident 2 (Resident 1's roommate), Resident 2 stated that no housekeeping services had been provided that day, and that the floor had not been cleaned since the previous day. Further observations in resident rooms identified food droppings on floors, which creates an unsanitary environment and increases the risk for pest attraction, including insects such as roaches.During an interview on 4/23/2026 at 1:51 PM with Certified Nursing Assistant 1 (CNA1), the CNA1 stated he had assisted Resident 1 with a bed bath, provided breakfast, and assisted with activities of daily living such as cleaning his linen and toileting. The CNA1 stated Resident 1 had left the facility to go to his dialysis treatment around 11:50 AM. The CNA1 stated he should have emptied out the urinal that had urine inside to promote a clean environment.During an interview on 4/23/2026 at 2:43 PM, with the Director of Nursing (DON), stated that housekeeping staff are expected to make routine rounds, and residents receive meals/snacks at approximately 10:00 AM, 2:00 PM, 6:00 PM and 8:00 PM, requiring consistent cleaning to maintain sanitation. CNAs are supposed to empty out the urinals and not let them sit with open lids on the bed rails. The DON confirmed that residents should have a clean environment throughout the day.During a review of the facility's policy and procedures titled Homelike Environment dated 1/16/2025, indicated the facility staff and management maximizes to the extent possible the characteristics of the facility that reflect a personalized homelike setting, to include a clean, sanitary and orderly environment, pleasant and neutral scents.

Based on interviews and record reviews, the facility failed to ensure one of two sampled residents (Resident 1) diagnosed with dementia (a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function) received the necessary care and services for dementia, by failing to: Ensure Resident 1's dementia diagnosis was indicated in Resident 1's Wander/Elopement (when a resident leaves/escapes from a facility without a physician's order and without the staff knowing) Risk Evaluation, dated 4/6/2026. This deficient practice resulted in an inaccurate elopement risk assessment and Resident 1 eloping from the facility on 4/11/2026. Findings: During a review of Resident 1's admission Record (AR), AR indicated Resident 1 was admitted to the facility originally on 9/12/2024 and was re-admitted on [DATE] with diagnoses including bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive [period of feeling sad, hopeless or empty] lows to manic [being in a state of extreme, elevated energy and emotion] highs), dementia and insomnia (sleep disorder). During a review of Resident 1's History and Physical (H&P) dated 9/10/2025, the H&P indicated the resident did not have the capacity to understand or make decisions. During review of Resident 1's Minimum Data Set (MDS - a standardized assessment tool), dated 3/16/2026, the MDS indicated Resident 1 had impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). A review of Resident 1's care plan report titled [Resident 1] with cognitive status that may put him at increased risk of wandering outside the facility or exit seeking related to history of attempted to exit facility dated 9/12/2024 indicated interventions for facility staff to implement included Assessment of resident risk for elopement/wandering on admission, quarterly, and as needed. During a review of Resident 1's Wander/Elopement Risk Evaluation dated 4/6/2026, the evaluation did not indicate Resident 1 had a diagnosis of dementia, or other diagnosis impacting decision making. The Wander/Elopement Risk Evaluation indicated Resident 1 was not an elopement or wander risk. During a review of Resident 1's nursing progress notes dated 4/11/2026 at 7:30 a.m., the notes indicated During rounds, resident was noted not in his room, per prior shift, resident was awake all night and seen up in his wheelchair, wheeling in the hallway back and fort. CN look for the resident and did not found anywhere, supervisor was notified. during medpass resident still noted not in his room. facility search initiated with no success and activated Code Green. Supervisor contacted [local PD] and reported resident missing. MD [medical doctor] and medical director MD notified and made aware. [Local PD] officers responded, completed assessment and searched surrounding area. resident not found in the nearby area as per police officers. During a concurrent observation of the facility's surveillance video of the front lobby and interview on 4/14/2026 at 9:29 a.m., the recording of the front lobby's video surveillance dated 4/11/2026 at 5:30 a.m. was viewed with the Director of Nursing (DON). The video showed a male resident (identified as Resident 1 by the DON) sitting in a wheelchair approximately 5-6 feet from the front door, behind three poles linked together by fabric (retractable barrier), facing the front door. Housekeeper 1 was observed in the lobby behind Resident 1 (at one point within 3-4 feet from the resident) mopping/sweeping the floor. At 5:31 am (4/11/2026) Housekeeper 1walked around a desk and entered a door, out of camera sight. Resident 1 then looked towards the door Housekeeper 1 entered and rapidly self-propelled around the retractable barrier and out of the unlocked front door. Approximately 4 seconds later Housekeeper 1 reentered the lobby, walked towards the front door while mopping/sweeping and continued to mop/sweep the lobby. The DON stated the time on the video surveillance was one hour ahead and the resident eloped per video surveillance on 4/11/2026 at 6:31 a.m. During a concurrent interview and record review with the Licensed Vocational Nurse 3 (LVN3) on 4/15/2026 at 8:44 a.m., LVN3 reviewed Resident 1's Wander/Elopement Risk Evaluation, dated 4/6/2026, LVN3 verified the evaluation indicated Resident 1 did not have any diagnosis of dementia, or other diagnosis impacting decision making. LVN3 verified the evaluation indicated Resident 1 was not an elopement or wander risk. LVN3 did not know if Resident 1 had a dementia diagnosis and stated Resident 1 had risk factors for elopement since Resident 1 used a wheelchair independently, had psychiatric (mental) illness that could impact cognition, memory and decision making. LVN3 stated that according to the resident's assessments and risk factors, Resident 1 was not at risk for elopement. During a concurrent interview and record review with the Director of Nursing (DON) on 4/15/2026 at 1:11 p.m., the DON reviewed Resident 1's Wander/Elopement Risk Evaluation, dated 4/6/2026. The DON verified the evaluation indicated Resident 1 did not have any diagnosis of dementia, or other diagnosis impacting decision making and Resident 1 was not an elopement or wander risk. The DON stated that based on LVN3's assessment, and documentation, Resident 1 had multiple risks for elopement that should have triggered Resident 1 as a risk for elopement. The DON stated that according to the instructions under Wander/Elopement Risk Evaluation documentation, residents with any risk factors had to be triggered for risk for elopement. During a review of the facility's policy and procedure (P&P), titled, Safety and Supervision of Resident, reviewed on 1/22/2026, the P&P indicated that facility-oriented and resident-oriented approaches to safety were used together to implement a systems approach to safety, which considered the hazards identified in the environment and individual resident risk factors and then adjusted interventions accordingly. During a review of the facility's P&P, titled, Wandering and Elopements, reviewed on 1/22/2026, the P&P indicated that the facility would identify residents who were at risk of unsafe wandering or elopement and strived to prevent harm while maintaining the least restrictive environment possible for residents. The P&P indicated if a resident was identified as not alert, or at risk for wandering, elopement, or safety concerns, the resident's care plan would include appropriate strategies and interventions to maintain the resident's safety while promoting the least restrictive environment. During a review of facility's P&P, titled, Dementia-Clinical Protocol, reviewed on 1/22/2026, the P&P indicated that for the individual with confirmed dementia, the interdisciplinary team (IDT) would identify and document the resident's condition and level support needed during care planning and review changing needs as they arise. P&P also indicated that IDT would adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors.

Based on observations, interview, and record reviews, the facility failed to ensure a resident and/or responsible party were informed in advance and signed consent of the risks and benefits of a psychotropic medication (drug that affects behavior, mood, thoughts, or perception) for one of four sampled residents, Resident 1. This deficient practice violated Resident 1's right to make an informed decision about the use of psychotropic medication Depakote (a mood stabilizing medication). Findings: During a review of Resident 1's admission Records, Resident 1 was admitted to the facility on [DATE] with a diagnoses including toxic encephalopathy (permanent brain damage that causes severe confusion and forgetfulness), lack of coordination, anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one's daily activities). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 1/5/2026, the MDS indicated Resident 1 had severe cognitive (ability to acquire and understand knowledge) impairment.During a review of Resident 1's History and Physical (H&P) dated 10/2/2025, the H&P indicated, Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Psychiatric Notes, the Psychiatric Notes dated 12/9/2025 indicated Resident 1 is currently managed by Depakote 500 mg three times a day (TID) for mood stabilizations/behavioral management. Plan continue current psychotropic medication as ordered. A review of Resident 1's Nursing Progress Notes dated 1/28/2026 indicated, Spoke with the resident to discuss the new psychotropic medication informed consent form, including the risk and benefits, possible side effects and Food and Drug Administration (FDA) black box warning ( warnings indicate that clinical data shows the drug can cause severe adverse reactions, requiring careful consideration before use) These were previously discussed by the MD prior to initiating the psychotropic medication. Resident verbalized understanding of the information provided, and he still wants the medication to be administered During a review of Resident 1's Psychotherapeutic Drug Informed Consent Form, on 1/28/2026 a psychiatrist (a medical doctor or physician who specializes in mental health) obtained an informed consent from Resident 1 for the medication Depakote. During a concurrent observation and interview on 4/1/2026 at 11 AM with Resident 1, Resident 1 was observed Alert and confused about place and situation, unable to verbalize understanding of medications administered. During an interview on 4/1/2025 at 11:45 with licensed vocational nurse (LVN)1, LVN 1 stated, a resident or responsible party consenting for a psychotropic medication must have the capacity to make decisions and understanding of the medication benefits and possible side effects. LVN 1 is unaware of who obtained the consent for the psychotropic medication Depakote for Resident 1. During an interview on 4/1/2026 at 12 PM with the director of social services (SS), SS stated, Resident 1 does not have the capacity to make medical decisions. Consent for treatment is signed by a resident, responsible party, or bioethics committee (multidisciplinary team that provide education, guidance, consultations for ethical dilemma such as medical decisions) in the absence of all. SS further stated, there was no discussion made by the bioethics committee for consent decisions on behalf of Resident 1. During a concurrent interview and record review on 4/1/2026 at 2:20 PM with registered nursing supervisor (RN), Resident 1's consent form was reviewed with RN. RN stated, It is not clinically sound to have a resident sign a consent when he or she does not have the capacity to make decisions and understandings. They can not tell if what they are signing is benefiting or harming them. RN acknowledged that, it is a deficiency to have Resident 1 sign a consent because Resident 1 does not have the capacity to understand and make decisions. During a telephone interview on 4/6/2026 at 1:13 PM with the facility psychiatrist, the psychiatrist stated, I went by what the nurses said, I did not assess the resident before signing the consent for the medication Depakote. The psychiatrist acknowledged, it is a deficiency to have a resident without a capacity sign a consent for medications or treatment. During a review of the facility's policy and procedure (P&P) revised 1/22/2026, titled Consent to Treatment Policy, the P&P indicated, Consent is obtained prior to initiation of treatment, except in emergency situations as permitted by las. Consent may be written or verbal, as appropriate, and must be documented in the medial record. If the resident lacks capacity, consent is obtained from the legally authorized representative (e.g., POA).

Based on interview and record review, the facility failed to ensure to provide adequate supervision for one of four sampled residents (Resident 1) to prevent a resident-to-resident altercation (negative and aggressive physical or verbal interactions). On 2/1/2026 at approximately 7:55 AM, Resident 1, who required a one-on-one supervision (assignment of a dedicated staff member), stepped inside Resident 2's room and Resident 2 pushed Resident 1 out of her (Resident 2's) room. This failure caused Resident 2 to push Resident 1 and had the potential for Resident 1 and Resident 2 to sustain physical injuries.Findings: During a review of Resident 1's admission Record, the admission Recorded indicated the facility admitted Resident 1 on 9/25/2025, and readmitted the resident on 11/25/2025, with diagnoses including but not limited to unspecified affective mood disorder (a mental health condition characterized by significant, long-term disruptions in a person's emotional state, including extreme sadness (depression) or extreme highs (mania/hypomania), and psychosis (a mental health symptom characterized by a loss of contact with reality, where an individual has trouble distinguishing between what is real and what is imaginary). During a review of Resident 1's Care Plan Report dated 9/29/2025, the Care Plan Report indicated Resident 1 was at risk for attempting elopement (resident makes an intentional, unauthorized departure) as evidenced by two attempts to leave the facility. The Care Plan Report indicated for the nursing staff to conduct frequent visual checks. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/2/2025, the MDS indicated the resident sometimes made himself-understood and understood others. The MDS indicated Resident 1 had severely impaired cognition (means a person has a very serious difficulty with thinking, remembering, concentrating, and making decisions). The MDS indicated Resident 1 was dependent on needing maximal assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's History and Physical (H&P), dated 11/7/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 1's Progress Notes Psychiatric Narrative Note dated 1/17/2026, the Progress Notes Psychiatric Narrative Note indicated Resident 1 was seen for a psychiatric (is the branch of medicine that focuses on the prevention, diagnosis, and treatment of mental, behavioral, and emotional disorders) evaluations following nursing reports of multiple attempted elopements. The Progress Notes Psychiatric Narrative Note indicated Resident 1 required close monitoring and was currently placed on one-to-one supervision to ensure safety. During a review of Resident 1's Progress Notes dated 2/1/2026 at 7:55AM, the Progress Notes indicated there was an altercation between two residents (Resident 1 and Resident 2). The Progress Notes indicated Resident 2 pushed Resident 1 out of Resident 2's room. The Progress Notes indicated Resident 1 and Resident 2 grabbed each other. During a review of Resident 2's admission Record indicated, the admission Record indicated the facility admitted Resident 2 on 9/25/2025 with diagnoses including but not limited to schizophrenia (severe mental disorder, making it difficult to distinguish reality from imagination) and Major depressive order (mood disorder characterized by persistent sadness). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 made herself understood and understood others. The MDS indicated Resident 2 had intact cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 1 was independent with mobility and ADLs. During phone interview on 2/9/2026 at 12:49 PM, with Certified Nursing Assistant 1 (CNA1), CNA1 stated she (CNA1) was familiar with Resident 1. CNA1 stated Resident 1 had mood swings (mental health issues) and might have been confused when he (Resident 1) entered another resident's room (Resident 2). CNA1 stated Resident 1 could be in a better place with more supervision. CNA1 stated she (CNA1) saw Resident 2 pushed Resident 1 out of her room on 2/1/2026. During a concurrent interview and record review on 2/9/2025, at 3:45 PM, with the Director of Nursing (DON), Resident 1's Care Plan Report was reviewed. The DON stated Resident 1's Care Plan Report dated 9/29/2025 and revised 2/1/2026 indicated Resident 1 was at risk for attempting elopement as evidenced by two attempts to leave the facility. The DON stated the one-to-one was not reflected in the Care Plan Report. During a concurrent interview and record review on 2/9/2025 at 4:01 PM, with the DON, Resident 1's Progress Note Psychiatric Narrative Note dated 1/17/2026 was reviewed. The DON stated the Progress Note Psychiatric Narrative Note indicated Resident 1 required close monitoring and was placed on one- to-one supervision to ensure safety. The DON stated that Resident 1 required supervision. The DON stated the psychiatrist's plan indicated to continue the one-on-one supervision. The DON stated the one-on-one supervision was not done on 2/1/2026. The DON stated the facility failed to provide supervision. During a review of the facility's policy and procedure (P&P) titled Safety and Supervision of Residents, last reviewed on 1/16/2025, the P&P indicated the facility strived to make the environment as free from accident hazards as possible. The P&P indicated that resident safety and supervision and assistance to prevent accidents were facility-wide priorities. The P&P indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive. During a review of the P&P titled Care Plans, Comprehensive Person-Centered, last reviewed on 1/16/2025, the P&P indicated the comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. During a review of the facility's P&P titled Wandering [move about aimlessly or without any destination and Elopements], last reviewed on 1/16/2025, the P&P indicated the facility will identify who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

Based on interview and record review, the facility failed to notify the resident representative of a significant change in behavior and safety risk for one of four sampled residents (Resident 2) who attempted to leave the facility on 10/5/2025 stating his daughter needed him.This failure had the potential to place the resident at risk for elopement and compromised the ability of the resident representative to participate in care planning and safety interventions.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities). Resident 2 was listed as his own responsible party in the admission Record.During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 10/6/2025, indicated Resident 2 had severely impaired cognition (mentality to think, remember and reason) for decisions of daily living. The MDS indicated Resident 2 required partial assistance for oral hygiene, toileting, showering, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 2 required supervision for eating, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, and toilet and chair transfer.During a review of Resident 2's History and Physical (H&P), dated 11/19/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.During a review of Resident 2's SBAR Communication Form, dated 10/5/2025, indicated Resident 2 had increased confusion and disorientation, and attempted to leave the facility stating his daughter needed him. There was no documented evidence staff notified family, guardian, or another responsible representative of the resident's attempt to leave or change in behavior.During an interview on 2/6/2026 at 12:42 PM, with Licensed Vocational Nurse 1 (LVN1), the LVN1 verified the SBAR communication form and acknowledged the facility staff had failed to notify Resident 2's family members regarding the episode of confusion and elopement on 10/5/2025. The LVN1 stated it is the facility policy to notify family members and coordinate with them when residents are unable to make their own decisions.During an interview on 2/6/2026 at 12:51 PM, with the Director of Nursing (DON), the DON stated it is important to notify family and make a change of condition for residents who demonstrate behavioral issues such as elopement or increased confusion. DON stated licensed nurses should write the person of the family member who was notified following an episode of confusion.During a review of the facility's policy and procedure titled Change in a Resident's Condition or Status, undated, indicated the facility will promptly notify the resident representative of changes in the resident's medical/mental condition or status following a significant change in the resident's physical, mental, or psychosocial status.

Based on interview and record review the facility failed to notify the physician when the resident had a change of condition for one of three sampled residents (Resident 1). For Resident 1, the facility failed to notify the primary physician on 8/23/25 when Resident 1 had a seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), irregular heart rate and desaturation (when blood oxygen level drops below the normal range). This deficient practice had the potential for Resident 1 to have worsening conditions without appropriate intervention. During a review of the admission Record indicated the facility admitted Resident 1 on 6/3/19 and re-admitted on [DATE] with diagnoses including failure to thrive (presence of one or more medical condition that put them at risk of further decline), dementia (a progressive state of decline in mental abilities) and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 8/18/25 indicated Resident 1 had severe cognitive impairment. Resident 1 was dependent on eating, oral hygiene, toileting, shower, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During a review of the Change of Condition (COC) dated 8/23/25 at 6:35 p.m., indicated on 8/23/25 at 5:30 p.m., Resident 1 had a heart rate of 147 to 152 beats per minute (bpm, normal resting heart rate ranges from 60 to 100 bpm), temperature of 99.8 degrees Fahrenheit (normal range is 97 degrees F to 99 degrees F), oxygen saturation (amount of oxygen that's circulating in the blood) of 85% (normal range is 95% to 100%) and had a seizure like activity. The COC indicated Resident 1 was given oxygen at five liters by nasal cannula (NC, nasal prongs) and seizure precautions were implemented. The COC indicated Resident 1's primary physician was notified, and a message was left with the answering service. The same COC indicated .new orders awaited. During a concurrent interview and record review on 9/12/25 at 9:33 a.m., Resident 1's COC dated 8/23/25 was reviewed with licensed vocational nurse (LVN 1). LVN 1 stated on 8/23/25 Resident 1 had a COC that included seizure-like activity lasting about 10 seconds, heart rate of 147 bpm and oxygen saturation was 85%. LVN 1 stated Resident 1 was given oxygen five liters and Resident 1's oxygen saturation improved to 90%. LVN 1 stated Resident 1's physician was notified by leaving a message with the primary physician's answering service. LVN 1 stated she was unable to find documentation that Resident 1's physician called back, or new orders were given. LVN 1 further stated the physician needs to be notified when Resident 1 had a COC because the physician would give orders or may want to give order to transfer Resident 1 to the general acute hospital for evaluation. During a telephone interview on 9/12/25 at 11:35 a.m., Resident 1's nurse practitioner (NP) stated when Resident 1 had a COC on 8/23/25 he would have sent Resident 1 to the general acute hospital by paramedics for evaluation. During an interview on 9/19/25 at 12:38 p.m., the director of nursing (DON) stated if Resident 1's physician did not call back, we are supposed to call the medical director for orders. During a review of the facility's policy and procedures (P&P) titled Acute Condition Changes - Clinical Protocol reviewed on 1/16/25, the P&P indicated the nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). The same policy indicated the attending physician (or practitioner providing back-up coverage) will respond in a timely manner to notification of problems or changes in condition and status. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response.

