Every finding on record at Hyde Park Healthcare Center

Based on interview and record review, for one of 3 residents (Resident 1), the facility failed to:1). Implement interventions as indicated in the resident's care plan titled At risk for impaired skin integrity.2). Create a care plan for Resident 1's bowel and bladder incontinence care.These failures placed Resident 1 at risk for skin breakdown and the potential to affect the health status, like developing urinary tract infections (bacterial infection that affects any part of the urinary system, including the bladder, urethra, or kidneys) which may require further treatment and hospitalization. Findings: During a review of Resident 1's admission Record, dated 8/11/2026, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of polyneuropathies (a medical condition where multiple peripheral nerves throughout the body malfunction at the same time), chronic obstructive pulmonary disease (COPD- a group of long-term lung conditions that block airflow and make it hard to breathe) and stiff-man syndrome (it causes severe, painful muscle stiffness and spasms-mainly in the lower back, trunk, and abdomen-that can be triggered by sudden noises, touch, and emotional stress). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 6/30/2026, the MDS indicated Resident 1 had clear speech, the ability to express ideas and wants, and understands. The MDS indicated resident 1 was incontinent of bowel and bladder (the accidental loss of control over urine or stool) and required substantial/maximal assistance (helper does more than half) with toileting hygiene, shower/bathe self and lower body dressing. During a review of Resident 1's care plan, titled, At risk for impaired skin integrity, dated 7/9/2026, one of the interventions included to evaluate bowel and urinary incontinence and skin integrity. During a review of Resident 1's Documentation Survey Report, for the month of 8/2026, the Documentation Survey Report on 8/3/2026 and 8/4/2026 11p.m. to 7a.m. shift; 8/4/2026 7a.m. to 3p.m. shift; 8/4/2026, 8/5/2026, 8/7/2026, and 8/8/2026 3p.m. to 11p.m. shift for the bowel and bladder elimination, and toilet use were left blank. During an interview on 8/14/2026 at 11:30 a.m., with the Director of Nursing (DON), the DON stated the interventions of the care plan, titled, At risk for impaired skin integrity, were not implemented when the bowel and bladder elimination in the Documentation Survey Report were left blank. The DON stated lack of documentation of the care needed would indicate that staff did not provide the care necessary for Resident 1's risk for impaired skin integrity. The DON stated that Resident 1's care plan for bowel and bladder incontinence were not created. Without care plan in place, and lack of documentation of incontinence care provided, staff may not have provided the necessary care to improve Resident 1's health status. During a review of the facility's policy and procedures (P&P) titled, Comprehensive Plan of Care, dated 12/2016, the P/P indicated it was the facility's policy to provide each resident with a comprehensive plan of care to meet their medical, nursing, mental and psychosocial needs. The comprehensive care plan must describe services that are provided to the residents to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not greater than 5 percent (%). The facility had two (2) errors out of 25 opportunities which equated to 8% medication error rate. This deficient practice had the potential to negatively affect the residents' well-being or health conditions.Findings:During observations made on 8/4/2026, 8/5/2026, and 8/6/2026, the facility had 2 medication errors out of 25 opportunities.During an observation on 8/4/2026 at 9:22 AM with Licensed Vocational Nurse (LVN) 2, LVN 2 was observed administering insulin glargine (a long-acting, synthetic human insulin analog that could provide a steady 24-hour baseline, or basal, blood sugar control) 10 units subcutaneously (SQ, under the skin) into Resident 33's upper left arm.During a review of Resident 33's admission record, the admission Record indicated Resident 33 was admitted to the facility on [DATE] with diagnoses including diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer (open sore or wound), muscle wasting and atrophy (the partial or complete wasting away of a body part, tissue, or cell), and epilepsy (a common brain disorder that causes repeated, unprovoked seizures)During a review of Resident 33's Physician's order dated 3/31/2026, the order indicated to administer insulin glargine 10 units SQ to Resident 33 at bedtime. During an interview on 8/4/2026 at 12:36 PM with LVN 2, LVN 2 stated Resident 33 received the insulin glargine this morning (on 8/4/2026 at 9:22 a.m.). LVN 2 stated the Physician's order indicated to administer insulin glargine at bedtime, not in the morning. (Refer to F-760)During an observation on 8/6/2026 at 9:01 AM with LVN 4, LVN 4 was observed administering a multiple vitamins tablet to Resident 23.During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 23's diagnoses included metabolic encephalopathy (a brain function loss caused by a chemical imbalance, toxin buildup, or lack of energy, like oxygen or glucose, in the blood) and malnutrition (the body is not getting enough calories or the right balance of nutrients to stay healthy).During a review of Resident 23's Physician's order dated 3/30/2026, the order indicated to give multiple vitamins with