Based on interview and record review the facility failed to obtain blood sugar level by fingerstick according to accepted professional standards of practice for one of two sampled residents (Resident 2). For Resident 2, who had diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), the facility failed to obtain blood sugar level when Resident 2 had nothing to eat from 3 p.m. to 9:30 p.m. on 8/30/25.This deficient practice had the potential for Resident 2 to suffer from either hypoglycemia (blood sugar level drop below normal) or hyperglycemia (abnormally high blood sugar) and for the facility not giving Resident 2 proper intervention. During a review of the admission Record indicated the facility admitted Resident 2 on 8/25/25 with diagnoses including DM and dysphagia (difficulty swallowing).During a review of the Minimum Data Set (MDS, a resident screening tool) dated 8/26/25 indicated Resident 2 had severe cognitive impairment. Resident 2 was dependent on oral hygiene, toileting hygiene, shower, upper/lower body dressing and putting on/taking off footwear. During a review of Resident 2's care plan initiated on 8/26/25 indicated Resident 2 had diagnosis of DM and was at risk for hyperglycemia and hypoglycemia. The care plan goal indicated Resident 2 will have blood sugar level within normal limits of 65 millimoles per liter (mmol/L, unit of measurement) to 115 mmol/L. The care plan interventions included to monitor blood sugar as ordered. During a review of the Change of Condition (COC) dated 8/30/25 at 3:21 p.m., indicated Resident 2 pulled out his nasogastric tube (NGT, a thin, soft tube that goes through the nose, down the throat and into the stomach) on 8/30/25 at 3 p.m. The COC indicated the facility attempted to re-insert the NGT but was unsuccessful. Resident 2's primary physician was notified, and the physician gave order to transfer Resident 2 to the general acute hospital (GACH) for NGT replacement. During a concurrent interview and record review with licensed vocational nurse (LVN 1) on 9/12/25 at 8:45 a.m., Resident 2's COC dated 8/30/25 was reviewed. LVN 1 stated Resident 2 pulled out his NGT on 8/30/25 at around 3 p.m. Resident 2's primary physician gave order to transfer Resident 2 to GACH for NGT placement. LVN 1 stated the ambulance came at 9:30 p.m. and transferred Resident 2 to GACH. LVN 1 stated Resident 2 had nothing to eat for six and half hours from 3 p.m. to 9:30 p.m. LVN 1 stated Resident 2's blood sugar level was not obtained. LVN 1 stated it is important to test Resident 2's blood sugar level to ensure Resident 2's blood sugar level .was not low or high. During a telephone interview on 9/12/25 at 9:14 a.m., LVN 2 stated Resident 2 pulled out his NGT on 8/30/25 and the primary physician gave an order to transfer Resident 2 to GACH. LVN 2 stated she did not obtain Resident 2's blood sugar level. LVN 2 stated Resident 2 had the potential to have hyperglycemia or hypoglycemia. During a review of the facility's policy and procedures (P&P) titled Nursing Care of the Older Adult with Diabetes Mellitus reviewed on 1/16/25, the P&P indicated to monitor the blood glucose as indicated if the individual is fasting before a medical procedure, has returned to the facility after a significant absence or has an acute infection or illness.

Based on interview and record review the facility failed to provide laboratory services for one of three sampled residents (Resident 1). For Resident 1, the facility failed to follow the physician order to obtain blood sample for comprehensive metabolic panel (CMP, series of 14 blood tests that provide information about a person's current metabolism) on 8/15/25. This deficient practice resulted in Resident 1 not provided laboratory services that would help determine the medical and diagnostic needs of Resident 1. During a review of the admission Record indicated the facility admitted Resident 1 on 6/3/19 and re-admitted on [DATE] with diagnoses including failure to thrive (presence of one or more medical condition that put them at risk of further decline), dementia (a progressive state of decline in mental abilities) and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 8/18/25 indicated Resident 1 had severe cognitive impairment. Resident 1 was dependent on eating, oral hygiene, toileting, shower, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During a review of the Physician Order dated 8/13/25 at 9:53 a.m., indicated an order to obtain blood sample from Resident 1 for CMP to be done on 8/15/25. During a concurrent interview and record review, on 9/12/25 at 10:25 a.m., the Physician Order dated 8/13/25 was reviewed with LVN 3. LVN 3 stated the physician gave an order on 8/13/25 to get blood sample from Resident 1 for CMP. The order indicated the blood sample was to be done on 8/15/25. LVN 3 stated she was unable to find the CMP result and stated she was unable to find documentation why the CMP was not done. During an interview, on 9/12/25 at 10:35 a.m., the medical record director (MRD) stated she was unable to find the result of Resident 1's CMP because the CMP was not done on 8/15/25. During an interview on 9/12/25 at 10:50 a.m., the director of staff development (DSD) stated if Resident 1's CMP was not done, we will not be able to identify what is wrong. with the resident. During a review of the facility's policy and procedures (P&P) titled Laboratory and Diagnostic Test Results - Clinical reviewed on 1/16/25, the P&P indicated the physician will identify and order diagnostic and laboratory testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The same Policy indicated a nurse will try to determine whether the test was done that included:a. as a routine screen or follow-up.b. To assess a condition change or recent onset of signs and symptomsc. to monitor the drug level.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from sexual abuse (non-consensual sexual contact of any type or sexual harassment) from Resident 2 who had a history of inappropriate sexual behavior of walking around the facility with his genitals (sexual organs) out and masturbating (stimulate own genitals for sexual pleasure) excessively (extremely) while residing in the facility. On 9/6/2025 at approximately 3:55 AM to 4 AM, Certified Nursing Assistant 1 (CNA1) heard grunting (mumbling)/moaning from Resident 1's room (who was nonverbal). CNA1 observed Resident 2 on top of Resident 1 who was in a supine (lying face up) position between Resident 1's legs naked from the waist down on Resident 1's bed. Licensed Vocational Nurse (LVN1 who came into Resident 1's room after CNA1 screamed for help) noticed Resident 2 pulling his pants up walking away from Resident 1. Resident 1 was unable to verbalize the incident. The facility called 911 (emergency phone number) and sent Resident 1 to the General Acute Care Hospital 2 (GACH2) for a trauma evaluation (assessing the immediate physical injuries). GACH2 admitted Resident 1 for an evaluation on sexual assault (nonconsensual sexual act). This failure resulted in Resident 1 to experience sexual abuse from Resident 2 under the care of the facility and resulted in Resident 1 to be admitted to GACH2 for an evaluation on sexual assault. On 9/9/2025 at 2:21PM, the Department called an Immediate Jeopardy Situation (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) related to the failure to protect Resident 1 from sexual abuse from Resident 2 for allowing inappropriate sexual behavior of walking around the facility with his genitals out and masturbating excessively while residing in the facility. This placed Resident 1 and other potential unidentified residents in the facility at risk for sexual abuse. On 9/12/2025 at 2:44 PM, the Department removed the IJ situation while onsite in the presence of the ADM and DON after the surveyor verified the facility's implementation of the IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) through observation, interview, and record review, which included: -On 9/6/2025, the facility staff (unidentified) separated Resident 2 from Resident 1 and placed Resident 1 on a one-to-one supervision (where a single staff member is assigned to directly supervise no more than one individual). -On 9/6/2025 at 4:30 AM, the facility transferred Resident 1 to GACH2 via emergency services for immediate trauma evaluation. -On 9/6/2025 at 12:33PM, the facility transferred Resident 2 to GACH3 for an evaluation of inappropriate sexual behavior. -On 9/7/2025 at 12:12AM, the facility readmitted Resident 2 from GACH3 and provided one-to-one supervision. -On 9/8/2025 at 12:24 AM, the facility transferred Resident 2 to GACH4 via 5150 (involuntary 72-hour psychiatric [relating to mental illness or its treatment] hold) due to inappropriate sexual behavior. -On 9/9/2025 the Director of Clinical and Regional Director of Operations provided training on abuse prevention education to the ADM, the DON, to all the department heads, and staff. -On 9/10/2025, the facility conducted a wide safety check for all 80 in-house residents to ask for any exposure and physical advances or touching by Resident 2. -On 9/11/2025, the licensed nurses (unidentified) checked seven nonverbal residents for any signs of skin discoloration to the genital areas. Findings: 1.During a review of Resident 1's admission Record, the admission record indicated the facility admitted the resident 1 on 5/27/2025 with diagnoses including generalized muscle weakness (a widespread loss of muscle strength that affects multiple muscle groups throughout the body), anxiety (excessive worry, fear, and nervousness), and developmental disorders of speech and language (difficulties in learning, understanding, and using spoken words). During a review of Resident 1's History and Physical (H&P) dated 6/9/2025, the H&P indicated Resident 1 did not have capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/29/2025, the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired (reduced). The MDS indicated Resident 1 had unclear speech (slurred or mumbled words) and was rarely/never understood. The MDS indicated Resident 1 was dependent (helper does all the effort) with eating, personal hygiene (practices and habits that maintain cleanliness and health of the body) oral(mouth) hygiene, showering/bathing, dressing, and toilet use. The MDS indicated Resident 1 was dependent on staff to go from sitting to lying position and from lying position to a sitting position on the side of the bed. During a review of Resident 1's Progress Notes dated 9/6/2025 at 3:55 to 4AM, indicated the CNA (CNA1) heard grunting/moaning from Resident 1's room. The Progress Notes indicated Resident 1 was nonverbal. The Progress Notes indicated the CNA (CNA1) went to Resident 1's room and the CNA (CNA1) observed Resident 2 on top of Resident 1who was in a supine (lying face up) position naked from the waist down, and the hospital gown pulled up. The Progress Notes indicated the CNA (CNA1) yelled for help and the Charge Nurse (LVN1) noticed Resident 2 pulling his pants up walking away from Resident 1. The Progress Notes indicated Resident 1 was unable to verbalize the incident. The Progress Notes indicated the facility called 911 at 4:13AM. The Progress Notes indicated Resident 1's medical doctor ordered at 5:41AM to transfer Resident 1 to the hospital for trauma evaluation. During a review of Resident 1's GACH2 Emergency Department (ED) record dated 9/6/2025 at 11:32 AM, the ED record indicated Resident 1 arrived from the facility to GACH2 for complaints of sexual assault at 3:55AM that was witnessed by a CNA (unidentified). The GACH2 record indicated the Emergency Medical Services (EMS, emergency medical personnel who respond to emergency situations) reported that another resident (unidentified) was apparently on top of Resident 1 with no pants on. The GACH record indicated the GACH admitted Resident 1 for further evaluation. 2. During a review of Resident 2's GACH1 Progress Notes dated 7/23/2025 (prior to admission), the GACH1 record indicated Resident 2 had a history of psychoses (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and hypersexuality (compulsive [uncontrollable] sexual behavior). During a review of Resident 2's GACH1 Consultation Notes dated 8/19/2025, the GACH1 record indicated Resident 2 was positive (showed action) for masturbating and disrobing (removing clothes) at Resident 2's nursing home facility (different facility) with sexual aggression towards his roommate. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 8/22/2025 with diagnoses including other psychotic disorder (severe mental illness where the individual's thoughts and perceptions are so out of sync with those around them that they have trouble functioning in daily life) not due to a substance or known physiological condition (how the body functions at any given moment) unspecified severity, with other behavioral disturbance (a consistent pattern of problematic, disruptive, or unhealthy behaviors that interfere with a person's ability to function normally in daily life, affecting their self-control and respect for rules and the rights of others). During a review of Resident 2's H&P dated 8/23/2025, the H&P indicated Resident 2 had hypersexual behavior. During a review of Resident 2's Order Summary Report dated 8/25/2025, the Order Summary Report indicated Resident 2 had an order for Haloperidol (medication used for behavioral issues) manifested(shown) by inappropriate sexual behavior, walking around with penis out and masturbating excessively. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was able to walk without assistance. During a review of Resident 2's Progress Notes dated 8/25/2025 at 11:17 AM, the Progress Notes indicated Resident 2 had inappropriate sexual behavior and was walking around the facility with his penis out and masturbating excessively. During a review of Resident 2's Care Plan Report dated 8/25/2025, the Care Plan Report indicated Resident 2 had a potential for behavior disturbance related to psychosis manifested by inappropriate sexual behavior, walking around with his penis out and masturbating excessively. The Care Plan Report indicated the nursing intervention was to intervene as needed to protect the rights and safety of others. During a review of Resident 2's Medication Administration Record (MAR) dated September 2025, the MAR indicated Resident 2 had inappropriate sexual behavior, walking around with his penis out and masturbating excessively on the following dates: -On 9/2/2025 during the 11PM to 7AM shift. -On 9/3/2025 during the 11PM to 7AM shift. -On 9/4/2025 during the 7AM-3PM shift and the 3-11PM shift. -On 9/5/2025 during the 11PM-7AM shift. -On 9/6/2025 during the 7AM-3PM shift, and the 11PM-7AM shift. -On 9/7/2025 7during the 7AM-3PM shift and on 3PM-11PM shift. -On 9/8/2025 during the 7AM-3PM shift. During a review of Resident 2's The Nursing Progress Notes dated 9/6/2025 at 8:20AM, The Nursing Progress Note indicated at 3:55 AM to 4AM the CNA (CNA1) heard grunting/moaning from Resident 1's room. The Nursing Progress Notes indicated the CNA (CNA1) went to Resident 1's room and CNA1 observed Resident 2 on top of Resident 1 naked, and the CNA (CNA1) yelled for help. The Progress Notes indicated that the Charge Nurse (LVN1) noticed Resident 2 pulling his pants up walking away from Resident 1. During a review of Resident 2's Application for up to 72-hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (5150 form) dated 9/7/2025, the 5150-form indicated Resident 2 was a danger to others and at risk for hurting someone (unidentified) sexually and required further evaluation. During an interview on 9/8/2025 at 2:02 PM, with CNA1, CNA1 stated that on 9/6/2025 between 3:55AM to 4AM she (CNA1) heard commotion coming out of Resident 1's room. CNA1 stated she (CNA1) saw Resident 2 naked on top of Resident 1's bed in between Resident 1's legs. CNA1 stated Resident 1 was naked from the waist down and Resident 1's legs were open. During an interview and record review on 9/9/2025 at 8:18 AM, with Registered Nurse Supervisor (RNS), Resident 2's Care Plan Report initiated on 8/25/2025 was reviewed. RNS stated the Care Plan Report indicated Resident 2 had a behavior of inappropriate sexual behavior, walking around with his penis out and masturbating excessively. RNS stated the interventions were to intervene as needed to protect the rights and safety of others. The RNS stated the facility did not follow the care plan. The RNS stated the incident between Resident 1 and Resident 2 could have been prevented. The RNS stated Resident 2 should have been closely monitored. During an interview and record review on 9/9/2025, at 8:42 AM with LVN3, Resident 2's MAR dated September 2025 was reviewed. LVN3 stated the MAR indicated Resident 2 had inappropriate sexual behavior of walking around with penis out and masturbating on the following dates: on 9/2/2025 during the 11PM-7AM shift, on 9/3/2025 11PM to 7AM shift, on 9/4/2025 during the 7AM-3PM and the 3PM-11PM shifts, on 9/5/2025 during the 11PM-7AM, and on 9/6/2025 during the 11PM-7AM. During an interview on 9/9/2025 at 9:44 AM, with LVN2, LVN2 stated she (LVN2) saw Resident 2 masturbating inside his room in his bed on 9/4/2025 (time unidentified) during the 7-3 pm shift with the privacy curtains open. During an interview and a record review of Resident 2's medical chart (in general) on 9/9/2025 at 10:07AM, with the Social Services Director (SSD), the SSD stated the facility did not conduct an interdisciplinary team meeting (IDT, a collaborative group of diverse health care professionals from different fields who work together) to address Resident 2's inappropriate sexual behavior of walking around with his penis out and masturbating. The SSD stated the facility should have conducted an IDT to discuss Resident 2's inappropriate sexual behaviors to have better interventions. During an interview on 9/9/2025 at 12:45 PM with the DON, the DON stated she (DON) reviewed Resident 2's preadmission GACH1 record and that she (DON) was aware Resident 2 had a behavior of masturbation and that the facility would be able to care for Resident 2. The DON stated there was no IDT conducted. The DON stated there should have been an IDT to have interventions. The DON stated the Medical Director was notified on 9/9/2025 of Resident 1 and Resident 2's sexual abuse incident. During an interview with the Medical Director on 9/9/2025 at 1:15PM, the Medical Director stated the DON notified him of Resident 1 and Resident 2 allegation of sexual abuse on 9/9/2025. The Medical Director stated the facility needed to conduct an IDT regarding Resident 2's behavior of inappropriate sexual behavior to have better interventions. During a review of the facility's Abuse, Neglect, Exploitation (means taking advantage of a resident for personal gain through the use of manipulation, intimidation, or threats), and Misappropriation Prevention Program, policy and procedure (P&P) dated April 2021 and reviewed 1/16/2025, the P&P indicated the residents have the right to be free from abuse including sexual abuse. The P&P indicated the facility would protect residents from abuse, neglect .by anyone including, but not necessarily limited to . other residents. During a review of policy titled, Residents Rights dated 1/16/2025 indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from abuse .

Based on interview and record review, the facility failed to implement its policies and procedures to prohibit and prevent sexual abuse (non-consensual sexual contact of any type or sexual harassment), for one of four sampled residents (Resident 1) by failing to: -Ensure to closely monitor Resident 2 who had a history of inappropriate sexual behavior of walking around the facility with his genitals (sexual organs) out and masturbating (stimulate own genitals for sexual pleasure) excessively (extremely) while residing in the facility. -Ensure Resident 1 was free from sexual abuse from Resident 2. -Ensure to conduct an interdisciplinary team meeting (IDT, a collaborative group of diverse health care professionals from different fields who work together) to address Resident 2's inappropriate sexual behavior of walking around with his genitals out and masturbating. On 9/6/2025 at approximately 3:55 AM to 4 AM, Certified Nursing Assistant 1 (CNA1) heard grunting (mumbling)/moaning from Resident 1's room (who was nonverbal). CNA1 observed Resident 2 on top of Resident 1 who was in a supine (lying face up) position between Resident 1's legs naked from the waist down on Resident 1's bed. Licensed Vocational Nurse1 (LVN1 who came into Resident 1's room after CNA1 screamed for help) noticed Resident 2 pulling his pants up walking away from Resident 1. Resident 1 was unable to verbalize the incident. The facility called 911 (emergency phone number) and sent Resident 1 to the General Acute Care Hospital 2 (GACH2) for a trauma evaluation (assessing the immediate physical injuries). GACH2 admitted Resident 1 for an evaluation on sexual assault (nonconsensual sexual act). This failure resulted in Resident 1 to experience sexual abuse from Resident 2 under the care of the facility and resulted in Resident 1 to be admitted to GACH2 for an evaluation on sexual assault. On 9/9/2025 at 2:31 PM, the Department called an Immediate Jeopardy Situation (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) related to the failure to implement its policies and procedures to prevent and to protect Resident 1 from sexual abuse from Resident 2 and for not monitoring Resident 2 closely and allowing Resident 2's inappropriate sexual behavior of walking around the facility with his genitals out and masturbating excessively while residing in the facility. This placed Resident 1 and other potential unidentified residents in the facility at risk for sexual abuse. On 9/12/2025 at 2:44 PM, the Department removed the IJ situation while onsite in the presence of the ADM and DON after the surveyor verified the facility's implementation of the IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) through observation, interview, and record review, which included: -On 9/6/2025, the facility staff (unidentified) separated Resident 2 from Resident 1 and placed Resident 1 on a one-to-one supervision (where a single staff member is assigned to directly supervise no more than one individual). -On 9/6/2025 at 4:30 AM, the facility transferred Resident 1 to GACH2 via emergency services for immediate trauma evaluation. -On 9/6/2025 at 12:33PM, the facility transferred Resident 2 to GACH3 for an evaluation of inappropriate sexual behavior. -On 9/7/2025 at 12:12AM, the facility readmitted Resident 2 from GACH3 and provided one-to-one supervision. -On 9/8/2025 at 12:24 AM, the facility transferred Resident 2 to GACH4 via 5150 (involuntary 72-hour psychiatric [relating to mental illness or its treatment] hold) due to inappropriate sexual behavior. -On 9/9/2025 the Director of Clinical and Regional Director of Operations provided training on abuse prevention education to the ADM, the DON, to all the department heads, and staff. -On 9/10/2025, the facility conducted a wide safety check for all 80 in-house residents to ask for any exposure and physical advances or touching by Resident 2. -On 9/11/2025, the licensed nurses (unidentified) checked seven nonverbal residents for any signs of skin discoloration to the genital areas. Findings: 1.During a review of Resident 1's admission Record, the admission record indicated the facility admitted Resident 1 on 5/27/2025 with diagnoses including generalized muscle weakness (a widespread loss of muscle strength that affects multiple muscle groups throughout the body), anxiety (excessive worry, fear, and nervousness), and developmental disorders of speech and language (difficulties in learning, understanding, and using spoken words). During a review of Resident 1's History and Physical (H&P) dated 6/9/2025, the H&P indicated Resident 1 did not have capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/29/2025, the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired (reduced). The MDS indicated Resident 1 had unclear speech (slurred or mumbled words) and was rarely/never understood. The MDS indicated Resident 1 was dependent (helper does all the effort) with eating, personal hygiene (practices and habits that maintain cleanliness and health of the body) oral(mouth) hygiene, showering/bathing, dressing, and toilet use. The MDS indicated Resident 1 was dependent on staff to go from sitting to lying position and from lying position to a sitting position on the side of the bed. During a review of Resident 1's Progress Notes dated 9/6/2025 at 3:55 to 4AM, indicated the CNA (CNA1) heard grunting/moaning from Resident 1's room. The Progress Notes indicated Resident 1 was nonverbal. The Progress Notes indicated the CNA (CNA1) went to Resident 1's room and the CNA (CNA1) observed Resident 2 on top of Resident 1 who was in a supine position naked from the waist down, and the hospital gown pulled up. The Progress Notes indicated the CNA (CNA1) yelled for help and the Charge Nurse (LVN1) noticed Resident 2 pulling his pants up walking away from Resident 1. The Progress Notes indicated Resident 1 was unable to verbalize the incident. The Progress Notes indicated the facility called 911 at 4:13AM. The Progress Notes indicated Resident 1's medical doctor ordered at 5:41AM to transfer Resident 1 to the hospital for trauma evaluation. During a review of Resident 1's GACH2 Emergency Department (ED) record dated 9/6/2025 at 11:32 AM, the ED record indicated Resident 1 arrived from the facility to GACH2 for complaints of sexual assault at 3:55AM that was witnessed by a CNA (unidentified). The GACH2 record indicated the Emergency Medical Services (EMS, emergency medical personnel who respond to emergency situations) reported that another resident (unidentified) was apparently on top of Resident 1 with no pants on. The GACH record indicated the GACH admitted Resident 1 for further evaluation. 2. During a review of Resident 2's GACH1 Progress Notes dated 7/23/2025 (prior to admission), the GACH1 record indicated Resident 2 had a history of psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and hypersexuality (compulsive [incontrollable] sexual behavior). During a review of Resident 2's GACH1 Consultation Notes dated 8/19/2025, the GACH1 record indicated Resident 2 was positive (showed action) for masturbating and disrobing (removing clothes) at Resident 2's nursing home facility (different facility) with sexual aggression towards his roommate. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 8/22/2025 with diagnoses including other psychotic disorder (severe mental illness where the individual's thoughts and perceptions are so out of sync with those around them that they have trouble functioning in daily life) not due to a substance or known physiological condition (how the body functions at any given moment) unspecified severity, with other behavioral disturbance (a consistent pattern of problematic, disruptive, or unhealthy behaviors that interfere with a person's ability to function normally in daily life, affecting their self-control and respect for rules and the rights of others). During a review of Resident 2's H&P dated 8/23/2025, the H&P indicated Resident 2 had hypersexual behavior. During a review of Resident 2's Order Summary Report dated 8/25/2025, the Order Summary Report indicated Resident 2 had an order for Haloperidol (medication used for behavioral issues) manifested(shown) by inappropriate sexual behavior, walking around with his genitals out and masturbating excessively. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was able to walk without assistance. During a review of Resident 2's Progress Notes dated 8/25/2025 at 11:17 AM, the Progress Notes indicated Resident 2 had inappropriate sexual behavior and was walking around the facility with his genitals out and masturbating excessively. During a review of Resident 2's Care Plan Report dated 8/25/2025, the Care Plan Report indicated Resident 2 had a potential for behavior disturbance related to psychosis manifested by inappropriate sexual behavior, walking around with his genitals out and masturbating excessively. The Care Plan Report indicated the nursing intervention was to intervene as needed to protect the rights and safety of others. During a review of Resident 2's Medication Administration Record (MAR) dated September 2025, the MAR indicated Resident 2 had inappropriate sexual behavior, walking around with his genitals out and masturbating excessively on the following dates: -On 9/2/2025 during the 11PM to 7AM shift. -On 9/3/2025 during the 11PM to 7AM shift. -On 9/4/2025 during the 7AM-3PM shift and the 3-11PM shift. -On 9/5/2025 during the 11PM-7AM shift. -On 9/6/2025 during the 7AM-3PM shift, and the 11PM-7AM shift. -On 9/7/2025 7during the 7AM-3PM shift and on 3PM-11PM shift. -On 9/8/2025 during the 7AM-3PM shift. During a review of Resident 2's The Nursing Progress Notes dated 9/6/2025 at 8:20AM, The Nursing Progress Note indicated at 3:55 AM to 4AM the CNA (CNA1) heard grunting/moaning from Resident 1's room. The Nursing Progress Notes indicated the CNA (CNA1) went to Resident 1's room and CNA1 observed Resident 2 on top of Resident 1 naked. The Progress Nursing Notes indicated CNA (CNA1) yelled for help. The Progress Notes indicated that the Charge Nurse (LVN1) noticed Resident 2 pulling his pants up walking away from Resident 1. During a review of Resident 2's Application for up to 72-hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (5150 form) dated 9/7/2025, the 5150-form indicated Resident 2 was a danger to others and at risk for hurting someone (unidentified) sexually and required further evaluation. During an interview on 9/8/2025 at 2:02 PM, with CNA1, CNA1 stated that on 9/6/2025 between 3:55AM to 4AM she (CNA1) heard commotion coming out of Resident 1's room. CNA1 stated she (CNA1) saw Resident 2 naked on top of Resident 1's bed in between Resident 1's legs. CNA1 stated Resident 1 was naked from the waist down and Resident 1's legs were open. During an interview and record review on 9/9/2025 at 8:18 AM, with Registered Nurse Supervisor (RNS), Resident 2's Care Plan Report initiated on 8/25/2025 was reviewed. RNS stated the Care Plan Report indicated Resident 2 had a behavior of inappropriate sexual behavior, walking around with his genitals out and masturbating excessively. RNS stated the interventions were to intervene as needed to protect the rights and safety of others. The RNS stated the facility did not follow the care plan. The RNS stated the incident between Resident 1 and Resident 2 could have been prevented. The RNS stated Resident 2 should have been closely monitored. During an interview and record review on 9/9/2025, at 8:42 AM with LVN3, Resident 2's MAR dated September 2025 was reviewed. LVN3 stated the MAR indicated Resident 2 had inappropriate sexual behavior of walking around with genitals out and masturbating on the following dates: on 9/2/2025 during the 11PM-7AM shift, on 9/3/2025 11PM to 7AM shift, on 9/4/2025 during the 7AM-3PM and the 3PM-11PM shifts, on 9/5/2025 during the 11PM-7AM, and on 9/6/2025 during the 11PM-7AM shift. During an interview on 9/9/2025 at 9:44 AM, with LVN2, LVN2 stated she (LVN2) saw Resident 2 masturbating inside his room in his bed on 9/4/2025 (time unidentified) during the 7-3 pm shift with the privacy curtains open. During an interview and a record review of Resident 2's medical chart (in general) on 9/9/2025 at 10:07AM, with the Social Services Director (SSD), the SSD stated the facility did not conduct an interdisciplinary team meeting (IDT, a collaborative group of diverse health care professionals from different fields who work together) to address Resident 2's inappropriate sexual behavior of walking around with his genitals out and masturbating. The SSD stated the facility should have conducted an IDT to discuss Resident 2's inappropriate sexual behaviors to have better interventions. During an interview on 9/9/2025 at 12:45 PM with the DON, the DON stated she (DON) reviewed Resident 2's preadmission GACH1 record and that she (DON) was aware Resident 2 had a behavior of masturbation and that the facility would be able to care for Resident 2. The DON stated there was no IDT conducted. The DON stated there should have been an IDT to have interventions. The DON stated the Medical Director was notified on 9/9/2025 of Resident 1 and Resident 2's sexual abuse incident. During an interview with the Medical Director on 9/9/2025 at 1:15PM, the Medical Director stated the DON notified him of Resident 1 and Resident 2 allegation of sexual abuse on 9/9/2025. The Medical Director stated the facility needed to conduct an IDT regarding Resident 2's behavior of inappropriate sexual behavior to have better interventions. During an interview with the ADM on 9/9/2025 at 1:38PM, the ADM stated the facility was responsible for knowing what type of residents (in general) would be admitted to the facility. The ADM stated he (ADM) was aware of Resident 2's behavior of masturbating and not of any other Resident 2's sexual behavior that was inappropriate. During a review of the facility's Abuse, Neglect, Exploitation (means taking advantage of a resident for personal gain through the use of manipulation, intimidation, or threats), and Misappropriation Prevention Program, policy and procedure (P&P) dated April 2021 and reviewed 1/16/2025, the P&P indicated the residents have the right to be free from abuse including sexual abuse. The P&P indicated the facility would protect residents from abuse, neglect .by anyone including, but not necessarily limited to . other residents. During a review of policy titled, Residents Rights dated 1/16/2025 indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from abuse .

Based on interviews and record reviews, the facility failed to:1. Implement the plan of correction (POC - a formal document that explains step-by-step how an organization will fix a problem and ensure it does not happen again) as indicated on the CMS 2567 statement of deficiency signed and dated 10/6/2025 to prevent and protect the residents from resident-to-resident sexual abuse (any unwanted sexual contact of any type, behavior, or act forced upon a person without their freely given consent).2. Ensure a third-party consulting agency (an outside business [not affiliated with the facility] hired to give expert advice or perform a specialized service) not affiliated with the facility, provided sexual abuse prevention training to the facility staff by the POC completion date (the specific date by which the facility will correct the deficiencies) of 10/9/2025. These failures placed the facility residents at increased risk of further resident-to-resident abuse.Findings: A review of the facility POC signed and dated 10/6/2025 indicated that on 10/9/2025, the facility Administrator coordinated with a third-party consulting firm will deliver directed inservice training (DIST) to facility staff. The DIST focused on prevention and appropriate response to resident-to-resident sexual abuse in alignment with regulatory requirements (specific rules and laws that a government says a facility must follow). The POC indicated monitoring (keeping a close eye on something to check its progress using data to make sure it's going well and to spot problems early) and the monthly activities outlined(described) commenced (start/begin) during week of 10/19/2025 and to continue through 4/20/26 (6 months). The POC completion date was 10/9/2025. A review of facility email dated 10/10/2025 at 4:32PM titled POC . from the nursing consulting agency to the DON, indicated, The monthly DIST will not start until after the POC is accepted. Therefore, there has been no training as of today. A review of the facility CMS 2567 indicated the state agency accepted the facility POC on 10/20/2025. A review of an email dated 10/22/2025 at 11:46AM titled POC accepted from the nursing consulting agency to the DON, email indicated, .start coming on my visits beginning on Thursday 10/30/2025. On 10/29/2025 at 7:42AM, the California Department of Public health (CDPH) conducted an unannounced onsite revisit (an official follow-up visit to confirm and verify that the facility corrected federal deficiencies identified during previously investigated resident to resident sexual abuse). abbreviated survey to verify if the facility had corrected and implemented its POC verification revisit at the facility the POC was reviewed. During an interview on 10/29/2025 at 2PM, the Director of Nursing (DON) stated that the third-party nurse consulting agency had not started raining the facility on monitoring, preventing and how to appropriately respond to resident-to-resident sexual abuse. The DON stated the facility will start the DIST on 10/30/2025. During an interview on 10/29/2025 at 2:30PM, Licensed Vocational Nurse (LVN) 4 stated, I have not attended any class on resident-to resident abuse this month by an outside consultant. There was posted information about training on 10/30/2025. LVN 4 stated there was a scheduled training for the POC because of the Immediate Jeopardy (IJ-is an official finding that a healthcare facility's failures in following safety rules have caused, or are highly likely to cause, serious injury, harm, or death to a patient or resident, requiring immediate action to fix the problem) called at the facility. LVN 4 stated, It was very important to know what to do to prevent abuse -from happening again. During an interview on 10/29/2025 at 2:38PM, LVN 5 stated, I have not received training from an outside nursing consultant agency on abuse. During a concurrent interview and concurrent record review with the DON on 10/29/2025 at 2:44 PM, the facility POC with a completion date of 10/9/2025 was reviewed. The DON stated training by the outside third-party agency consultant was not stated. The DON stated the facility contacted the third-party nurse consultant for the monthly in- services, the nurse consultant company stated the abuse training would start after the state agency accepted the facility POC. The DON stated the POC had been accepted, however, the abuse training and monitoring that was supposed to start the week of 10/19/2025 had not started, and that the third-party consultant nurse had done nothing. The DON stated, I can't think of the potential harm on the residents for not implementing resident-to-resident sexual abuse training. The DON further stated, Our Director of Staff Development (DSD) had in-serviced our staff. There is no difference between the clinical mentor (an experienced healthcare professional who guides and trains less experienced staff) we had and the outside agency nurse consultant. It was the same way that we provided the abuse training, so I do not see the potential for harm. During a concurrent interview and concurrent record review on 10/29/2025 at 3PM with the DON, the facility's POC with a completion date of 10/9/2025 was reviewed. The DON confirmed and stated that the facility POC indicated the facility will implement the following: 1. Develop and implement by the third party a monitoring tool to support weekly on-site (physical location) compliance (adherence to) observations.2. Clinical Auditing (examination) Tool by the third party used in charts(records) reviewed.3. Weekly on-site monitoring.4. Reporting to California Department of Public Health the findings of weekly monitoring visits.5. Training materials and evaluation.6. Ongoing In-service training.7. Monthly Training Reports. The DON confirmed and stated the facility did not implement anything indicated on the POC. A review of the facility policy and procedures (P&P) titled, Abuse Prevention Program dated 1/16/2025, the P&P indicated, Our residents have the right to be free from abuse, neglect. This includes but is not limited to .verbal, mental, sexual or physical abuse. As part of the resident abuse prevention, the administration will: Require staff training/orientation programs that includes such topics as abuse prevention, identification and reporting abuse. and handling verbally or physically aggressive resident behavior.