minerals one tablet a day to Resident 23 for supplement and skin maintenance.During a concurrent observation and interview on 8/6/2026 at 9:42 AM with LVN 4 at medication cart 1, surveyor asked to see the multiple vitamin bottles. LVN 4 opened the medication cart drawer and stated there was 1 bottle of multiple vitamins without minerals. LVN 4 stated, Resident 23's Physician's order indicated to administer multiple vitamins with minerals. LVN 4 stated Resident 23 received multiple vitamins without minerals because the multiple vitamins with minerals were out of stock.During an interview on 8/6/2026 at 10:01 AM with Registered Nurse (RN) 1, in the medication room, RN 1 stated there were no multiple vitamins with minerals in stock. RN 1 stated multiple vitamins without minerals and multiple vitamins with minerals were different supplements.During an interview on 8/6/2026 at 10:28 AM with the Director of Nursing (DON), the DON stated medications should have been administered as ordered by the Physician. The DON stated multiple vitamins without minerals were not the same as those with minerals. Nurses should document holding the dose, order the medication from the pharmacy or central supply and contact the physician for a potential change in order, if nurses discovered a medication was out of stock.During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration - General Guidelines dated 3/2024, the P&P indicated medications shall be administered in accordance with the orders of the attending physician.

Based on interview and record review, the facility failed to maintain a clear system for the administration and tracking of controlled substances (chemical or narcotic medication that are strictly used and regulated by the government due to their potential for abuse, addiction, and physical or psychological dependence), by failing to: Ensure the documented Norco (a narcotic or controlled substance prescribed for pain relief combining hydrocodone and acetaminophen [a common medication for pain]) removals on the count sheet (accountability record) matched the electronic Medication Administration Record (eMAR) for one (1) of 3 sampled residents (Resident 22); 3 doses removed did not have a corresponding documentation in the eMAR.Ensure Resident 22 had coverage for pain level at 4 out of 10 (pain rating reference 1-3 mild pain; 4-7 moderate pain; 8-10 severe pain). Resident 22 received Norco dosage prescribed for pain level 5 to 7 out of 10, when the resident expressed a pain level at 4 out of 10.Maintain a policy and procedure (P&P) that would track the receipt of narcotic medications and ensure there was an accurate and detailed tracking system for periodic reconciliation of narcotic medications. These deficient practices had the potential of medication errors and/or loss of accountability of controlled substances.Findings: During a review of Resident 22's admission record, the facility admitted Resident 22 on 4/29/2026 with diagnoses included but not limited to symptoms and signs involving the musculoskeletal system. During a review of Resident 22's order for Norco, dated 7/2/2026 at 4:21 PM, the order indicated to give 1 tablet of Norco 5-325 milligrams (mg, unit to measure medication dosage) every 4 hours as needed for moderate pain level of 5 to 7 out of 10. During an interview on 8/04/2026 at 1:20 PM, and a concurrent review of Resident 22's Norco count sheet and electronic medication administration record (eMAR) at the medication cart 2 with the licensed vocational nurse (LVN 2), the count sheet indicated there was 1 tablet of Resident 22's Norco removed on 8/1/2026 at 1:10 PM, however, LVN 2 stated Resident 22's August 2026 eMAR did not indicate an administration of Norco on 8/1/2026. During an interview on 8/4/2026 at 1:45 PM, the director of nursing (DON) confirmed that there was no documentation on the eMAR for the Resident 22's Norco removed on 8/1/2026 at 1:10 PM; in addition, the doses removed on 7/28/2026 at 8:31 AM and on 7/30/2026 at 10 AM also lacked documentation on the eMAR. During an interview on 8/4/2026 at 1:55 PM and a concurrent review of Resident 22's Norco order, DON stated the order was for moderate pain (5-7/10). However, Resident 22's eMAR of July 2026 indicated the pain level documented on 7/30/26 was 4, and outside of the aforementioned parameter. During a concurrent review of Resident 22's medication orders, DON stated Resident 22 had an order of acetaminophen (a common medication for pain) for pain level 1 to 3 out of 10, but Resident 22 did not have an order of pain medication for pain level at 4 out of 10. DON stated nurses should have notified the attending physician that there was no pain medication for pain level 4. During a review of the facility's policy and procedures, Medication Administration - General Guidelines (dated 3/2024), the policy indicated individual who administers the medication dose shall record the administration on the resident's MAR directly after the medication is given. During an interview on 8/5/2026 at 11:10 AM, and a concurrent review of the delivery receipts of controlled substances (dated 8/4/2026), the registered nurse (RN 1) stated those receipts did not have signature of the staff who received them. During an interview on 8/5/2026 at 3:40 PM, DON stated nursing staff were supposed to verify controlled medications received upon delivery against the receipts, signed and filed. However, DON did not provide the policy and procedure of the process.