Based on observation, interview, and record review, the facility failed to maintain safe resident smoking practices for two of three sampled residents (Resident 27 and Resident 79) investigated under the smoking care area by failing to: 1. Ensure Resident 27 did not to store smoking materials (cigarettes) in his room without supervision. 2. Ensure to provide Resident 79 with a smoking apron, ash tray, and an appropriate place to discard his used unlit cigarette butt (the end of a cigarette) while Resident 79 smoked outside the patio on 8/12/2025 at 9:37 AM. These failures had the potential for Resident 27 and Resident 79 to sustain injuries such as cigarette burns.Findings:1. During a review of Resident 27's admission Record, the admission Record indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer (a slow-healing open sore on the foot of someone with diabetes), complete traumatic amputation (when a body part, like a finger, toe, arm, or leg, is entirely ripped or torn away from the rest of the body in an accident) of two or more left lesser toes, hyperlipidemia (excess of fats in your blood), essential primary hypertension (high blood pressure that develops gradually over time and has no known single cause), unsteadiness of feet, lack of coordination (you have trouble controlling your movements, making them jerky, unsteady, or clumsy instead of smooth and precise), and nicotine dependence (your body and mind become so used to nicotine [the addictive chemical in tobacco] that you feel a compulsive need for it). During a review of Resident 27's VB-IDT (interdisciplinary team - a group of different healthcare experts who work closely together to create a single, coordinated treatment plan for a resident) Smoking/Vaping Risk Evaluation (helps the facility determine how they can help a resident who smokes) dated 5/1/2025 at 3:15 PM, the evaluation indicated Resident 27 was not able to light cigarette with lighter or match without difficulty and handles it securely and safely. The evaluation indicated Resident 27 needed to be assessed (evaluated) by the IDT for possible requirements that the resident may smoke only if supervised, such as wearing a protective apron, or follow other specifically identified guidelines. The evaluation indicated the outcome section was left blank. The evaluation indicated Resident 27 was a supervised smoker with an intervention to monitor Resident 27 for unsafe smoking practices. During a review of Resident 27's Minimum Data Set (MDS, a resident assessment tool) dated 5/14/2025, the MDS indicated Resident 27 had the ability to understand others and make himself understood. The MDS indicated Resident 27 used tobacco. During a review of Resident 27's Care Plan Report dated 5/18/2023, the Care Plan Report indicated Resident 27 was a supervised smoker at risk for injury and respiratory distress (someone is having difficulty breathing, making it hard to get enough air) non-compliance (not following the rules) with apron (a special fire-resistant cover worn by people, often wheelchair users, to protect their clothes and surrounding furniture from). The Care Plan Report indicated smoking materials were stored in a safe place out of view of the residents. The Care Plan Report indicated the resident's visitor, and family would be advised not to give cigarettes to any residents until they check with nursing. During a review of Resident 27's Progress Note dated 8/11/2025, the Progress Note indicated Resident 27 was found with an unused cigarette inside his room at the bedside drawer. The progress note indicated Resident (Resident 27) stated, My Godbrother gave it to me when he came (unknown date). During a concurrent observation and interview on 8/11/2025 at 10:53 AM with Certified Nursing Assistant 2 (CNA 2) in Resident 27's room, an unused cigarette was observed left unattended on Resident 27's bedside cabinet. CNA 2 stated she (CNA2) observed the cigarette on Resident 27's bedside cabinet and stated he (Resident 27) gets mad when the facility tried to take away his cigarettes. During a concurrent observation and interview on 8/11/2025 at 10:59 AM with Licensed Vocational Nurse 5 (LVN 5) in Resident 27's room, an unused cigarette was observed left unattended on Resident 27's bedside cabinet. LVN 5 stated she (LVN5) observed the cigarette on Resident 27's bedside cabinet and stated Resident 27 was not supposed to have cigarettes at the bedside. During an interview on 8/12/2025 at 10:08 AM with Resident 27, Resident 27 stated he (Resident 27) got his cigarettes from the Activity Director (AD). Resident 27 preferred not to respond whether he (Resident 27) would keep cigarettes in his room. During an interview on 8/12/2025 at 2:29 PM with the Director of Nursing (DON), the DON could not provide an answer why the facility allowed Resident 27 to keep cigarettes in his room. During an interview on 8/12/2025 at 2:53 PM with Family Member 1 (FAM 1), FAM 1 stated he (FAM1) would bring cigarettes to the facility for Resident 27 for years. FAM 1 stated he (FAM1) would bring Resident 27 cigarettes about once a week and Resident 27 would store the cigarettes in a black pouch around his (Resident 27) neck or on the bedside cabinet in his (Resident 27) room. FAM 1 stated the next time he (FAM1) would come to the facility to bring Resident 27 cigarettes; he (FAM1) would check in with the staff first. FAM 1 stated he (FAM1) was certain the facility's staff was aware he (FAM1) would bring cigarettes to Resident 27. During an interview on 8/12/2025 at 3:42 PM with the DON, Social Services Director (SSD) and the Minimum Data Set nurse (MDS nurse who specializes in the assessment and documentation of patient care), the SSD stated she (SSD) was aware Resident 27's family would bring cigarettes to Resident 27 as of 7/30/2025. The MDS nurse stated she (MDS nurse) was aware the family brought Resident 27 cigarettes when Resident 27's care plan was created in 2023 (Care Plan Report that indicated Resident 27 was a supervised smoker at risk for injury and respiratory distress non-compliance with apron dated 5/18/2023). The DON and the MDS nurse stated they (DON, SSD, and the MDS nurse) could not provide evidence Resident 27's care plan regarding educating the family not to bring Resident 27 any cigarettes or that the facility updated the care plan. 2. During a review of Resident 79's admission Record, the admission Record indicated Resident 79 was admitted to the facility on [DATE] with diagnoses that included fracture (broken bone) of the right lower leg, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing, schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), muscle weakness, difficulty walking, cardiomyopathy (disease of the heart muscle, where the heart becomes weakened, enlarged, thickened, or stiff, making it harder to pump blood effectively), and tobacco (plant with leaves that have high levels of the addictive chemical nicotine) use. During a review of Resident 79's VB-ITD Smoking/Vaping Risk Evaluation, dated 5/7/2025 at 9:06 AM, the evaluation indicated Resident 79 was not able to light cigarette with lighter or match without difficulty and handles it securely and safely. The evaluation indicated Resident 79 extinguishes cigarette safely and completely when finished smoking and gets all ashes into the ashtray. The evaluation indicated Resident 79 required supervision per facility policy. The evaluation indicted Resident 79 must wear a protective non-flammable (cannot catch fire) vest/apron when smoking. During a review of Resident 79's Care Plan Report dated 5/9/2024, indicated Resident 79 was a supervised smoker at risk for respiratory distress and injury noncompliant with apron use. The Care Plan Report indicated the goal for Resident 79 was to only smoke in designated areas and use of approved ash tray. The Care Plan Report indicated the interventions included to keep smoking materials in a safe place out of view of the resident, offer smoking apron, monitor by staff continuously, and to monitor for any unsafe smoking practices. During a review of Resident 79's MDS dated [DATE], the MDS indicated Resident 19 usually understood others and usually could make himself understood. The MDS indicated Resident 79 used tobacco. During a review of Resident 79's doctor's Progress Notes dated 5/20/2025, the Progress Notes indicated Resident 79 had the capacity to understand and make his own medical decisions During an observation on 8/12/2025 at 9:37 AM in the facility's designated smoking patio, Resident 79 was observed sitting in a wheelchair wearing a leg brace on his right leg and his exposed left leg showed redness and swelling. Resident 79 was observed smoking without a smoking apron, dropping cigarette ashes on the side of the wheelchair he (Resident 79) was sitting on. There was no ashtray within reach of Resident 79 observed. Resident 79 was observed dropping his (Resident 79) cigarette butt to the floor next to his wheelchair once he was finished smoking. During a concurrent observation and interview on 8/12/2025 at 9:42 AM with Smoking Aid 1 (SA 1) in the facility's designated smoking patio, Resident 79 was observed smoking without a smoking apron and smoking without an ashtray within reach. SA 1 stated if a resident refused to use a smoking apron, she (SA1) would watch the resident, looking at the cigarette. SA 1 stated sometimes ashes could fall on a resident's (in general) clothes and could cause a burn to the resident. SA 1 stated residents (in general) should have an ashtray because a resident's cigarette could fall to the floor and a resident could get burned if they tried to put it out by stepping on it. SA 1 stated residents should have an ashtray they can reach when a resident started smoking so they could put the cigarette ashes in the ashtray. During an interview on 8/12/2025 at 9:51 AM with the DON, the DON stated the facility assessed (evaluated) a resident's ability to smoke independently (on their own) or if the resident needed supervision (to be monitored/watched). The DON stated the facility monitored all residents for smoking whether or not the residents were independent or needed supervision for smoking. The DON stated residents (in general) needed to have ashtrays near them for cigarette ashes/butts and residents should not be flicking ashes anywhere except in the ashtray and not on themselves or around them. The DON stated a resident could stain an injury if they did not use the ashtray and flick their ashes on themselves. The DON stated the facility should educate residents not to throw their cigarette butts on the floor. The DON stated the facility made a care plan for Resident 79 and should have continued to offer Resident 79 a smoking apron even though he continued to refuse it. The DON stated the facility educated residents with a diagnosis of COPD on the risks of smoking because these residents could end up in the hospital. During a review for the facility's policy and procedure (P&P) titled, Smoking Policy - Residents, dated 4/9/2025 the P&P indicated metal containers, with self-closing cover devices, are available in smoking areas, ashtrays are emptied only into designated receptacles. The P&P indicated the results of the smoking evaluation, including any safety measures will be added to the care plan. (for example~ need for close monitoring, aprons, other safety equipment etc). During a review of the facility's House Rules, dated 8/26/2025, the House Rules indicated Resident 27 did not sign the form until 8/26/2025. The form indicated Items not permitted in resident rooms: Coffee Makers, Space Heaters, Extension Cords, Rugs, Aerosol Cans (includes cleaning agents and air fresheners), Laundry Soap (can be kept in the laundry room), Smoking Paraphernalia (cigarettes, lighter, etc.).

Based on observation, interview, and record review, the facility failed to store food with a food label and/or date in one of four food storage areas. This failure had the potential to result in a foodborne illness (illness caused by the ingestion of contaminated food or beverages) for the residents.Findings:During a concurrent observation and interview on 8/11/2025 at 8:23 AM with the Dietary Supervisor (DS) in the facility kitchen, the following items were found in the freezer:1. 16 light brown meat patties in a freezer bag with no food label or date.2. A package of unopened frozen beef chorizo with manufacture date 10/24/2024 with no expiration date or best used by date.3. Frozen ham in a freezer bag dated 5/28/2025 with no expiration date or best used by date.4. A clear bag of chopped white pieces of meat with no food label or date.5. A freezer bag with meat had a food label whose ink had faded, making the name and date unreadable.During a concurrent observation and interview on 8/11/2025 at 8:23 AM with the DS, the DS stated there should be a label on the bags with the name of contents and dates because the residents could be at risk of an allergic reaction or a food borne illness.During a review of the facility's policy and procedure (P&P) titled, Food Storage, last reviewed 1/16/25, the P&P indicated, All opened and partially used foods shall be dated, labeled and sealed before being returned to the storage area.

Based on observation, interview, and record review, the facility failed to follow infection control (a set of practices and procedures used to prevent the spread of infections, particularly in healthcare settings) practices for three of six sampled residents (Resident 2, Resident 70 and Resident 85), and for laundry services by failing to: - Ensure Certified Nursing Assistant 1 (CNA 1) washed/sanitized (clean it well enough to reduce germs to a safe, healthy level) her (CNA1) hands before and after she (CNA1) assisted Resident 2 on 8/11/2025 at 9:52 AM. -Ensure Resident 70's mattress and bed linen were not in direct contact with the facility's floor. -Ensure Certified Nursing Assistant 4 (CNA4) disinfected (cleaned) Resident 70's call light that was on the floor before CNA4 placed the call light (a device used by a patient to signal his or her need for assistance) on Resident 70's mattress on 8/12/2025 at 10:35 AM. -Ensure Resident 85's laundry was not folded in a non-designated (the hallway) for folding laundry. -Ensure the facility's linen was not left uncovered in a hallway These failures placed the residents at risk for infections. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 6/25/2025 with diagnoses that included dependence on renal (kidney) dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), long-term use of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication), unspecified cirrhosis of the liver (permanent scarring that damages your liver and interferes with its functioning , but the exact cause is not yet known or documented), gastro-esophageal reflux disease (a condition where stomach contents flow back up into the esophagus, the tube that carries food from the mouth to the stomach), essential primary hypertension (HTN - high blood pressure), peripheral vascular disease (a circulation problem where blood vessels outside the heart and brain are narrowed or blocked, most commonly in the legs and feet, causing pain, numbness, or slow-healing sores), polyneuropathy (w [NAME] many nerves outside of your brain and spinal cord, called peripheral nerves, are damaged and start to malfunction), anemia in chronic kidney disease (damaged kidneys can't make enough of a hormone called erythropoietin, which tells your body to make oxygen-carrying red blood cells), viral hepatitis (an infection that causes swelling and damage to the liver), and type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) During a review of Resident 2's Care Plan Report (a document that outlines a person's individual health and social care needs and the specific actions and support required to meet those needs), dated 2/14/2025, the Care Plan Report indicated Resident 2 was at risk for Multidrug Resistant Organism (MDRO,- bacteria that resist treatment with more than one antibiotic) due to right upper chest permcath (a soft, flexible tube placed into a large vein in your chest or neck to create a reliable, long-term access point for dialysis treatments). The Care Plan Report indicated for the staff to utilize (use) gowns and gloves for high-contact resident care activities to minimize or reduce the risk of developing/transmission of infection (when germs move from an infected person, animal, or the environment to a person). The Care Plan Report indicated an intervention (any action taken to help a patient and achieve a specific health goal) for the staff to clean their hands, including before entering and when leaving the room. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 7/15/2025, the MDS indicated Resident 2 had the ability to understand others and had the ability to make himself understood. During a concurrent observation and interview on 8/11/2025 at 9:52 AM in Resident 2's room, CNA 1 was assisted Resident 2's roommate (Resident 77) and then moved to assist Resident 2 without washing/sanitizing her (CNA 1) hands. CNA 1 stated she (CNA1) did not wash/sanitize her hands because Resident 2 called right away. CNA 1 stated she (CNA1) did not touch Resident 2 and that she (CNA1) took his (Resident 2) water pitcher out of the room. CNA 1 stated not washing/sanitizing her hands could cause an infection control risk. During an interview on 8/14/2025 at 7:11 AM with the Director of Nursing (DON), the DON stated it would be an infection control issue if a CNA (any CNA at the facility) did not wash or sanitize their hands when caring for resident. The DON stated the facility staff should wash or sanitize their hands before and after helping residents. 2. During a review of Resident 70's admission Record, the admission Record indicated the facility admitted Resident 70 on 7/30/2025 with diagnoses that included surgical aftercare (provided to support recovery, prevent complications, and manage pain and wound healing following surgery) following colostomy surgery (surgical procedure that creates an opening in the abdomen to divert stool to an external bag). During a review of Resident 70's MDS dated [DATE], the MDS indicated the resident presented with an ostomy (a surgically created opening on the abdomen). The MDS indicated Resident 70 required surgical wound care. During a review of Resident 70's Care Plan Report, dated 8/12/2025, the Care Plan Report indicated Resident 70 was at risk of infection at the left lower colostomy site, the area shall be kept clean and dry and monitored for signs and symptoms of infection. During an observation on 8/11/2025 at 10:01 AM in Resident 70's room, Resident 70 was lying on a mattress placed directly on the floor without a bed frame. The bed linen was in contact with the floor, with the floor surface within Resident 70's immediate arm reach. During an interview on 8/12/2025 at 9:45 AM with Certified Nursing Assistant 4 (CNA 4), CNA4 stated positioning the mattress directly on the floor without a bed frame limited the ability to adequately clean the area around and beneath the mattress. CNA 4 stated this positioning (the mattress on the floor) created challenges for the staff (in general) to maintain proper infection control practices for safe resident cleaning, turning, and repositioning. During a concurrent observation and interview on 8/12/2025 at 10:35 AM with CNA 3 in Resident 70's room, CNA 3 picked up a call light from the floor and placed it on Resident 70's bed without disinfecting it first. CNA 3 stated this practice exposed Resident 70 to pathogens, putting her (Resident 70) at an increased risk of developing a colostomy site infection. During an interview on 8/13/2025 at 2:46 PM, the Infection Preventionist (IP - disease control expert for hospitals and other healthcare settings, working to stop the spread of infections among patients and staff) stated placing Resident 70's mattress directly on the floor and placing a call light from the floor onto Resident 70's bed without disinfection were not appropriate infection control practices. 3 During a review of Resident 85's admission Record, the admission Record indicated the facility admitted Resident 85 on 5/21/2024 with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), autistic disorder (a condition that affects the brain, leading to differences in how a person interacts with others, communicates, and behaves), severe morbid obesity (a person is significantly overweight, often 100 or more pounds over their ideal weight, putting them at serious risk for health problems), anxiety disorder (a mental health condition where a person has excessive and persistent worry, fear, and unease that can interfere with daily life), muscle weakness, and metabolic encephalopathy (a condition where the brain struggles to function normally because of a chemical imbalance). During a review of Resident 85's MDS dated [DATE], the MDS indicated Resident 85 could understand others and could make herself understood. During a concurrent observation and interview on 8/14/2025 at 7:30 AM in the hallway of the facility's basement, Laundry Aid 1 (LA 1) was observed folding laundry in the basement.LA 1 stated it was ok to fold the laundry in the hallway because it was the resident's (Resident 85) belongings.LA 1 stated folding clean laundry in the hallway instead of the designated (the place where it is supposed to be/take place) folding area could spread infection to the residents (in general). During a concurrent observation and interview on 8/14/2025 at 7:40 AM with the Maintenance Supervisor (MS), LA 1 was observed folding clean clothes in the hallway.The MS instructed LA 1 to bring the clothes to the correct area for folding clean linen.The MS stated folding clean linens in the hallway could spread bacteria/infection. During an interview on 8/14/2025 at 8:05 AM with the Director of Staff Development (DSD) and the facility's DON,the DSD stated the laundry being folded by LA 1 belonged to Resident 85.The DSD and the DON both stated LA 1 created an infection control issue when she (LA 1) folded Resident 85's clothes in the hallway.Both the DSD and the DON stated LA 2 created an infection control issue by leaving her keys, badge, and cell phone on the designated folding area/table. 4. During a concurrent laundry service observation and interview on 8/13/2025 at 8:45 AM with Laundry Aid 2 (LA 2) in the basement hallway, an uncovered linen bin held resident (unidentified) clothing. LA 2 stated the resident clothing was clean and must be covered to prevent contamination. LA 2 stated the uncovered clothing could become contaminated as dirty linen and soiled cleaning solutions or equipment were transported through the basement hallway. During a concurrent laundry service observation and interview on 8/13/2025 at 8:50 AM with LA 2 in the clean linen folding room (area where laundered linens are folded, organized, and prepared for use), blankets were stored in ripped plastic bags with the exposed blankets touching the floor. LA 2 stated this practice may result in residents receiving blankets without proper disinfection. LA 2 stated blankets shall be stored inside sealed plastic bags without tears or openings and maintained on a raised surface not in direct contact with the floor. During an interview on 8/13/2025 at 2:46 PM with the IP, the IP stated clean linen needed to always be covered and needed to be stored elevated, above the floor to prevent contamination and promote infection control. During a concurrent observation and interview on 8/14/2025 at 7:35 AM, in the designated area/table for folding laundry with LA 2, a set of keys, a cell phone, and a badge belonging to LA 2 was observed lying on the folding area/table designated for folding clean laundry. LA 2 stated she (LA 2) did not know she (LA2) could not leave her keys, badge, and cell phone on the folding area/table. LA 2 stated leaving her belongings on the folding area/table could be an infection control issue. During a review of the facility's policy and procedures (P&P) titled, Infection Prevention and Control Program, dated 1/16/2025, the P&P indicated facets of infection prevention include identifying possible infections or potential complications, instituting measures to avoid complications or dissemination [spreading], ensuring staff adhere to proper techniques and procedures, and following established general and disease-specific guidelines from the Centers for Disease Control. During a review if the facility's P&P titled, Laundry and Bedding, Soiled, dated 1/16/2025, the P&P indicated clean linen is protected from dust and soiling during transport and storage to ensure cleanliness.The P&P indicated Sorting and rinsing of contaminated laundry at the point of use, hallways, or other open resident care spaces is prohibited (not allowed). During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 1/16/2025, the P&P indicated the facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections (an infection you get while receiving medical care which was not present when you first sought treatment). The P&P indicated all personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.

Based on observation, interview, and record review the facility failed to provide appropriate assistance to residents using special eating equipment for two of four sampled residents by:1. Failing to place the plate guard (a crescent shaped dining aid designed to help prevent food from falling off the edge of a plate while eating) in the correct position for Residents 28 and 73.2. Failing to provide the correct assistive eating device for Resident 73.These failures had the potential to cause inadequate nutrition, weight loss, loss of dignity and confidence for Residents 28 and 73.Findings:1.During a review of Resident 28's admission Record, (undated), the admission Record indicated the facility admitted the resident on 9/13/24, with diagnoses including but not limited to generalized muscle weakness, dementia (a loss of brain function that occurs with certain diseases), and encephalopathy (a disease or condition that affects the brain's structure or function, causing it to not work properly).During a review of Resident 28's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/30/2024, the MDS indicated resident has functional limited range of motion (a body part can't move as far or in as many directions as it should) in both arms.During a review of Residents 28's care plan, initiated 9/26/24, the care plan indicated the resident was at a risk for nutrition and weight loss. May use PLATEGUARD during meal to prevent food spillage and ease in scooping food off plate. During review of Resident 28's physician order, dated 7/11/2025, the physician order indicated, May use PLATEGUARD during meal to prevent food spillage and ease in scooping food off plate. During a review of Residents 28 ‘s Occupational Therapy Treatment Encounter Note(s), dated 8/13/25, The note indicated, Caregiver educated on proper use/positioning of plate guard during mealtimes in order to promote [patient] independence with self-feeding, w/ good carryover of task. 2.During a review of Resident 73's admission Record, (undated), the admission Record indicated the facility admitted the resident on 8/28/20, with diagnoses including but not limited to epilepsy (sudden and temporary disturbances in brain activity that cause changes in behavior, movement, or consciousness) and dementia.During a review of Resident 73's MDS dated [DATE], the MDS indicated Resident 73 has no impairment on both upper and lower extremities. Resident 73 needs set-up or clean up assistance for eating.During review of Resident 73's physician order, dated 11/23/2022, the physician order indicated, May have Divided plate during mealtime. During review of Resident 73's care plan, initiated 9/26/24, the care plan indicated, the resident had a potential nutritional problem related to diet restrictions. Provide divided plate (a regular plate with built-in walls or barriers that create separate sections) during mealtime. During a review of Resident 73's, Occupational Therapy Treatment Encounter Note(s), dated 8/13/25, The note indicated, Caregiver educated on proper use/positioning of plate guard during mealtimes in order to promote [patient] independence with self-feeding, w/ good carryover of task. During a concurrent observation and interview on 8/11/25 at 12:30 PM with Licensed Vocational Nurse (LVN) 4 in the activity/dining room, Resident 28 and 73's plate guard was in the incorrect position on their plate. The opening to the plate guard faced Resident 28 and 73 and food spilled onto the table. Resident 73 had a regular plate with plate guard instead of divided plate as ordered by physician. LVN 4 stated the assistive eating devices were incorrect for Residents 28 and 73. LVN 4 stated the plate guards are used to help residents pick up their food easier and were in the wrong position. LVN 4 stated the residents could spill food on themselves, hurting their dignity and possibly burning themselves with hot food.During an interview on 8/14/25 at 8:45 AM with the Rehabilitation Supervisor (PT), PT stated residents are observed at least monthly to determine if residents need an assistive device such as a plate guard. PT stated education on proper usage of assistive devices is provided to Certified Nursing Assistants (CNA), Licensed Vocational Nurses (LVN), and residents prior to first use. PT stated if an assistive device is used incorrectly, PT will educate staff and document in the electronic health record (EHR) under Caregiver Treatment Education.During a review of the facility's policy and procedure (P&P) titled, Assistive Devices and Equipment, reviewed 1/16/25, the P&P indicated Staff and volunteers are trained and demonstrate competency on the use of devices and equipment prior to assisting or supervising residents.

Based on observation, interview, and record review, the facility failed to review/revise the care plans for two of two sampled residents (Resident 5 and Resident 27) by failing to: 1. Ensure to review/revise Resident 5's care plan when Resident 5's Foley catheter (a flexible tube inserted into the bladder to drain urine) was discontinued. 2. Ensure to review/revise Resident 27's care plan for smoking. This failure had the potential to result in a delay in care and interventions for Resident 5 and Resident 27.Findings:1. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 7/31/2025 with diagnoses that included diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), and dementia (a progressive state of decline in mental abilities). During a review of Resident 5's physician orders, dated 8/11/2025, the physician orders indicated to discontinue Resident 5's Foley catheter. During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool) dated 8/12/2025, the MDS indicated Resident 5 has severe cognitive impairment (a condition where someone experiences significant difficulty with cognitive functions like memory, learning, concentration, and decision-making, to the point where they can no longer live independently). During a concurrent interview and record review on 8/12/2025 at 11 AM with Registered Nurse 1 (RN 1), Resident 5's Care Plan dated 7/31/2025 was reviewed. The Care Plan Indicated Resident 5 had a Foley catheter. RN 1 stated the care plan should have been reviewed and updated to reflect that Resident 5 did not have a foley catheter. RN 1 stated care plans should be individualized based on each resident's care. 2. During a review of Resident 27's admission Record, the admission Record indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included Type 2 DM with foot ulcer (a slow-healing open sore on the foot of someone with diabetes), complete traumatic amputation (when a body part, like a finger, toe, arm, or leg, is entirely ripped or torn away from the rest of the body in an accident) of two or more left lesser toes, hyperlipidemia (excess of fats in your blood), essential primary hypertension (high blood pressure that develops gradually over time and has no known single cause), unsteadiness of feet, lack of coordination (you have trouble controlling your movements, making them jerky, unsteady, or clumsy instead of smooth and precise), and nicotine dependence (your body and mind become so used to nicotine [the addictive chemical in tobacco] that you feel a compulsive need for it). During a review of Resident 27's VB-IDT (interdisciplinary team - a group of different healthcare experts who work closely together to create a single, coordinated treatment plan for a resident) Smoking/Vaping Risk Evaluation (helps the facility determine how they can help a resident who smokes) dated 5/1/2025 at 3:15 PM, the evaluation indicated Resident 27 was not able to light cigarette with lighter or match without difficulty and handles it securely and safely. The evaluation indicated Resident 27 needed to be assessed (evaluated) by the IDT for possible requirements that the resident may smoke only if supervised, such as wearing a protective apron, or follow other specifically identified guidelines. The evaluation indicated the outcome section was left blank. The evaluation indicated Resident 27 was a supervised smoker with an intervention to monitor Resident 27 for unsafe smoking practices. During a review of Resident 27's MDS dated [DATE], the MDS indicated Resident 27 had the ability to understand others and make himself understood. The MDS indicated Resident 27 used tobacco. During a review of Resident 27's Care Plan Report dated 5/18/2023, the Care Plan Report indicated Resident 27 was a supervised smoker at risk for injury and respiratory distress (someone is having difficulty breathing, making it hard to get enough air) non-compliance (not following the rules) with apron (a special fire-resistant cover worn by people, often wheelchair users, to protect their clothes and surrounding furniture from). The Care Plan Report indicated smoking materials were stored in a safe place out of view of the residents. The Care Plan Report indicated the resident's visitor, and family would be advised not to give cigarettes to any residents until they check with nursing. During a review of Resident 27's Progress Note dated 8/11/2025, the Progress Note indicated Resident 27 was found with an unused cigarette inside his room at the bedside drawer. The progress note indicated Resident (Resident 27) stated, My Godbrother gave it to me when he came (unknown date). During a concurrent observation and interview on 8/11/2025 at 10:53 AM with Certified Nursing Assistant 2 (CNA 2) in Resident 27's room, an unused cigarette was observed left unattended on Resident 27's bedside cabinet. CNA 2 stated she (CNA2) observed the cigarette on Resident 27's bedside cabinet and stated he (Resident 27) gets mad when the facility tried to take away his cigarettes. During a concurrent observation and interview on 8/11/2025 at 10:59 AM with Licensed Vocational Nurse 5 (LVN 5) in Resident 27's room, an unused cigarette was observed left unattended on Resident 27's bedside cabinet. LVN 5 stated she (LVN5) observed the cigarette on Resident 27's bedside cabinet and stated Resident 27 was not supposed to have cigarettes at the bedside. During an interview on 8/12/2025 at 10:08 AM with Resident 27, Resident 27 stated he (Resident 27) got his cigarettes from the Activity Director (AD). Resident 27 preferred not to respond whether he (Resident 27) would keep cigarettes in his room. During an interview on 8/12/2025 at 2:29 PM with the Director of Nursing (DON), the DON could not provide an answer why the facility allowed Resident 27 to keep cigarettes in his room. During an interview on 8/12/2025 at 2:53 PM with Family Member 1 (FAM 1), FAM 1 stated he (FAM1) would bring cigarettes to the facility for Resident 27 for years. FAM 1 stated he (FAM1) would bring Resident 27 cigarettes about once a week and Resident 27 would store the cigarettes in a black pouch around his (Resident 27) neck or on the bedside cabinet in his (Resident 27) room. FAM 1 stated the next time he (FAM1) would come to the facility to bring Resident 27 cigarettes; he (FAM1) would check in with the staff first. FAM 1 stated he (FAM1) was certain the facility's staff was aware he (FAM1) would bring cigarettes to Resident 27. During an interview on 8/12/2025 at 3:42 PM with the DON, Social Services Director (SSD) and the Minimum Data Set nurse (MDS nurse who specializes in the assessment and documentation of patient care), the SSD stated she (SSD) was aware Resident 27's family would bring cigarettes to Resident 27 as of 7/30/2025. The MDS nurse stated she (MDS nurse) was aware the family brought Resident 27 cigarettes when Resident 27's care plan was created in 2023 (Care Plan Report that indicated Resident 27 was a supervised smoker at risk for injury and respiratory distress non-compliance with apron dated 5/18/2023). The DON and the MDS nurse stated they (DON, SSD, and the MDS nurse) could not provide evidence Resident 27's care plan regarding educating the family not to bring Resident 27 any cigarettes or that the facility updated the care plan. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 1/16/2025, the P&P indicated, assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The P&P indicated the interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MOS assessment (a research approach for evaluating the effectiveness of medical treatments and interventions).

Based on interview and record review, the facility failed to obtain an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for antipsychotic medication (medication that affects brain activity and is used to treat mental health disorders) administration for one of two sampled residents (Resident 11) by failing to: -Ensure to complete an informed consent form (a formal conversation and a signed document that acknowledges the resident's understanding and agreement to the medication treatment plan) for the following medications: - risperidone (Risperdal, a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought])-quetiapine (Seroquel, a medication used to treat schizophrenia) -valproic acid (a medication used to treat bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]).These failures had the potential for Resident 11 to experience adverse effects (a harmful, unintended result caused by taking medication) from taking risperidone, quetiapine, and valproic acid; and affected the ability of Resident 11 to exercise her right to be informed of, participate in, and refuse treatment.Findings:During a review of Resident 11's admission Record (a document that collects essential information about a resident when they enter a healthcare facility), the admission Record indicated the facility readmitted Resident 1 on 5/22/2025 with diagnoses that included schizophrenia and bipolar disorder. During a review of Resident 11's Order Summary Report (a document that lists a resident's current medical orders) with an order date of 5/22/2025, the Summary Report indicated for Resident 11 to take Risperidone 2 milligrams (mg, unit of measurement) one tablet by mouth at bedtime for schizophrenia, Seroquel oral tablet 100 mg one tablet by mouth at bedtime for schizophrenia, valproic acid oral solution 250 mg/5 milliliters (mL, unit of volume) 10 mL by mouth in the morning for mood disorder (characterized by significant disturbances in a person's emotional state, often causing prolonged periods of sadness, irritability, or mania that interfere with daily life), and valproic acid oral solution 250 mg/5 mL 15 mL by mouth at bedtime for mood disorder. During a review of Resident 11's History and Physical (H&P, a medical document that includes medical history and physical examination findings) dated 5/23/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool) dated 5/23/2025, the MDS indicated the resident exhibited impaired memory recall. The MDS indicated Resident 11 was taking antipsychotic medication. During a review of Resident 11's Informed Consents: Risks and Benefits of Antipsychotic Medications forms dated 5/23/2025, the Informed Consents: Risks and Benefits of Antipsychotic Medications forms indicated the resident consented to taking Risperidone, Seroquel, and valproic acid. The Informed Consents: Risks and Benefits of Antipsychotic Medications forms indicated verbal consent from resident in the signature box designated for resident representative. The Informed Consents: Risks and Benefits of Antipsychotic Medications forms did not indicate the signature of the resident or a Responsible Party (RP, an individual who is responsible for handling a resident's finances and medical care). During an interview on 8/14/2024 at 12:20 PM, with the Director of Nursing (DON), the DON stated Resident 11 did not have the capacity to provide informed consent for antipsychotic medications. The DON stated the facility was required to obtain an informed consent prior to the administration of antipsychotic medications. During an interview on 8/14/2025 at 12:27 PM, with the Medical Director (MD), MD stated the facility did not obtain informed consent from Resident 11 or Resident 11's RP for the administration of Risperidone, Seroquel, or valproic acid.During an interview on 8/14/2025 at 1:40 PM with the DON, the DON stated the consent forms for Risperidone, Seroquel, and valproic acid were completed inaccurately and did not reflect Resident 11's cognitive capacity to consent to medication therapy. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated February 2025, the P&P indicated psychotropic medication is any medication that affects brain activity associated with mental processes and behavior including antipsychotics. The P&P indicated prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: non-pharmacological alternatives, the indication and rationale for recommendation, the potential risks and benefits, and the resident's/representative's right to accept or decline the treatment.

Based on interview and record review, the facility failed to ensure to provide an advanced directive (a legal document indicating resident preference on end-of-life treatment decisions) to the Responsible Party (RP, an individual who is responsible for handling a resident's finances and medical care) for one of three sampled residents (Resident 70).This failure had the potential for Resident 70 to receive unwanted medical treatments or experience a delay in medical care and had the potential to affect Resident 70's ability to exercise her right to formulate an advanced directiveFindings:During a review of Resident 70's admission Record (a document that collects essential information about a resident when they enter a healthcare facility), dated 8/13/2025, the admission Record indicated the facility admitted Resident 70 on 7/30/2025 with a diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), lack of expected normal physiological development (developmental delay or failure to reach expected physical, cognitive, or behavioral milestones), and surgical aftercare (provided to support recovery, prevent complications, and manage pain and wound healing following surgery) following colostomy surgery (surgical procedure that creates an opening in the abdomen to divert stool to an external bag). During a review of Resident 70's Minimum Data Set (MDS, a resident assessment tool) dated 7/30/2025, the MDS indicated the resident had severely impaired cognition (impairment in the ability to think, understand, and reason). The MDS indicated Resident 70 was taking antipsychotic medication (used primarily to treat symptoms of psychosis [a mental state characterized by a disconnect from reality, often involving hallucinations, delusions, and disorganized thinking]) and antianxiety medication (used to treat anxiety). During a review of Resident 70's medical records (official documentation of a resident's health information and care), the medical records did not contain an advanced directive or advanced directive planning. During an interview on 8/12/2025 at 3:38 PM with the Social Services Director (SSD), the SSD stated she (SSD) contacted Resident 70's Regional Center Service Coordinator (RCSC, a professional who helps individuals with developmental disabilities access and manage services and support) on 8/6/2025 to request signed copies of the Physician Orders for Life-Sustaining Treatment (POLST-treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) form and the Request for admission and Authorization for Treatment and Medication form. The SSD stated she (SSD) did not inquire whether Resident 70 had executed an advanced directive. The SSD stated that she (SSD) did not provide Resident 70's RCSC advanced directive information. During an interview on 8/13/2025 at 9:36 AM, Resident 70's RCSC stated the facility did not inquire whether Resident 70 had executed an advanced directive. The RCSC stated the facility did not provide her (RSC) with advanced directive information or include her (RSC) in advanced directive planning. During a review of facility's policy and procedure (P&P) titled Advanced Directives, dated 1/16/2025, the P&P indicated the resident has the right to formulate an advanced directive. The P&P indicated upon admission the resident or representative is provided with written information concerning the right to formulate an advanced directive. The P&P indicated if the resident is incapacitated and unable to receive information about her or his right to formulate an advanced directive, the information may be provided to a resident's legal representative. The P&P indicated the resident information about whether the resident has executed an advanced directive is displayed prominently in the medical record.