Based on interview and record review, the facility failed to involve the resident's responsible party (resident representative-individual acting on behalf of the resident) for care plan meeting (a regular gathering where the facility's care team, the resident, and their family or legal representative review the resident health needs, assess ongoing goals and update the written plan of care) for one of one sampled resident (Resident 45).This deficient practice violated Resident 45's and his representative's right to be fully informed and had the potential to result in a delay of care and services.Findings:During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was initially admitted to the facility to the facility on 4/4/2026 and readmitted on [DATE]. Resident 45's diagnoses included dementia (a progressive state of decline in mental abilities), bronchitis (an inflammation of the large breathing tubes in the lungs), and Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 45's Attestation of Responsible party, dated 4/4/2026, the Attestation of Responsible Party indicated Resident 45's Responsible Party 1 (RP 1) signed the admission agreement and attested to be the Responsible Party and to make medical decisions for Resident 45.During a review of Resident 45's Minimum Data Set (MDS, a resident assessment tool), dated 7/8/2026, the MDS indicated Resident 45 was able to understand and be understood by others. The MDS indicated Resident 45's cognition (ability to think and process) was moderately impaired. The MDS indicated Resident 45 required supervision (helper provided verbal cues or contact guard assistance as resident completes activity) from staff with oral hygiene, toileting hygiene, and upper body dressing.During a review of Resident 45's Multidisciplinary Care Conference Meeting, dated 7/1/2026 and 7/29/2026, the Multidisciplinary Care Conference Meeting did not indicate RP 1 was among the members who attended the meeting.During a phone interview on 8/5/2026 at 9:48 a.m. with RP 1, RP 1 stated she was the designated responsible party of Resident 45. RP 1 stated the facility never invited her for a phone or in-person meeting to discuss the health conditions of Resident 45.During an interview on 8/5/2026 at 1:16 p.m., with the Social Service Director (SSD), the SSD stated she was responsible for inviting the resident's responsible party to the interdisciplinary team (IDT, team members from different disciplines who come together to discuss resident care) meeting. The SSD stated Resident 45 was diagnosed with dementia but was not aware Resident 45 had a responsible party. The SSD stated the IDT meeting with the resident's responsible party could be conducted over the phone or in person depending on the responsible party's availability or preference. The SSD stated it was important for the responsible party to be involved in the IDT meeting because the responsible party was in charge of the resident. The SSD stated the responsible party could discuss concerns during the meeting and the facility staff could explain the current plan of care and services provided to the resident. The SSD stated it was a violation of resident rights by not informing or allowing the resident's responsible party to be part of the care plan meeting.During an interview on 8/6/2026 at 1:31 p.m., with the Director of Nursing (DON), the DON stated it was important to conduct an IDT meeting with resident's responsible party so they would be updated with the plan of care of the resident and for continuity of care.During a review of the facility's policy and procedure (P&P), titled Care Plan Conference; dated 12/2016, the P&P indicated to provide each resident, resident's family, surrogate or representative a way to hold a care conference to meet and discuss the progress, needs and goals of care. The P&P indicated the facility would encourage residents, surrogates or representatives and families to participate in care planning to include their attendance at the care planning conference.

Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 1 and Resident 83) were treated with respect, dignity and care in a manner that maintained or enhanced their quality of life.This deficient practice resulted in residents being subjected to interactions and care practices that did not promote dignity, respect, and individualized care for Resident 1 and Resident 83.Findings:a) During a review of Resident 1's admission Record, the admission Record indicated Resident 9 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Diabetes Mellitus Type II (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertensive heart disease (a heart problem caused by having high blood pressure for a long period of time), and sensorineural hearing loss, bilateral (hearing loss in both ears caused by damage to the inner ear or the nerves that carry sound signals to the brain).During a review of Resident 1's History and Physical (H&P) dated 6/18/2026, the H&P indicated Resident 9 does not have the capacity to make own medical decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/21/2026, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 1 used a manual wheelchair and was dependent (helper does all the effort) on staff for activities of daily living and mobility. During an observation and interview on 8/4/2026 at 11:00 a.m. with the Activities Director (AD), there was no communication board in Resident 1's room. The AD stated Resident 1 was hard of hearing but could not locate the communication board. The AD stated the best way to facilitate communication with Resident 1 was to speak loudly into Resident 1's right ear and ask if he was okay. The AD yelled in Resident 1's right ear and asked if he was okay. Resident 1 responded by stating his name. The AD stated that speaking loudly in the resident's ear was her usual method of communication.During a concurrent interview and record review on 8/6/2026 at 8:30 a.m. with the Director of Nursing (DON), Resident 1's medical record was reviewed. The DON stated he recalled speaking directly into Resident 1's ear to ask if the resident had eaten lunch, to which Resident 1 responded affirmatively. The DON stated he was aware of the AD yelling into Resident 1's ear and noted that Resident 1 may perceive staff as angry, disrespectful, or lacking dignity in their interactions. The DON stated he and staff should have used a communication board or paper to communicate with Resident 1. b) During a review of Resident 83's admission Record, the admission Record indicated Resident 83 was admitted to the facility on [DATE], with diagnoses including DM, acute pulmonary edema (a sudden, serious condition where fluid quickly builds up in the lungs), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body).During a review of Resident 83's H&P, dated 9/5/2025, the H&P indicated Resident 83 does not have the capacity to make own medical decisions.During a review of Resident 83's MDS, dated [DATE], the MDS indicated Resident 83 was able to understand and be understood by others. The MDS indicated Resident 83's cognition was moderately impaired. The MDS indicated Resident 83 used a manual wheelchair and required substantial assistance (helper does more than half the effort) from staff for activities of daily living and mobility. During an observation and interview on 8/4/2026 at 11:00 a.m. with the Infection Preventionist (IP), the IP stood near the nurse's station while Resident 83 sat in his wheelchair at the entrance of his room and requested a toothbrush. The IP raised his voice and told Resident 83 he would have to wait until after the lunch trays were distributed. The IP stated he was not aware of Resident 83's request and acknowledged he should not have raised his voice. The IP stated he should have walked to Resident 83's room and clarified the request. During a concurrent interview and record review on 8/6/2026 at 8:30 a.m. with the Director of Nursing (DON), Resident 83's medical record was reviewed. The DON stated he was not aware the IP spoke loudly at the nurse's station while Resident 83 sat in his wheelchair in the doorway. The DON stated Resident 83 and the residents could perceive the IP's loud communication in the hallway as disruptive, disrespectful, and lacking dignity. The DON stated the IP should have approached Resident 83, spoken to him face-to-face to clarify his request, and responded promptly.During a review of the facility's policy and procedure (P&P) titled, Resident Dignity & Personal Privacy, dated 12/2016, the P&P indicated the facility was committed to provide care for residents in a manner that respected and enhanced each resident's dignity, individually, and right to personal privacy. The P&P indicated staff would carry out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth, and each resident had the right to be treated with dignity and respect.