Based on observation, interview, and record review, the facility failed to ensure the resident 's environment promoted and enhanced their quality of life when her bed mattress was placed directly on the floor for one of one sampled resident (Resident 70).This failure had the potential to result in Resident 70 acquiring a healthcare-associated infection (infections acquired during healthcare delivery and are not present at the time of admission), experiencing physical safety hazards and psychological harm; and affected the quality of care provided to Resident 70.Findings:During a review of Resident 70's admission Record (a document that collects essential information about a resident when they enter a healthcare facility), dated 8/13/2025, the record indicated Resident 70, a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis that included metabolic encephalopathy (brain dysfunction caused by underlying medical conditions that disrupt the body's metabolism [the process by which the body converts food into energy]), dysphagia (difficulty swallowing), and surgical aftercare (provided to support recovery, prevent complications, and manage pain and wound healing following surgery) following colostomy surgery (surgical procedure that creates an opening in the abdomen to divert stool to an external bag).During a review of Resident 70's Minimum Data Set (MDS, a resident assessment tool) dated 7/30/2025, the MDS indicated the resident was completely dependent on assistance from medical staff for self-care needs (eating, oral care, showering, toileting, dressing, and putting on/taking off footwear) and mobility. MDS indicated Resident 70 had a surgical wound.During a review of Resident 70's Care Plan Report (a document that outlines a person's individual health and social care needs and the specific actions and support required to meet those needs), dated 8/12/2025, the report indicated Resident 70 needed a safe environment with a high-low bed (a fully adjustable bed with head, foot, and height adjustability) in low position while resident is in bed. The report indicated Resident 70 had impaired bed mobility and needed bedrails to assist with mobility. The report indicated Resident 70 required perineal care (cleaning the genital and anal area) and surgical wound care (the process of managing a surgical incision to promote healing, prevent infection, and minimize complications). During a review of Resident 70's Care Plan Report, dated 8/12/2025, the report indicated Preadmission Screening and Resident Review (PASARR, a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level 2 Evaluation (a person-centered evaluation that is completed for anyone identified by the Level 1 Screening as having a serious mental illness, intellectual disability, developmental disability, or related condition) determined Resident 70 required nursing facility services due to her medical condition and/or schizophrenia and bipolar disorder. During an observation on 8/11/2025 at 10:01 AM in Resident 70's room, Resident 70 was lying on a bed mattress placed directly on the floor without a bed frame or bedrails. During an interview on 8/12/2025 at 9:45 AM with Certified Nursing Assistant4 (CNA 4), CNA 4 stated transferring Resident 70 from a mattress placed on the floor could result in discomfort. CNA 4 stated transferring Resident 70 from a mattress placed directly on the floor with a mechanical lift was unsafe, the lift may become unstable and topple, creating a risk of fall and injury to the resident. CNA 4 stated the placement of the mattress directly on the floor compromised Resident 70's quality of care by restricting the ability of staff to provide appropriate care. During an interview on 8/12/2025 at 10:08 AM with CNA 5, CNA 5 stated Resident 70 ate meals in bed positioned against the Wall for support. CNA 5 stated the facility had high-low beds that could be positioned very near to the ground. During an interview on 8/14/2025 at 11:11 AM with the Director of Staff Development (DSD), DSD stated the facility cannot ensure Resident 70's bed was in the lowest setting if the mattress was not placed on a height-adjustable bedframe. During the interview on 8/14/2025 at 11:11 AM with the DSD. DSD stated the facility had not provided training on care for individuals with intellectual disabilities since Resident 70's admission. The DSD stated the facility had not provided training on care practices associated with floor-level mattress placement. During an interview on 8/14/2025 at 1:24 PM with the Director of Nursing (DON), DON stated alternative safety interventions that did not involve placing Resident 70's mattress on the floor were available. The DON stated Resident 70 may have felt she was not treated equally to other residents. During a review of the facility's policy and procedures (P&P) titled, Dignity, dated 1/16/2025, the P&P indicated each resident shall be cared for in a manner that promotes her or his sense of well-being and feelings of self-worth and self-esteem. The P&P indicated staff are expected to treat cognitively impaired residents with dignity and sensitivity. The P&P indicated when staff assist with resident care, residents are supported in exercising their rights.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 2), who was subjected to Resident 1's physical attack, who had diagnoses of schizophrenia (a serious mental disorder in which people interpret reality abnormally, may result in delusions and behavior that impairs daily functioning, may have grandiose delusions [strong beliefs of things that are untrue]). The facility failed to: -Implement the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Prog, reviewed 1/31/2024, which indicated the facility shall uphold the resident's right to be free from physical abuse. -Revise and update Resident 1's Behavior Problem Care Plan dated 1/16/2025, after a Change in Condition (COC) with three different panic attacks of yelling, hitting himself, and grabbed the nursing staff on 2/4/2025. -Ensure an Interdisciplinary Team (IDT, healthcare professionals from various disciplines to collaborate and discuss a patient's case, share information, and develop a coordinated care plan) Meeting was conducted on 2/7/2025 upon Resident 1's re-admission to the facility after being transferred to General Acute Care Hospital (GACH) 1 for being a danger to himself and to others, per the facility's P&P titled, Behavioral Assessment, Intervention and Monitoring, reviewed 1/31/2024. This deficient practice resulted in Resident 2 being subjected to physical abuse by Resident 1 while under the care of the facility. On 3/5/2025, one month after Resident 1 was transferred to a GACH for a psychiatric evaluation due to being a danger to self and others, Resident 1 punched Resident 2 in the face. Resident 2 complained of pain, had discoloration on the right side of her face and first aid was rendered. Resident 2 was transferred to GACH 2 and diagnosed with a left orbital fracture (a break in the bony structure that supports the eye). Findings: A review of Resident 1's Admission Record indicated the facility initially admitted the resident on 10/1/2024 with diagnoses including schizophrenia, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities of living), panic disorder (a mental and behavioral disorder characterized by sudden periods of intense fear, discomfort, or a sense of losing control), and anxiety disorder (a mental health condition characterized by feelings of worry or fear that interferes with daily activities of living). A review of the Minimum Data Set (MDS, a resident assessment tool) dated 12/13/2024, indicated Resident 1 was cognitively intact (had the ability to think, understand, and reason) and did not exhibit any physical or verbal behaviors directed towards others. The MDS indicated Resident 1 was taking an antipsychotic (medication used to treat symptoms of schizophrenia) and an antidepressant (used to treat depression) medication. A review of Resident 1's Change of Condition (COC) documentation dated 1/16/2025 at 7:23 PM, indicated the resident was having behavioral symptoms and panic attacks without provocation (an action or statement that is intended to make someone angry). The COC indicated Resident 1 was yelling and striking the wall, door, and medical carts. The COC indicated Resident 1 verbalized having panic attacks, the physician was notified and recommended to monitor the resident for 72 hours. A review of Resident 1's care plan initiated 1/16/2025, indicated the resident had a behavior problem of slamming doors, walls, and the medical cart related to the resident verbalizing he had a panic attack. The care plan indicated a goal for Resident 1 to have fewer episodes of behavior. The care plan interventions indicated to administer Resident 1's medication as ordered, monitor for side effects and effectiveness, anticipate and meet the resident's needs, assist the resident to develop more appropriate methods of coping and interacting, encourage the resident to express feelings appropriately, minimizing the potential for the resident's disruptive behaviors by offering tasks which divert attentions such as encouraging the resident to come to activities, discussing the resident's behavior if reasonable, explaining and reinforcing why the behavior was inappropriate or unacceptable to the resident, providing the resident opportunities for positive interaction, intervening as necessary to protect the rights and safety of others, approaching and speaking in a calm manner, removing the resident from the situation and taking him to an alternate location as needed, and listening to music with his phone and headset to help calm the resident. According to a review of Resident 1's COC documentation dated 2/4/2025 (approximately three weeks later) at 2:31 AM, the resident was having behavioral symptoms and grabbed the nursing staff when he was having a panic attack. The COC indicated Resident 1 came out of the room yelling into the hallways. The COC indicated when Resident 1 approached the nursing station, the Charge Nurse (CN) asked Resident 1 what happened. Resident 1 stated he had a panic attack but felt okay and went back into his room. The COC indicated the Certified Nursing Assistant (CNA) informed the CN that as soon as Resident 1 came out of his room, he saw the CNA sitting in the hallway, grabbed the CNA, and then shook the CNA. The COC indicated Resident 1's physician was notified and ordered to inform the resident's psychiatrist (a medical doctor who specializes in the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders). A review of Resident 1's Nursing Progress Note dated 2/4/2025 at 2:34 PM (12 hours later), indicated the resident had another panic attack, suddenly started yelling, went to the lobby, started striking the wall, went to the social worker's office, came out, went to his room, and yelled again. The progress note indicated the facility ensured Resident 1's safety by removing objects in the resident's way and by watching the resident closely. The progress note indicated staff attempted to assess the cause of Resident 1's panic attack, but the resident did not want to discuss. The progress note further indicated Resident 1's psychiatric nurse practitioner was notified. A review of Resident 1's Behavior Note (BN) dated 2/4/2025 at 3:18 PM, indicated Resident 1 suddenly stormed to his room yelling and screaming, hit himself and the wall with his hands, and attempted to hit the staff. The BN indicated Resident 1's psychiatric nurse practitioner was called and provided orders to transfer the resident on 5150 (a temporary, involuntary psychiatric hold, also known as a 72-hour hold, initiated by law enforcement or mental health professionals) and administer a one-time dose of Ativan (a medication used to treat anxiety) 1 milligram (mg) intramuscularly (IM, medication is injected directly into a muscle). A review of Resident 1's Nursing Progress Note dated 2/4/2025 indicated at 5:30 PM Resident 1 had a third episode of anxiety, screaming, and yelling in the hallways. The progress note indicated at 7 PM an ambulance arrived to transfer Resident 1 to GACH 1 for a psychiatric evaluation due to being a danger to self and others. A review of Resident 1's 'application for up to 72-hour assessment, evaluation, and crisis intervention or placement for evaluation and treatment' form dated 2/4/2025, indicated detainment of Resident 1 began at 6 PM. The form indicated Resident 1 was observed pacing, pulling his hair, that staff and residents were in fear for their safety and that Resident 1 was unpredictable. The form further indicated there was probable cause to believe that Resident 1 was a danger to themselves and a danger to others as a result of mental health disorders. According to a review of Resident 1's care plan related to behavior problem of slamming doors, walls, and the medical cart, initiated 1/16/2025, the care plan failed to indicate an update or revision after Resident 1's COC on 2/4/2025. A review of Resident 1's Nursing Progress Note dated 2/7/2025 at 4:10 PM, indicated the resident was readmitted to the facility with no aggressive behaviors noted. A review of Resident 1's electronic health record (EHR) indicated the facility failed to conduct an Interdisciplinary Team Meeting to discuss and address Resident 1's behaviors from 2/4/2025, after the resident returned to the facility from GACH 1 on 2/7/2025. A review of Resident 1's COC documentation dated 3/5/2025 at 5:24 PM (one month after being readmitted to the facility), indicated Resident 1 had a physical altercation with another resident (Resident 2). Resident 1's physician was notified and recommended to transfer Resident 1 to GACH 3 for a psychiatric evaluation. A review of Resident 1's Nursing Progress Note dated 3/5/2025 indicated at approximately 5:15 PM, a physical altercation occurred between Resident 2 and Resident 1 in the facility lobby. The progress note indicated Resident 2 and Resident 1 were seated side by side, with Resident 2's wheelchair positioned between both residents. The progress note indicated that according to witness reports, Resident 1 moved Resident 2's wheelchair, which upset Resident 2 and lead to a verbal disagreement. The progress note indicated both Residents stood up, and Resident 1 suddenly threw a punch at Resident 2 striking the right side of Resident 2's face. The progress note indicated Resident 1 had no injuries, Resident 1's physician was notified and gave orders to transfer the resident to the GACH for further evaluation of his behavior. The progress note indicated at 5:35 PM the RN supervisor and CN interviewed Resident 1 about the incident and Resident 1 called Resident 2 a derogatory name. A review of Resident 1's Nursing Progress Note dated 3/11/2025 indicated that at 2:30 PM, Resident 1 returned to the facility from the GACH. A review of the IDT Note dated 3/11/2025 indicated Resident 1 wrote a letter indicating that Resident 1 would not bring physical harm to residents or to staff and Resident 1 signed the letter. A review of Resident 2's Admission Record indicated the facility admitted the resident on 1/7/2025 with diagnoses including schizophrenia, bipolar disorder (a mental disorder that causes dramatic shifts in a person's mood or energy and may affect the person's ability to think clearly), depression, unsteadiness on their feet, muscle weakness, and anxiety disorder. According to a review of Resident 2's MDS dated [DATE], the resident had moderately impaired cognition (problems with the ability to think, understand, and reason), did not exhibit physical or verbal behavioral symptoms towards others, and Resident 2 was taking antipsychotic medication. A review of Resident 2's COC documentation dated 3/5/2025 at 5:28 PM, indicated the resident had a physical altercation with another resident (Resident 1). Resident 2's physician was notified and recommended to transfer the resident to the GACH for further evaluation and treatment. A review of Resident 2's Nursing Progress Note dated 3/5/2025 indicated at approximately 5:15 PM, Resident 2 was noted to have discoloration on the right side of her face due to the altercation with Resident 1. The progress note indicated first aid was rendered, and a neuro check and vital sign assessment was completed for Resident 2. The progress note indicated Resident 2's attending physician was notified and provided orders to apply an ice pack to the affected area every 15 minutes for three applications and to transfer Resident 2 to the GACH for further evaluation of her injury. The progress note indicated at 5:40 PM the CN interviewed Resident 2 regarding the incident, and the resident stated she did not remember exactly what happened, all she could remember was a big man punched her in the face. A review of the Physician's Order dated 3/5/2025, indicated to transfer Resident 2 to GACH 2 for further evaluation of facial trauma. During a concurrent observation and interview on 3/18/2025 at 9:03 AM, in Resident 1's room, the resident was observed sitting on the side of the bed, calm, and watching television. Resident 1 stated he hit Resident 2 because she was irritating him. Resident 1 stated Resident 2 tried to throw her wheelchair at him, so he punched Resident 2 in her face. Resident 1 stated Resident 2 also punched him in his face. During an interview on 3/18/2025 at 9:12 AM, the Director of Social Services (DSS) stated Resident 1 had a history of mood swings and tantrums. The DSS stated Resident 1 verbalized and admitted that what he did to Resident 2 was wrong. On 3/21/2025 at 9:21 AM, during an interview with Resident 3, who was cognitively intact, Resident 3 stated she witnessed the altercation between Resident 1 and Resident 2. Resident 3 stated Resident 2 used curse words and told Resident 1 to move, get out of the way. Resident 3 stated Resident 1 got up and punched Resident 2 in the face. During a telephone interview on 3/18/2025 at 12:31 PM, RN 1 stated the altercation between Resident 1 and Resident 2 happened quickly. RN 1 stated Resident 2 complained of pain to the right side of her face 30 minutes after the incident, so the resident was given pain medication. RN 1 further stated Resident 1 previously had panic attacks, and when the resident would have these attacks he would scream, throw things on the floor, and bang the walls. During a concurrent interview and record review on 3/18/2025 at 2:44 PM, Resident 1's care plan, COC's, and progress notes were reviewed with RN 2. RN 2 stated she was familiar with Resident 1. RN 2 stated Resident 1 had grabbed another staff member during one of his previous panic attacks. RN 2 stated Resident 1 had a care plan for his panic attacks that was initiated on 1/16/2025 which was not revised after his panic attack on 2/4/2025. RN 2 further stated an IDT meeting was not conducted for Resident 1's behaviors after the resident was transferred to the GACH for a psychiatric evaluation on 2/4/2025. During a concurrent interview and record review on 3/18/2025 at 4:09 PM, Resident 1's care plan, COC's, and progress notes were reviewed with the DON. The DON stated Resident 2 could not remember much about the altercation and that Resident 1 admitted to punching Resident 2. The DON stated that on 2/4/2025 Resident 1 had a series of panic attacks during which he shook a CNA. The DON stated the resident's care plan for panic attacks was initiated on 1/16/2025 and had not been updated or revised after his panic attacks on 2/4/2025. The DON stated Resident 1's care plan for panic attacks should have been revised after having a change of condition on 2/4/2025. The DON confirmed and stated there was no IDT meeting conducted after Resident 1's change of condition on 2/4/2025 and she also looked in Resident 1's EHR and did not see that an IDT meeting was held to discuss Resident 1's behaviors after the 5150 hold. The DON stated an IDT meeting should have been held within 72 hours of Resident 1's return to the facility. The DON stated Resident 1's panic attacks were an ongoing area of concern for the resident which was why it was important to ensure the resident's behaviors were discussed during an IDT meeting. The DON stated punching another resident was not acceptable behavior and abuse was not acceptable in the facility. A review of the facility's P&P titled, Behavioral Assessment, Intervention and Monitoring, reviewed 1/31/2024, indicated under Interventions and Management, the IDT evaluated behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and developed a plan of care accordingly. Atypical behavior was differentiated from behavior that was dangerous or problematic for the resident (s) or staff, or behavior that signals underlying distress. If a behavior was atypical but not problematic or dangerous and the resident did not appear to be in distress, then the IDT monitors for changes but did not necessarily intervene to normalize the behavior. Safety strategies were implemented immediately, if necessary, to protect the resident and others form harm. The P&P indicated the care plan included as a minimum: a description of the behavioral symptoms, including frequency, intensity, duration, outcomes, location, environment; and precipitating factors or situations; targeted and individualized interventions for the behavioral and/or psychosocial symptoms; the rationale for the interventions and approaches; specific and measurable goals for targeted behaviors; and how the staff would monitor the effectiveness of the interventions. Interventions were individualized and part of an overall care environment that supports physical, functional, and psychosocial needs, and strives to understand, prevent, or relieve the resident's distress or loss of abilities. A review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, reviewed 1/31/2024, indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The IDT, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan or each resident .Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition, when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment. A review of the facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Prog, reviewed 1/31/2024, 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. The resident abuse, neglect, and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone include but not necessarily limited to: facility staff, other residents, consultants, volunteer, staff from other agencies, family members, legal representatives, friends, visitors, and/or any other individual .Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by Certified Nursing Assistant 1 (CNA) for one of two sampled residents (Resident 1). CNA 1 grabbed the back collar of Resident 1's gown (who was severely cognitively impaired [never/rarely made decisions]) and pushed Resident 1 into the resident's room. As a result, on 11/24/2022, Resident 1 was evaluated for injury or distress, was at risk for negative psychological impact due to alleged physical abuse. A reasonable person would have suffered emotional distress such as becoming fearful and suffer psychosocial harm when remembering the incident. Findings: A review of Resident 1's admission record indicated the facility readmitted Resident 1 on 7/5/2022 with diagnoses including Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), diabetes mellitus Type II (a chronic condition that affects the way the body processes blood sugar), and hypertension (HTN - elevated blood pressure). A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 9/26/2022, indicated Resident 1 was severely cognitively impaired (never/rarely made decisions) and required limited assistance with one person assist for bed mobility, transfer, and walk in corridor. The MDS indicated Resident 1 was not steady, only able to stabilize with staff assistance with no upper and lower extremity impairments. According to a review of the facility's Elder Abuse in-service records, CNA 1 received Elder Abuse training on 11/17/2022. A review of Resident 1's nursing progress note, dated 11/24/2022 at 11:11 AM indicated the police was contacted for a report alleging physical abuse of CNA 1 and Resident 1. A review of Resident 1's Change of Condition form (COC - a technique that can be used to facilitate prompt and appropriate communication between the different disciplines caring for the resident), dated 11/24/2022 indicated Resident 1 had an alleged physical abuse. The primary physician recommended to monitor for any negative psychological impact status post alleged physical abuse. The COC did not indicate the perpetrator of the alleged abuse or any description of the alleged abuse. A review of the staff assignment sheet, dated 11/24/2022, indicated Certified Nursing Assistant 1 (CNA 1) was assigned to Resident 1. According to a review of Resident 1's care plan for physical abuse, initiated on 11/24/2022, the care plan interventions included to evaluate for injury or distress and take actions. The care plan indicated Resident 1 was at risk for negative psychological impact due to alleged physical abuse, on 11/24/2022. A review of Resident 1's interdisciplinary team (IDT, - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) note, dated 11/25/2022 for physical abuse indicated to observe resident for any psychological impact and emotional distress. Resident 1 had Alzheimer's disease and had no recollection of what happened. During an interview on 12/8/2022 at 10:45 AM, the Receptionist (RCT) stated that on 11/24/2022 8:30 AM he was at the reception desk in the front of the office. He stated he observed Resident 1 walking in the hallway with Resident 2. The RCT stated he observed CNA 1 approach Resident 1, and CNA 1 grabbed Resident 1 by the collar on the back of gown with right hand and pushed Resident 1 into the room. The RCT stated he did not see what occurred after CNA 1 and Resident 1 entered the room. The RCT stated the Housekeeper (HK) approached him and told the RCT he witnessed CNA 1 push Resident 1 to her bed. According to a review of CNA 1's Notice of Employee as to Change in Relationship, dated 12/9/2022, indicated discharge effective date 12/9/2022. A review of the Psychiatric Note dated 12/12/2022, indicated Resident 1 was interviewed due to the alleged abuse done by CNA 1. Resident 1 was unable to recall the incident. The Psychiatric Note indicated to provide emotional support for compliance with treatment, increase socialization to prevent isolation, and continue to monitor. During an interview on 12/8/2022 at 11:25 AM, the Housekeeper (HK) stated that on 11/24/2022 at around 8:30 AM he was in the hallway near Resident 1's room. The HK stated he witnessed CNA 1 grab Resident 1 by the collar and physically push Resident 1 into the resident's room. He stated he was not able to see anything after they entered the room. The HK stated he asked Resident 2 if he saw what happened with Resident 1 and Resident 2 stated he saw CNA 1 grab and push Resident 1 into the room. The HK stated he informed the Receptionist of what occurred. During an interview on 12/8/2022 at 11:40 AM, Resident 2 stated that on 11/24/2022 at around 8 or 9 AM, he saw CNA 1 grab Resident 1 on the back of her gown around the collar and push Resident 1 into her room. Resident 2 stated Resident 1 did not fall. Resident 2 stated if CNA 1 grabbed and pushed him like she did Resident 1, he would feel sad and afraid. A review of Resident 2's admission record indicated the facility admitted Resident 2 on 7/28/2022 with diagnoses including Schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves), anxiety disorder (a mental disorder characterized by feelings of excessive uneasiness and apprehension), and hypertension (HTN - elevated blood pressure). A review of the Resident 2's MDS, dated [DATE], indicated Resident 2 was cognitively intact (decisions consistent/reasonable). During an interview on 12/8/2022 at 11:50 AM, the Director of Staff Development (DSD) stated that on 11/24/2022 at around 9:30 AM she was informed of the incident. She stated she spoke with CNA 1 and CNA 1 stated she did not push the resident but did grab Resident 1's gown by the neck. The DSD stated CNA 1 was sent home immediately that day on 11/24/2022 pending the investigation. The DSD stated she spoke with the HK and the RCT, who validated and collaborated they witnessed CNA 1 grabbed and pushed Resident 1 into the room. The DSD stated pushing and grabbing a resident can be considered a form of physical abuse. During an interview on 12/8/2022 at 12 PM, Resident 1 stated she does not remember being grabbed by the collar by CNA 1, but stated she was pushed in the back in the morning by CNA 1. Resident 1 stated she could not remember what day it happened and that she feels ok. During an interview on 1/24/2023 at 10:23 AM, CNA 1 stated she was working on 11/24/2022 from 7 AM to 3:30 PM shift. CNA 1 stated she was assigned to care for Resident 1 and was walking in the hallway when she helped Resident 1 with her gown because it was slightly opened. She stated the backside was open, so she tied the gown. CNA1 stated she directed the resident back to her room by putting both her hands on both of Resident 1's right and left shoulders. She stated she guided and did not push the resident to her room and put the resident back to her bed. CNA1 stated the DSD called her after she left Resident 1's room and indicated she needed to go home due to allegedly pushing Resident 1. She stated while she was transferring resident from hallway to her room, there was no additional staff with her. She stated Resident 1 was ambulatory and able to follow directions and required limited assistance while walking. When CNA 1 was asked why she stood behind Resident 1 when Resident 1 was ambulatory, followed directions, and required limited assistance while walking, CNA 1 stated she was standing behind the resident to cover Resident 1's gown. CAN1 stated she was grabbing Resident 1's gown and not holding onto both her shoulders to cover resident's open gown in the back. On 1/24/2023 at 11:21 AM, during an interview, the Director of Nursing (DON) stated the facility conducted a thorough investigation and concluded CNA 1 conducted inappropriate handling of Resident 1. The DON stated the investigation substantiated the allegation of physical abuse that occurred on 11/24/2022 between Resident 1 and CNA 1. She stated CNA 1 held Resident 1 by her gown collar. The DON stated staff were trained to guide residents while holding their hands versus holding residents by the shoulder or collar of the clothes. She stated staff were trained to hold residents who have difficulty walking by the hand to assist and if necessary to grab residents by the waist. The DON stated the conclusion of the investigation indicated CAN 1 did not follow facility protocol in properly transferring residents by grabbing Resident 1 by the back of the collar and pushing resident from the back. She stated CNA 1 grabbing and pushing Resident 1 can potentially be considered physical abuse. She stated the staff was terminated from the facility and reported to her licensing board for abuse. The DON stated an average cognitively intact resident would be very upset with being grabbed and pushed into the room. She stated the resident could potentially experience emotional distress from the incident. During an interview on 1/24/2023 at 2:07 PM, the Administrator (Admin) stated the grabbing of the resident by the back of the collar and pushing the resident can be considered a form of abuse. He stated when the facility was informed of the incident, the staff was sent home immediately, and appropriate authorities notified including the ombudsman, police, and local CPDH. He stated after the facility investigated the incident, staff CNA 1 was determined to be in violation of the facility abuse policy and procedure and was terminated and reported to the licensing board for abusive behavior towards Resident 1. He stated a cognitive intact person or reasonable person who was intact would not like to be grabbed by the collar and pushed by a staff. He stated they may have felt frustrated, angry, and even fearful. A review of the facility's policy and procedure titled, Abuse Prevention Program, revised 12/2016, indicated residents have a right to be free from abuse. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, or physical abuse. The policy indicated as part of the resident abuse prevention, the administration will develop and implement policies and procedure to aid our facility in preventing abuse, neglect, or mistreatment of our residents.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had diagnoses including epilepsy (seizure disorder), was not subjected to physical and mental abuse inflicted by Resident 2. On 10/12/2022, at 2 AM., Resident 2 physically abused Resident 1 on by hitting Resident 1 in the head causing pain and bleeding. Resident 1 was transferred to the General Acute Care Hospital (GACH) where he received treatment for the laceration to the head. As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 was subjected to physical assault, had physical pain, and was at risk for negative psychological impact due to the physical altercation. Findings: A review of Resident 1's Admission Record indicated the resident was readmitted to the facility on [DATE], with diagnoses including epilepsy (seizure disorder), muscle weakness and Type II diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care-screening tool) dated 8/16/2022, indicated the resident's cognitive skills of daily decision were severely impaired (never/rarely made decision). The MDS also indicated Resident 1 required one - person physical assist with activities of daily living (transfer, toileting, and personal hygiene). A review of Resident 1's Change in Condition (COC) form dated 10/12/2022, timed at 3:03 AM., indicated Resident 1 was struck on the head by his roommate (Resident 2) with a humidifier machine. The COC form indicated Resident 1 sustained a 3cm x 0.1cm laceration to the top of his head that was bleeding, and the resident complained of a headache with pain rated at 10 out of 10 (10 being the most severe pain). A review of Resident 1's progress note dated 10/12/2022, timed at 5:33 AM indicated that at approximately 2:05 AM, a certified nursing assistant notified the registered nurse supervisor that Resident 1 was bleeding from his head and the roommate allegedly had hit him. The progress note indicated the resident had a three-centimeter laceration (a deep cut or tear in skin or flesh) and tramadol (narcotic, controlled substance treats moderate to severe pain) 50 mg was given for the resident's pain rated on a scale as 10. According to a review of the Physician's Order Summary Report, dated 10/12/2022, Resident 1 was transferred to the general acute care hospital (GACH) 1 via 911 due to the laceration requiring sutures and persistent headache. A review of the GACH's treatment record dated 10/12/2022, indicated Resident 1 had a laceration on the top of his head, the computerized tomography (CT) scan of Resident 1's cervical spine was completed and there was no fracture. Resident 1 was stable to discharge back to the facility. A review of Resident 1's risk for pain care plan initiated 10/12/2022, after the alleged abuse indicated that the resident was at risk for negative psychological impact due to the physical altercation. The care plan interventions included to treat his head laceration, provide a calm safe environment and to encourage the resident to share his feelings. According to a review of Resident 1's alteration in skin care plan initiated on 10/12/2022, (after the incident), Resident 1 was at risk for infection, pain, and discomfort. The care plan interventions included to administer pain medications as needed and to handle the resident gently during care. A review of Resident 2's Admission Record indicated the resident was admitted to the facility on [DATE], with the diagnoses including anxiety disorder (restlessness and worry) and dysarthria (difficult or unclear articulation of speech) and anarthria (total inability to articulate speech in the absence of any deficit both of hearing comprehension and of written language). A review of Resident 2's MDS dated [DATE] indicated the resident's cognition was intact (able to make decisions) and required extensive assistance with one - person physical assist with transferring, toileting, and personal hygiene. The MDS indicated Resident 2 exhibited no indicators of psychosis (hallucinations or delusions). A review of Resident 2's anti-anxiety medication (Ativan) care plan initiated 9/15/2022, indicated Resident 2 had an anxiety disorder and an adverse reaction included impaired thinking and judgement. The care plan interventions indicated to monitor the resident every shift for safety and to monitor/document any adverse reactions including the unexpected side effects of mania, hostility, rage, aggressive or impulsive behavior. A review of Resident 2's COC dated 10/12/2022, timed at 2:51 AM., indicated the resident was angry towards his roommate because of the television volume and Resident 2 had a new behavior of hitting. A review of Resident 2's risk for harm to self or others care plan initiated 10/12/2022, (after the incident) indicated the resident had a physical altercation. Interventions included monitoring the resident's location every hour and monitor for aggressive behavior every shift. According to a review of the Physician's Orders dated 10/12/2022, Resident 2 was transferred to GACH 2 to be evaluated for physical aggression by hitting roommate with an object. A review of Resident 2's Nursing Progress Note dated 10/12/2022 timed at 8:34 AM indicated the resident admitted to hitting his roommate. During an interview on 10/25/2022, at 12:10 PM, Resident 1 stated that he could not remember the date, but he went to the bathroom to wash his face. He sat on the bed when he came back and the guy in the middle bed (Resident 2) hit him on the head. Resident 1 stated he was hit three times on the head and back of his neck. Resident 1 stated there was a lot of blood and the roommate (Resident 2) had never been aggressive before. Resident 1 stated, I yelled, help, that guy crazy. The nurses came and called the police. During an interview on 10/25/2022, at 12:26 PM., the Director of Nursing (DON), stated after the incident Resident 2 was moved to another room. Resident 1's physician was notified, and the incident was reported to the police. A review of the facility's policy and procedure titled, Abuse Prevention Program, revised 12/2016, indicated the residents have the right to be free from abuse and neglect, including physical abuse. The policy indicated the administration would protect the residents from abuse by anyone including other residents or any other individual. The administration would develop and implement policies and procedures to aid the facility in preventing abuse and neglect or mistreatment of the residents. Implement measures to address factors that may lead to abusive situations. The facility will investigate and report any allegations of abuse within timeframes as required by federal requirements. The policy indicated the facility / administration would establish and implement QAPI review and analysis of abuse incidents and implement changes to prevent future occurrences of abuse.

Based on interview and record review, the facility failed to provide the necessary care and services to one of two sampled residents (Resident 1). For Resident 1 who was identified as high risk for elopement (leaving the facility unsupervised and unnoticed), the facility failed to: 1. Provide appropriate interventions (assess needs) when Resident 1, for six days, refused to take the medications the primary physician ordered, resisted nursing care, and showed aggressive behavior towards staff. 2. Implement plan of care for psychiatry and psychology consults as needed. 3. Develop a plan of care addressing Resident 1's high risk for elopement. These failures resulted in Resident 1 eloping from the facility and two days later being found by a bystander (someone who observes an event or incident) who called the paramedics. Resident 1 was face down in the street on a cold rainy night, 12 miles from the facility. Resident 1 was taken to the general acute hospital emergency room (GACH ER) and died the same day, due to having been exposed to cold weather. Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. activities), and [MEDICAL CONDITION] (characterized by persistently depressed mood or loss of interest in activities causing significant impairment in daily life). A review of the Elopement Risk Evaluation, dated [DATE] at 11:12 p.m., indicated Resident 1 had an elopement risk of 16 (score of 10 or higher is considered at risk for elopement). The evaluation indicated Resident 1 had an episode of staying near exit door but no episode of trying to get out from the facility and per Resident 1's family had a history of [REDACTED]. A review of the Initial History and Physical, dated [DATE], indicated Resident 1 did not have the capacity to understand and make decisions. According to a review of the Order Summary Report for [DATE], Resident 1's primary physician ordered the following medications: [REDACTED] 1. [MEDICATION NAME] (an anxyiolytic medication, used to manage anxiety, trouble sleeping and [MEDICAL CONDITION]) one milligram (mg) to be given by mouth, one tablet as needed two times a day for anxiety manifested by inability to relax for 14 days. 2. [MEDICATION NAME] tablet delayed release (an anticonvulsant, for [MEDICAL CONDITION]) 500 mg, by mouth at bedtime. 3. [MEDICATION NAME] (helps remove water and salt from the body by producing urine) 20 mg by mouth one time a day for high blood pressure. 4. Atorvastatin (helps remove certain bad fats from the blood) 20 mg by mouth at bedtime. 5. [MEDICATION NAME] (an antipsychotic medication, treats mental or mood disorder that improves thinking, mood and behavior) two mg by mouth, two times a day for [MEDICAL CONDITION] manifested by refusal of care. 6. [MEDICATION NAME] sodium (makes bowel movements softer and easier to pass) one tablet once a day 7. Multivitamin tablet (supplement) one tablet once a day. 8. Senna (for bowel management) 8.6 mg. one tablet by mouth at bedtime. A review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. In addition, the MAR indicated [REDACTED]. A review of Resident 1's Care Plan dated [DATE], indicated Resident 1 was at high risk for physical and social decline due to refusing to bathe/shower, refusing to change clothes, refusing medications and refusing to wear the wander guard (bracelet worn that would trigger an alarm in the exit doors when resident attempts to leave the facility unsupervised). The care plan goal indicated Resident 1 will have no adverse effects or complications from non-adherence or rejection of care. The care plan interventions included approach resident calmly and unhurriedly, explain risks and benefits, monitor episodes of refusal and notify the physician. A review of the Care Plan dated [DATE], indicated Resident 1 used [MEDICATION NAME] due to [MEDICAL CONDITION] manifested by refusal of care. One of the interventions included psychiatry or psychology consult as needed. A review of the Care Plan dated [DATE], indicated Resident 1 had a [MEDICAL CONDITION] disorder (a disorder in which nerve cell activity in the brain is disturbed). The intervention included give [MEDICATION NAME] 500 mg by mouth at bedtime and psychiatry and psychology consults as needed. A review of the Progress Notes dated [DATE], at 5:30 a.m. indicated Resident 1 was offered the PPD skin test but again refused. Resident 1 also refused vital signs check. At 1:34 p.m., Resident 1 was offered medications and care but refused. The Notes indicated the purpose of the medications were explained to Resident 1 using a translator but Resident 1 refused strongly. A review of the Progress Notes dated [DATE] at 3:24 p.m., indicated during the morning shift Resident 1 was observed walking around the facility and remained in the front lobby. When approached, resident screamed and cursed staff, refused care and medications. The Progress Notes indicated the facility tried to call the primary physician but were unable to leave a message because the physician's voicemail was full. At 4:13 p.m., the notes indicated Resident 1 refused to take all medications as ordered by the physician, PPD skin test, refused all nursing care and vital sign checks. A review of the Resident Monitoring Log dated [DATE], indicated Resident 1 was in the lobby at 11 p.m. On [DATE], Resident 1 remained in the lobby from 12 a.m. to 4 a.m. According to a review of the Progress Notes dated [DATE], at 6 a.m., Resident 1 was sitting in the chair in the facility lobby on [DATE] at 11 p.m. Resident 1 was encouraged to go to bed but refused. The progress notes indicated staff checked Resident 1 every thirty minutes. At 4 a.m., Resident 1 was observed sleeping soundly in the lobby. At 4:30 a.m., certified nursing assistant (CNA) reported that Resident 1 was not in the lobby. The progress notes indicated facility staff searched for Resident 1 inside the facility and within five mile radius but were unable to locate Resident 1. The police, Resident 1's family, and physician were notified. A review of the Progress Notes dated [DATE] to [DATE] indicated the facility called several general acute care hospitals (GACH) to find out if Resident 1 had been admitted but were unable to find Resident 1. A review of the Progress Notes, dated [DATE], at 9:53 p.m., indicated the facility received a call from the coroner's office (a government official that conducts or investigate the manner of or cause of death and investigates or confirms the identity of an unknown person who has been found dead) that the deceased body of Resident 1 was at the morgue and had been confirmed by Resident 1's family. A review of the Prehospital Care Report Summary, dated [DATE], indicated the paramedics found Resident 1 on [DATE], at 4:47 a.m., face down, on the sidewalk on a cold rainy night. The Care Report Summary indicated Resident 1 had extreme hypothermia (a medical emergency that occurs when your body loses heat faster than it can produce heat, causing a dangerously low body temperature) with weak and rapid pulse, shallow respirations, [MEDICATION NAME] head trauma to eyebrow and face. While being transported to the GACH emergency room (ER), Resident 1 stopped breathing and had no pulse. Cardio [MEDICAL CONDITION] resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) was started. A review of the GACH ER Documentation dated [DATE], indicated Resident 1 arrived at the ER at 5:05 a.m. and was intubated immediately on arrival. Resident 1 was hypothermic (when body loses heat faster than it can produce heat, causing a dangerously low body temperature below 95 degrees Fahrenheit (F) or 35 degrees Celsius (C). Normal body temperature is 98.6 F (37C). Resident 1 had a core body temperature (the temperature of the internal environment of the body) of 78.8 F (26C). Resident 1 was placed under warm blankets and warm solution given into the bladder through the indwelling catheter (a flexible tube inserted into the bladder that drains urine). The ER Documentation indicated a warming solution was also given to the orogastric tube (OGT, small tube inserted into the mouth that travel down to the stomach for feeding and medication administration). Resident 1's temperature increased to 88.7 F (31.5 C) but remained pulseless. Further resuscitation was deemed futile and Resident 1 was pronounced dead at 5:51 a.m. A review of the Autopsy Report dated [DATE], indicated that on [DATE], Resident 1 was found unresponsive on the sidewalk. Resident 1's clothes were soaked in water. The report indicated Resident 1 died of hypothermia due to environmental exposure and that Resident 1 had multiple scrapes on both knees, chest, middle finger of the left hand and face. There were numerous upper extremities bruises. There was evidence of [MEDICATION NAME] trauma to the head in the form of scalp bleeding and skull surface bleeding. The autopsy report indicated Resident 1 had a [MEDICAL CONDITION] side of the ribs, from the second to tenth rib. A review of weather data indicated on [DATE], the temperature was between 47 F to 56 F with heavy rain. During a telephone interview and concurrent record review of Resident 1's clinical record, on [DATE], at 11:22 a.m., registered nurse supervisor (RNS 1) stated Resident 1 was admitted on [DATE] and refused all the medications ordered by the primary physician from [DATE] to [DATE], six consecutive days. RNS 1 stated when Resident 1 refused the wander guard Resident 1 was placed on hourly monitoring. RNS 1 stated Resident 1 needed a psychiatric consultation because Resident 1 had mental disorder and was admitted with [MEDICAL CONDITION] medications (used to treat the symptoms of mental disorders, reduce disability and prevent relapse). RNS 1 stated Resident 1 did not have an order for [REDACTED].>During a telephone interview on [DATE], at 3:25 p.m., the facility's medical director (MD) stated when Resident 1 was refusing her medications since admission, Resident 1 was showing danger to self and others. Resident 1 could have been placed on 5150 hold (allows a person with mental illness to be involuntarily detained for 72 hours in a psychiatric hospital). The facility's MD stated Resident 1 could have a psychiatrist consult because Resident 1 had mental disorder and was prescribed with [MEDICAL CONDITION] medications. The MD stated residents with [MEDICAL CONDITION] medications when admitted to the facility should automatically have a psychiatrist consult. During a telephone interview on [DATE], at 8:12 a.m., Resident 1's clinical record was reviewed with RNS 2. RNS 2 stated there was no physician order for [REDACTED]. During a telephone interview on [DATE], at 7:54 a.m., Resident 1's care plan and elopement risk was reviewed with RNS 2. RNS 2 stated Resident 1's elopement risk was 16 which means a high risk for elopement. RNS 2 stated there was no care plan created addressing the risk of elopement. During a telephone interview on [DATE], at 7:15 a.m., licensed vocational nurse 1 (LVN 1) stated the front door of the facility was kept locked during the night. On [DATE], LVN 1 stated he mistakenly left the key in the front entrance lock. A review of the facility's policy titled, Wandering, Unsafe Resident, with a revised date of ,[DATE], indicated staff will identify residents who are at risk for harm because of unsafe wandering. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. The policy indicated interventions to try to maintain safety such as detailed monitoring plan will be included. A review of the facility's policy titled, Requesting, Refusing and/or Discontinuing Care of Treatment, with a revised date of ,[DATE], indicated if a resident requests, discontinues or refuses care or treatment, the unit manager, charge nurse or director of nursing services will meet with the resident to: 1. Determine why the resident is requesting, refusing or discontinuing care or treatment. 2. Try to address the resident's concerns and discuss alternative options 3. Discuss the potential outcomes or consequences (positive and negative) of the resident's decision. A review of the facility's undated policy titled, Psychotherapeutic Drug Management Program, indicated the physician's responsibility included obtains psychiatric consultation as resident's clinical condition requires.