Based on interview and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Comprehensive Plan of Care which indicated the facility will re-evaluate and modify care plans as necessary to reflect changes in care, service and treatment quarterly (every three months) for one of seven residents, (Resident 68).This failure had the potential of not providing updated care based on Resident 68's current condition.Findings:During a record review of Resident 68's admission Record, the admission Record indicated Resident 68 was admitted on [DATE] with diagnoses including cerebral infarction (stroke- loss of blood flow to a part of the brain) and quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury).During a record review of Resident 68's History & Physical (H&P), dated 3/18/2026, the H&P indicated Resident 68 has some confusion at baseline.During a record review of Resident 68's Minimum Data Set (MDS, a resident assessment tool) dated 6/19/2026, the MDS indicated Resident 68 has severe cognitive (ability to think and reason) impairment and required partial/moderate assistance (Helper provides verbal cues and/or touching/steading and/or contact guard assistance as resident completes activity) from staff for eating, oral hygiene, toileting hygiene, showering/bathing, upper body dressing, personal hygiene and bed mobility.During a record review of Resident 68's Care Plan titled, The resident has impaired physical mobility related to disease Process (functional quadriplegia), dated 3/23/2026, the Care plan indicated the last revision date was on 3/23/2026.During a concurrent interview and record review on 8/06/2026 at 12:34 p.m., with the DON, Resident 68's Care plan titled, The resident has impaired physical mobility related to disease process (functional quadriplegia) was reviewed. The DON stated the Care plan indicated it was last revised on 3/23/2026. The Care plan should have been reviewed and updated every three months (by 6/2026). The DON stated failing review and revise the resident's Care plan timely could lead to worsening of the resident's condition; the resident could become contracted, develop pain and decrease in independence. During a review of the facility's P&P titled, Comprehensive Plan of Care, dated 12/2026, the P&P indicated it is the policy of the facility to provide each resident with a comprehensive plan of care developed that includes goals, measurable objectives and timetables to meet their medical, nursing, mental and psychosocial needs. The P&P indicated the facility will re-evaluate and modify care plans as necessary to reflect changes in care, service and treatment quarterly.

Based on observation, interview, and record review, the facility failed to ensure licensed nurses contacted the physician to clarify an incomplete order for Vitamin B 12 (cyanocobalamin, a vitamin vital for brain function, nervous system health, and red blood cell formation) without the strength (or dosage, a specific amount of medication or supplement to administer), before administering the medication to one of ten sampled residents (Resident 33). At least four licensed nurses had not noticed the order for Resident 33's Vitamin B12 did not include the dose to administer. This deficient practice had the potential for a medication error. Findings: During a review of Resident 33's admission record, the admission Record indicated Resident 33 was admitted to the facility on [DATE] with diagnoses including Diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer (open sore or wound), muscle wasting and atrophy (the partial or complete wasting away of a body part, tissue, or cell), and epilepsy (a common brain disorder that causes repeated, unprovoked seizures) During a review of Resident 33's Physician's order dated 7/28/2026, the order indicated to give Vitamin B12 one tablet to Resident 33 daily for supplement. The Physician's order did not indicate the dosage of Vitamin B12 to be given to the resident. During concurrent interview on 8/4/2026 at 12:56 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she administered vitamin B12 500 micrograms (mcg, the unit to measure dose of medications) to Resident 33 in the morning. LVN 2 stated there were other doses available for vitamin B12. She administered vitamin B12 at 500 mcg because only the 500 mcg was available in the medication cart. LVN 2 stated the order did not indicate the dose for vitamin B12 and should have been clarified with resident's Physician. During a review of Resident 33's electronic Medication Administration Record (eMAR) for the months of 7/2026 and 8/2026, Vitamin B12 was listed without a strength or dose, and four different licensed nurses administered vitamin B12 at unknown dosages. During an interview on 8/4/2026 at 4:28 PM, with the Director of Nursing (DON), the DON stated Resident 33's Vitamin B12 order did not indicate the dosage. The DON stated Vitamin B12 was available in multiple strengths. Licensed nurses should have clarified with the Physician before administering the medication. The DON also stated, since the order was dated 7/28/2026 (7 days earlier), the DON stated multiple nurses should have been aware of the lack of dosage and contacted the Physician. During a review of the facility's Policy and Procedure titled, Prescriber Medication orders dated 3/2022, the P&P indicated medication orders shall specify dosage; any dose that appears inappropriate shall be verified with the attending physician before proceeding with processing.

Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was seen by an Audiologist (a healthcare professional who specializes in hearing and balance problems) and otolaryngologist (ENT, a physician who specializes in ear, nose and throat conditions) as ordered by the Physician. This failure delayed evaluation and treatment of Resident 1's hearing impairment, which could lead to worsening hearing loss, impaired communication, social isolation, and diminished quality of life.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. The admission Record indicated Resident 1's diagnoses included Diabetes Mellitus Type II (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertensive heart disease (a heart problem caused by having high blood pressure for a long period of time) and sensorineural hearing loss, bilateral (hearing loss in both ears caused by damage to the inner ear or the nerves that carry sound signals to the brain).During a review of Resident 1's History and Physical (H&P) dated 6/18/2026, the H&P indicated Resident 1 did not have the capacity to make medical decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/21/2026, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 used a manual wheelchair and dependent (helper does all the effort) on staff for toileting, dressing, personal hygiene and transfers. During a concurrent interview and record review on 8/5/2026 at 2:10 p.m., with the Social Services Director (SSD), Resident 1's Physician's order was reviewed. The SSD stated on 6/17/2026, the Physician ordered for an audiology and ENT consultation and treatment for Resident 1. The SSD stated Resident 1's audiology and ENT consultations had not been scheduled. The SSD stated she was responsible for scheduling these consultations. Timely scheduling of audiology and ENT appointments affected Resident 1's communication, quality of life, and ability to participate in care. The SSD stated untreated hearing loss could cause Resident 1 to have difficulty communicating needs, understanding staff, and may lead to feelings of isolation.During a concurrent interview and record review on 8/6/2026 at 8:30 a.m. with the Director of Nursing (DON), Resident 1's Physician's order was reviewed. The DON stated Resident 1 was experiencing hearing loss and required two appointments; one for audiology and one for ENT, which the SSD had not scheduled since 6/17/2026. The DON stated the SSD was responsible for scheduling residents' appointments. The DON stated when SSD does not schedule appointments, residents could experience delays in care, and their health conditions may worsen if treatments and medications were not provided in a timely manner.During a record review of the facility's policy and procedure (P&P) titled, Referrals to Outside Agencies, dated 8/2017, the P&P indicated the facility is committed to schedule referrals to outside agencies to meet the physical or psychosocial needs of the resident. Outside agencies may include, but are not limited to vision, dental or hearing consults. The P&P indicated the appointments, and transportation arrangements are communicated through the 24-hour report process. The P&P indicated the issue that prompted the service is monitored and the service provider kept appraised of the team's evaluation of progress or lack of progress.

Based on interview and record review, the facility failed to ensure a smoking assessment was completed and updated for one of one sampled resident (Resident 10).This deficient practice had the potential to place Resident 10 at risk for injury and inadequate care planning.Findings:During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 10's diagnoses included hypertension (HTN, high blood pressure), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool), dated 5/15/2026, the MDS indicated Resident 10 had the ability to make self-understood and understand others. The MDS indicated Resident 10's cognitive (ability to think and reason) skills for daily decision making were moderately impaired. The MDS indicated Resident 10 required supervision (resident requires verbal cues and/or contact guard assistance as resident completes activity) from staff with eating, oral hygiene, and toileting hygiene.During a review of Resident 10's Care Plan titled, Resident smokes cigarettes, dated 8/4/2026, the Care Plan goal indicated Resident 10 will smoke safely and remain free from smoking-related injuries, throughout the review period. The Care Plan intervention included, to assess Resident 10's ability to smoke safely.During a concurrent interview and record review on 8/5/2026 at 12:20 p.m., with Minimum Data Set Nurse (MDSN) 1, Resident 10's Smoking and Safety assessment, dated 6/26/2025, was reviewed. MDSN 1 stated Resident 10's Smoking and Safety assessment was not updated. MDSN 1 stated she was responsible for completing and updating resident's Smoking and Safety assessments every 3 months based on the MDS assessment calendar. It was an oversight on her part by not completing and updating Resident 10's Smoking and Safety assessment. MDSN 1 stated it was important to complete and update the Smoking and Safety assessment for the safety of the resident and the facility.During an interview on 8/5/2026 at 12:38 p.m., with the Director of Nursing (DON), the DON stated the Smoking and Safety assessment was a tool to identify the status of the resident if he or she could smoke cigarette safely. The DON stated failing to complete and update the Smoking and Safety Assessments placed residents at risk for injuries while smoking. During a review of the facility's Policy and Procedure (P&P) titled, Residents Smoking, dated 6/2022, the P&P indicated the facility shall establish and maintain safe resident smoking practices and documentation of smoking will be assessed and documented in the smoking assessment.

Based on interview and record review, the facility failed to ensure one of seven residents (Resident 4) received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) as ordered by the Physician, and transportation was arranged on 7/30/2026, 8/1/2026 and 8/4/2026. This failure placed Resident 4 at risk of developing fluid overload (resulted in hyperkalemia (high potassium buildup that could impair heart function and irregular heart rhythm that could lead to cardiac arrest) and required transfer to a general acute care hospital (GACH) for further evaluation. Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease (ESRD- irreversible kidney failure), dependent on renal dialysis and congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of Resident 4's Order Summary Report, dated 6/24/2026, the Order Summary Report indicated, on 6/25/2026, Resident 4 had a Physician's Order to undergo dialysis on Tuesday, Thursday, Saturday, with a chair time at 5:40 a.m. and the Social Services Director (SSD) was to provide transportation for the resident.During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 6/27/2026, the MDS indicated Resident 4 had moderate cognitive (ability to think and reason) impairment. The MDS indicated Resident 4 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) from staff for oral and toileting hygiene, personal hygiene, upper body dressing, moving from sitting on the side of bed to lying flat on bed, and moving from lying on the bed to sitting on the side of the bed.During a review of Resident 4's Care Plan titled, Resident 4 has had two missed scheduled dialysis treatments, placing him at risk for fluid overload, electrolyte imbalance (excess of sodium and potassium), uremia (waste products in the blood), and other complications related to inadequate dialysis treatments dated 8/4/2026, the Care Plan indicated Resident 4 missed two dialysis treatments.During a review of Resident 4's Change of Condition, dated 8/4/2026 at 7:00 a.m., the Change of Condition indicated Resident 4 missed three dialysis appointments starting on 7/30/2026 and the physician ordered for Resident 4 to be sent to the GACH for further evaluation. During a review of Resident 4's Transfer Form, dated 8/4/2026 at 4:04 p.m., the Transfer Form indicated Resident 4 had an unplanned transfer to a GACH.During a review of Resident 4's Progress Note, dated 8/4/2026 at 4:10 p.m., the Progress Note indicated Resident 4 was transferred to GACH due to missed dialysis treatments.During an interview on 8/6/2026 at 12:37 p.m. with the Social Services Director (SSD), the SSD stated she was responsible for arranging transportation to and from dialysis treatments. The SSD stated she called the transportation company and was informed that they did not see transportation scheduled for Resident 4 (on 7/30/2026 and 8/1/2026).During a telephone interview on 08/06/2026 at 1:37 p.m. with a representative of the transportation company (HNE 1), HNE 1 stated it was the facility's responsibility to call and schedule appointments for transportation. The last appointment for Resident 4 was on 7/28/2026 and no other transportation appointments were scheduled until 8/4/2026. During an interview on 8/6/2026 at 2:27 p.m. with the Director of Nursing (DON), the DON stated he did not know Resident 4 missed dialysis on 7/30/2026 and 8/1/2026 until 8/4/2026 when he noticed the resident was not at dialysis on his usual scheduled day (on 8/4/2026). The SSD informed him that transportation was not arranged after 7/28/2026 for Resident 4 and the resident was transferred to the hospital for evaluation due to missed dialysis on 7/30/2026, 8/1/2026 and 8/4/2026. The DON stated Resident 4 could have missed dialysis again if he did not notice the resident missing dialysis on 8/4/2026. The DON stated missed dialysis placed Resident 4 at risk for bloating, a change in their respiratory rate, an overall experience of discomfort from the extra fluid, and not being able to eat if the excess fluid affected the resident's stomach.During a review of the facility's Policy and Procedure (P&P) titled, Resident Transportation, dated 11/2017, the P&P indicated, it was the policy of the facility to ensure residents were transported to and from their (dialysis) appointments and services provided in the community according to their treatment plan.