Based on observation, interview, and record review, the facility failed to provide a safe environment for one of two sampled residents (Resident 1) who was at risk and had a history of [REDACTED].), when the Charge Nurse (CN) 1 left the key in the front entrance door alarm, after activating the alarm system. This failure gave Resident 1 the opportunity to elope, wander 15 miles away from the skilled nursing facility and died at a general acute care hospital. Findings: During a tour of the facility with the Maintenance Supervisor (MS) on [DATE] at 2:55 PM, the front entrance had a double door which locked from the inside. There was an alarm on the doors which the MS activated with a key. The MS pushed the emergency bar on one of the doors to open the door from the inside. This action triggered the alarm which the MS activated prior to opening the door. During a review of Resident 1's face sheet (a document which has data information about the resident) dated [DATE], showed an admission to the facility on [DATE]. Resident 1 had [DIAGNOSES REDACTED]. A review of Resident 1's Nursing Progress Notes dated [DATE] at 6:00 AM, indicated on [DATE] from 11:00 PM to 4:25 AM, Resident 1 sat on a chair in the lobby and fell sleep. At 4:30 AM, a certified nurse assistant noticed Resident 1 was no longer in the lobby. From 4:35 AM to 4:55, the facility staff searched within a 5-mile radius for Resident 1, called the police and different hospitals. The facility staff could not find Resident 1. A review of Resident 1's Elopement Risk Evaluation dated [DATE] at 11:12 PM, indicated a score of 16, which meant the resident was a high risk for elopement. A review of Resident 1's Plan of Care initiated on [DATE], focused on Resident 1's tendency to wander out of the facility. The Plan of Care indicated Resident 1 had Hx (history of) AMA (Against Medical Advice, leaving the facility with proper doctor's order for discharge), a HX of elopement, and refusal to wear a Wander Guard (an active tracking application designed to prevent persons at risk from leaving a facility unless they are accompanied). One of the interventions indicated to check the resident's whereabouts at least every hour and to check and see that all exits doors are properly alarmed. During an interview on [DATE] at 3:10 PM, the Maintenance Supervisor (MS) said the night nurse locks the doors and activates the alarm. After all the visitors leave the facility staff activates the alarm. The MS added at 4:30 AM, the alarm should be active. During an interview on [DATE] at 4:43 AM, Charge Nurse (CN) 1 stated about 4:30 AM on [DATE], CN 1 heard the Registered Nurse called Code Green (an overhead page which meant a resident is missing). Resident 1 had left the facility. During an interview on [DATE] at 4:56 AM, CN 2 stated, he was a charge nurse at Station 1 when Resident 1 eloped. CN 2 stated, he gave the certified nursing assistant (CNA), working in the rooms closest to the lobby, instructions to monitor Resident 1. CN 2 stated between 4:00 and 4:30 AM on [DATE], the CNA informed him Resident 1 was no longer in the front lobby. When asked about the alarm key, CN 2 stated he had the key and used it to activate the front door alarm. CN 2 further stated, after activating the front door alarm he left the key in the alarm at the front door. He reasoned, at the time there were many people coming in and out of the facility. When CN 2 heard Code green over the intercom, he noticed the front door alarm was off. CN 2 denied hearing someone turning off the front door alarm. During a follow-up interview on February 4, 2020 at 2:48 PM, the MS stated, the charge nurse who activates the front door alarm should keep the alarm key in their possession. The CN should not leave the key in the alarm. The MS added the leaving the key, in the alarm, can cause the alarm system to fail and provides an opportunity for anyone to disarm the alarm, including Resident 1 who eloped. During interview on February 4, 2020 at 2:57 PM, the director of staff development (DSD) stated, Station 1 has the key to the front door alarm. The DSD expected the charge nurse at Station 1 to lock the front door and activate the alarm, but not leave the key in the alarm at the front door. During an interview on February 4, 2020 at 3:05 PM, the administrator stated Resident 1's family informed the skilled nursing facility (SNF) on [DATE], that they found Resident 1, 15 miles away from the SNF, in a hospital where the resident died . During a review of the facility's, undated, policy and procedure title, Policies and Procedure for Door Alarm System, indicated, The night shift charge nurse should do his/her rounds and check that all doors are secured and all alarms are active.

Based on observation, interview and record review, the facility failed to identify and evaluate accident risks and hazards, and did not implement and monitor interventions when necessary for two of two sampled residents (Resident 1 and Resident 2). For Resident 1, who was diagnosed with [REDACTED]. As a result, Resident 1 had a suicide attempt on [DATE], and jumped from a bridge onto the highway. Resident 1 sustained multiple rib fractures, pelvic fractures and underwent surgery at the general acute care hospital (GACH). Resident 2 had the potential to commit suicide or harm himself. A pattern of the facility's failure to identify and evaluate accident risks for two residents with suicidal ideation including Resident 1, who verbalized hearing his dead father's voice telling him to join his dead father, and Resident 2 who was referred for psychiatric consultation for suicidal ideation constituted an immediate jeopardy (IJ) situation and need for an immediate corrective action. The system failed and resulted in an immediate threat to the health and safety for other residents in the facility. On 2/10/20, at 5:26 p.m., the Department declared an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident) regarding the facility's failure to implement the care plan and monitor residents with history of suicidal ideation, and who verbalized ideations of suicide, and implement the facility's policy and procedure, titled Suicide Threats. The Department notified the facility's Administrator of the serious noncompliance that threatened the health and safety of Residents 1 and 2 and the potential to affect the other residents in the facility. On 2/11/20 at 3:50 p.m., the facility provided an acceptable written plan of action (POA) which included the following: -One on one monitoring by staff was provided to resident 2 to prevent and to protect the resident from suicidal attempts or plans to commit suicide. -Licensed staff were in-serviced to review all residents acute hospital records strictly during admission process to ensure all identified concerns are promptly communicate to the admitting physician for orders as indicated and family notification as appropriate. identified concerns shall reflected in the resident comprehensive resident care plan. -Psychiatric consultation shall be done to evidence residents identified are adequately assessed and attended. -In-service staff on Policy and Procedure on Suicide Threats. -Staff were instructed to report any resident threats of suicide immediately to the Nurse Supervisor/Charge Nurse. The Nurse Supervisor/Charge Nurse shall immediately assess the situation and shall notify the Nurse Supervisor/DON of such threats. A staff member shall remain with the resident until the Nurse Supervisor/Charge Nurse arrives to evaluate the resident. After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident's Attending Physician and responsible party, and shall seek further direction from the physician. -Facility to utilize a suicide screening tool on admission and address level of risks appropriately. (Been utilized but recommended to include date of assessment and signage portion shall be added to determine the staff doing the assessment) -Develop an individualized plan of care for residents at high risk for suicide. -Discuss monthly all significant findings related to suicide from a resident and forward to the QA committee for further review and recommendations as applicable. -The social worker conducted behavior assessment in conjunction with the Registered Nurses who did the suicidal risk assessment to residents. Nobody was identified per assessments of resident. -The corporate Regional clinical mentors and the Director of Nurses guiding them on the subject to be in-service to facility staff. -The facility shall conduct daily stand-up meeting that includes but not limited to Suicidal Risks residents as indicated and protocol for suicidal shall be implemented. On 2/11/20 at 5:30 p.m., the Department lifted the Immediate Jeopardy after an on-site verification that the POA was implemented. Findings: An unannounced visit was made to the facility on [DATE], to investigate an allegation of accidents. a. A review of Resident 1's Transfer Record from the General Acute Care Hospital (GACH) to the skilled facility, dated [DATE], indicated the Reason for Transfer was suicidal, tried to hang himself with a shoelace; hits his head on wall. A review of the Admission record indicated Resident 1 was admitted to the skilled facility on [DATE] with [DIAGNOSES REDACTED]. A review of the skilled facility progress notes, dated 3/26/19 at 8:41 a.m., indicated Resident 1 told the Registered Nurse (RN) Supervisor he was hearing his dead father's voice telling him to join his dead father, that was why he tried to commit suicide. The progress notes indicated Resident 1 stated his family members did not accept him properly because he did not shine properly in his job and was unsuccessful in other aspects, making Resident 1 depressed. A review of the care plan dated 3/26/19, indicated Resident had a problem with alteration in mood manifested by little interest or pleasure in doing things, is depressed, hopeless, with suicidal ideation. The care plan goal indicated Resident 1 will show improvement in mood daily time ninety days. The plan approach indicated to give support and reassurance, to anticipate needs and meet daily, and to monitor signs of suicidal indication or harmful acts of behavior. A review of the History and Physical, dated [DATE], indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of the progress notes, dated [DATE] at 1:05 p.m. (three days after admission), the Social Services Designee indicated that around 9:30 a.m. Resident 1 walked out of the facility followed by staff. The progress notes indicated staff tried to convince Resident 1 to go back to the facility but the resident continued to walk towards the bridge and suddenly jumped off the bridge. The progress notes indicated paramedics took Resident 1 to the GACH. A review of the emergency room (ER) Documentation, dated [DATE], indicated the GACH admitted Resident 1 due to suicide attempt and was complaining of back pain, hip pain, chest pain, and head pain. The ER records indicated Resident 1 stated he was responding to the voice of his dead father telling him to join his dead father. The ER Documentation indicated Resident 1 had the following: 1. Large left retroperitoneal hematoma (bleeding inside the abdominal cavity resulting from ruptured solid organs) concerning for left main renal vein (veins that drain the kidney) injury; 2. Hepatic laceration (cut inside the liver); 3. Right-sided pneumothorax (collapsed lung); 4. Multiple rib fractures; and 5. Pelvic fractures. A review of the GACH Orthopedic Consultation Notes, dated [DATE] indicated Resident 1, who jumped off a highway overpass with a height of 25 feet, became hypotensive (low blood pressure) in the ER and was sent to the operating room (OR) for an exploratory-laparotomy (surgical operation where the abdomen is opened and the abdominal organs examined for injury or disease) and nephrectomy (surgical removal of a kidney). After the operating room, Resident 1, who was sedated and intubated (a tube placed into the lungs to assist the patient with breathing), was brought in the surgical intensive care unit (SICU). A review of the GACH Discharge Documentation, dated 5/2/19, indicated Resident 1 was discharged from the GACH on 5/2/19. During an interview, on 3/29/19 at 2:40 p.m., Certified Nurse Assistant 1 (CNA 1), who was assigned to Resident 1, stated that in the morning staff had huddles but CNA 1 did not receive any communication about Resident 1 having a suicide risk and there was no instruction given on how to handle the resident. During an interview, on 4/8/19 at 1:40 p.m., the Restorative Nurse Assistant 1 (RNA 1) stated he followed Resident 1 who left the facility building and eventually jumped off the bridge. RNA 1 stated he did not know anything about Resident 1 having suicidal ideation. During an interview on 2/10/20, at 1:18 p.m., the Minimum Data Set (MDS - assessment care screening tool) Nurse stated she admitted Resident 1 and confirmed that she read the [DIAGNOSES REDACTED]. The MDS Nurse stated she did not assess Resident 1 for suicide risk. During an interview, on 2/10/20 at 2:02 p.m., and concurrent record review, the Director of Nursing (DON) stated there was no documented evidence that the RN Supervisor did an assessment or evaluation to Resident 1 for suicide risk. The DON stated the RN Supervisor did not report to her about Resident 1's suicidal ideation and the RN Supervisor did not contact the family to get more information on the history of Resident 1's suicidal risks. The DON stated the RN Supervisor did not call the attending physician for orders on how to take care of Resident 1's suicidal ideation. The DON stated the RN Supervisor did not communicate Resident 1's suicide risk to other staff and there were no instructions on how to handle the behavior during stand up meeting in the morning. The DON stated that if the facility had done the steps according to the facility's policy on Suicide Threats, the facility could have prevented Resident 1's jumping off the bridge. During an interview on 2/10/20 at 2:46 p.m., the Social Services Designee (SSD) stated the RN Supervisor did not communicate to her about the suicidal ideation of Resident 1. The SSD stated she read the GACH notes and was aware about Resident 1's suicidal ideation, but did not make any referral for psychiatric evaluation. The SSD stated she did not communicate this to the DON. The SSD stated she did not do daily visits to Resident 1 and stated there was no discussion of Resident 1's suicidal ideation during the stand-up meetings. b. A review of the GACH Psychiatry Consultation Report, dated 12/15/19, indicated Resident 2 was referred for psychiatric consultation for suicidal ideation. The consultation report indicated Resident 2 was very anxious and demanding to have more food, and told the nurse at the hospital that if he would not get the food he wanted, he will shoot himself. A review of the Admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the care plan dated 1/24/20, indicated Resident 2 had depression manifested by verbalization of sadness. The care plan goal was to main free of signs and symptoms of depression, anxiety or sad mood. The care plan interventions indicated to assess, record and report to physician as needed any signs and symptoms of depression, including hopelessness, anxiety and sadness. The intervention also indicated to arrange for psyciatric consult and to follow up as indicated. A review of the MDS, dated [DATE], indicated Resident 2 was cognitively intact. During an observation on 2/10/20 at, 3:25 p.m., Resident 2 was noted in his bed watching television. When asked did he have any thoughts of harming himself, Resident 2 looked away and stated no, nothing of the sort. During an interview, on 2/10/20 at 2:46 p.m., the SSD stated no one communicated to her about Resident 2's statement in the GACH, that if he would not get the food he wanted, he will shoot himself. The SSD stated this was the first time she heard about it. During an interview , on 2/10/20 at 3:30 p.m., and concurrent record review, the DON stated the facility did a suicide risk screening tool for Resident 2, which was undated and indicated if Resident 2 answered no to all questions, no interventions were necessary. The screening tool also indicated clinical judgement can always override a negative screen. The DON stated the facility did not call the family member to get more information, for staff to get a better picture of Resident 2. The DON stated they did not call physician, did not monitor for behavior, and did not conduct an Interdisciplinary Team (IDT) meeting. The DON stated the facility should have done all of these things because it was difficult to tell with limited information whether Resident 2 was suicidal or not. A review of the Psychiatric Note for Resident 2, dated 2/11/20 (over two weeks from the start of the care plan and after the IJ was called), indicated he was diagnosed with [REDACTED]. A review of the facility's undated policy and procedure titled, Suicide Threats, indicated resident suicide threats shall be taken seriously and addressed appropriately. The Nurse Supervisor/Charge Nurse shall immediately assess the situation and shall notify the Charge Nurse/Supervisor and/or Director of Nursing Services of such threats. After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident's Attending Physician and shall seek further direction from the physician. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. The facility policy indicated a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present.

Based on interview and record review, the facility failed to implement and modify care plan interventions to reduce hazards and risks for falls for one of three sampled residents (Resident 1). For Resident 1, who was assessed as high risk for fall due to history of stroke resulting in [DIAGNOSES REDACTED] (paralysis of half the body) and hemiparesis (weakness of one side of the body), balance problem while standing and walking, and had decreased muscular coordination, the facility failed to provide adequate assistance during transfer and observe safety when handling the resident, per the care plan. This deficient practice resulted in Resident 1 suffering a fall with injuries, which included a fractured left hip and required surgery. Findings: A review of the admission face sheet indicated Resident 1 was originally admitted to the facility, on November 27, 2013, with [DIAGNOSES REDACTED]. The history and physical, dated February 7, 2016, indicated the resident had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, an assessment and care planning tool), dated November 20, 2015, indicated Resident 1 understood others and was able to make herself understood. The MDS indicated Resident 1 required extensive 1 person weight-bearing support for transfers between bed, chair, wheelchair, and required extensive 1 person assistance (resident involved in activity, staff provide weight-bearing support) with dressing, toileting, hygiene, and bathing. The MDS indicated the resident was not steady and only able to stabilize with staff assistance when moving from seated to standing position, and transferring between bed and chair or wheelchair. A review of the Fall Risk Assessment, dated November 20, 2015, indicated Resident 1 was chair bound and required assistance with elimination, had a balance problem while standing and walking, and had decreased muscular coordination. The fall risk assessment indicated Resident 1 was unstable when making turns, required use of assistive devices (such as cane, wheelchair or furniture), and had a total score of 14. The assessment form indicated scores above 10 represented high risk for falls. A review of the investigation for all incidents form, dated January 28, 2016, indicated on January 27, 2016 Resident 1 stood up while holding the side rail, suddenly lost her balance, fell on the floor, and hit her head against the bedside drawer and her left hip against the floor. The investigative form indicated at the time of the incident, Certified Nurse Aide 1 was standing in front of the resident to assist her with the transfer, but was not able to hold her to prevent her fall. A review of the documented facility interview with CNA 1, undated, indicated he responded to Resident 1's call light and the resident stood up, shifted to the chair, but started sliding before he could catch her. He stated he panicked because the chair was between them. CNA 1 stated when he got to the resident, she was in a fetal position on her left side. He stated the resident was not hysterical but said she was in pain. CNA 1 then stated after he made sure the resident was stable and as comfortable as he could make her, and there was nothing more he could do, he left her to call the nurse. A review of the documented facility interview with Resident 1 conducted by the Administrator while the resident was still in the acute hospital, undated, indicated Resident 1 stated she wished the CNA did not move her back to bed by himself, but called for help before moving her. A review of the care plan, dated November 20, 2015, indicated Resident 1 required assistance with transfers due to poor balance, poor endurance, poor safety awareness, use of psychoactive medications, and history of stroke with left sided hemiparesis. The care plan interventions included to assist to maintain proper body alignment, and observe safety when handling resident. The care plan did not address interventions or type of assistance Resident 1 required with transfers, such as extensive 1 person weight bearing support for transfers and only being able to stabilize with staff assistance when moving from seated to standing position, and transferring between bed and chair or wheelchair. A review of the care plan titled, At Risk for Falls Related to: Fall Risk Assessment Score of 14, dated November 30, 2015, indicated Resident 1 would have no falls or injuries in the next 90 days. The care plan interventions indicated to adapt environment to meet resident's safety needs and did not address the level of assistance Resident 1 required with transfers. During an interview with Resident 1, on February 17, 2016, at 12:15 p.m., she stated the night of the incident, CNA 1 responded to her call light to assist her to the bathroom. Resident 1 stated as she went to sit on the shower chair, the shower chair moved backward away from underneath her legs and she landed on the floor. Resident 1 stated she struck her head on a hard object as she fell . Resident 1 stated during the incident CNA 1 was standing behind the shower chair (the shower chair was between the resident and the CNA). Resident 1 stated after she fell , she was screaming in pain and CNA 1 picked her up from the floor by placing both his arms under her armpits and put her back in bed. She stated, It would have been better if he had left me on the floor, because that did not help the situation. The MDS indicated the resident weighed 185 pounds. During an interview with registered nurse (RN) 1, on April 21, 2016, at 6:50 a.m., she stated CNA 1 came to the nurses station frightened and said Hurry, (the resident) fell . RN 1 stated when she arrived at Resident 1's room, the resident was in bed, crying. RN 1 stated the resident rated her pain at a level of 9 out of 10 (10 being most severe) in the left hip area and she stated she hit her head. RN 1 stated she medicated the resident for pain and assessed the resident per protocol. During an interview with CNA 1, on April 21, 2016, at 7:10 a.m., he stated Resident 1 was independent with transferring from bed to chair. CNA 1 stated when he responded to the call light, Resident 1 braced herself on the TV stand next to her bed, stood up unassisted, and when she pivoted to sit in the chair, she slipped and went down on the floor. CNA 1 stated he was holding the shower chair and it did not move. He stated the resident fell and one of her legs was in a very awkward position. CNA 1 stated the resident was on the floor, he got behind her, picked her up and flopped her over onto her left (injured) side on the bed. During an interview with Resident 1, on April 21, 2016, at 7:40 a.m., she stated she did not slip, did not lose her balance, did not get dizzy or have any problem except that the shower chair rolled away from her as she was attempting to sit on it. The resident stated she fell and was screaming because the pain was excruciating and the CNA thought he was helping but it was excruciating. Resident 1 stated, I cannot straighten my leg and they said I will never walk again. A review of Interdisciplinary Notes, dated January 28, 2016, indicated on January 27, 2016, at 11:35 p.m., CNA 1 reported to the charge nurse (RN 1) that (Resident 1) fell on the floor. The charge nurse went to the resident's room and found the resident in bed, crying due to severe pain. A review of the Operative Report from the general acute care hospital indicated the preoperative [DIAGNOSES REDACTED]. The surgical procedure performed, on January 30, 2016, was open reduction and internal fixation of the intertrochanteric fracture (a metallic rod and screws were inserted into the thigh bone). The facility's policy and procedure titled, Post Falls, revised June 2012, indicated the intent of the policy was to evaluate the extent of injury and prevent complications. The policy indicated the procedures included to evaluate the resident's condition before moving him. A review of the facility's Job Description for CNA, revised September 2011, indicated the CNA's responsibilities included to report any unusual behavior or observations on any resident immediately to the charge nurse. The facility's policy and procedure titled, Fall Prevention, undated, indicated the prevention program was to be accomplished by identifying risks, resident assessments, and educating staff. Included in the interventions was to assess the resident's risk of falling on admission. The policy indicated if it was decided the resident was at risk, take steps to reduce the danger. Educate the patient and family about mobility limitations and fall reduction measures. A review of the facility's policy and procedure titled, Patient Care Plan, undated, indicated the care plan would include but not be limited to the care to be given, methods, approaches (interventions), and expected goals.