Based on interview and record review, the facility failed to act upon the Medication Regimen Review (MRR, a structured, comprehensive evaluation of a resident's entire medication list, conducted by a pharmacist to ensure safety and effectiveness) recommendation from the Consultant Pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) for one of five sampled residents (Resident 10).This deficient practice placed Resident 10 at risk of receiving unnecessary medication.Findings:Cross Reference to F605During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 10's diagnoses included hypertension (HTN, high blood pressure), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and anxiety disorder (excessive fear or worry that interfere with daily living).During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool), dated 5/15/2026, the MDS indicated Resident 10 had the ability to make self-understood and understand others. The MDS indicated Resident 10's cognitive (ability to think and reason) skills for daily decision making were moderately impaired. The MDS indicated Resident 10 required supervision (resident requires verbal cues and/or contact guard assistance as resident completes activity) from staff with eating, oral hygiene, and toileting hygiene.During a review of Resident 10's Physician Order, dated 5/20/2026, the Physician Order indicated to administer Lorazepam (a psychotropic drug [any drug that affects brain activities associated with mental processes and behavior], that treats anxiety disorder) 0.5 milligrams (mg, metric unit of measurement used for medication dosage and/or amount) by mouth every six hours to Resident 10 as needed for anxiety manifested by the inability to relax and pacing in the hallway.During a review of Resident 10's Pharmacist MRR dated 6/17/2026, the MRR indicated Resident 10 was on Lorazepam 0.5 mg by mouth every 6 hours as needed. The MRR indicated new Federal nursing facility regulations required to limit as needed psychotropic medications to a total of 14 days unless clinically contraindicated. The MRR indicated Lorazepam should be discontinued after 14 days or document reasons for continuation.During an interview on 8/6/2026 at 12:05 p.m., with the Director of Nursing (DON), the DON stated the licensed nursing staff should inform the resident's physician within 7 days from the time the MRR was completed and document in the progress notes if the physician agreed or disagreed with the MRR recommendation. The DON stated the physician needed to sign and acknowledge the MRR report then document his response in the progress notes. The DON stated there was no documentation by licensed nursing staff that the MRR report for Resident 10 was completed and addressed by Resident 10's physician. The DON stated all MRR reports should have been completed accordingly to ensure residents were not receiving unnecessary medications.During a review of the facility's Policy and Procedure (P&P), titled Monthly Drug Regimen, dated 3/2022, the P&P indicated resident-specific Drug Regimen Review recommendations and findings shall be documented and acted upon by the facility and/or physician.

Based on observation, interview, and record review, the facility failed to ensure Resident 33 received insulin glargine (a long-acting, synthetic human insulin analog that could provide a steady 24-hour baseline, or basal, blood sugar control) 100 units per (/) millimeter (ml, unit to measure volume) at bedtime as ordered by the Physician. On 8/4/2026 Resident 33 received insulin Glargine in the morning (at 9:22 a.m.). This deficient practice had the potential for Resident 33 to develop hypoglycemia (low blood sugar level that can be severe if blood sugar levels drop too low and the brain lacks energy to function) that could significantly affect the resident's health condition. Findings:During an observation on 8/4/2026 at 9:22 AM with Licensed Vocational Nurse (LVN) 2, LVN 2 was observed administering insulin glargine 10 units subcutaneously (SQ, under the skin) into Resident 33's upper left arm. During a review of Resident 33's admission record, the admission Record indicated Resident 33 was admitted to the facility on [DATE] with diagnoses including diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer (open sore or wound), muscle wasting and atrophy (the partial or complete wasting away of a body part, tissue, or cell), and epilepsy (a common brain disorder that causes repeated, unprovoked seizures). During a review of Resident 33's Physician's order dated 3/31/2026, the order indicated to administer insulin glargine 10 units SQ to Resident 33 at bedtime. During an interview on 8/4/2026 at 12:36 PM with LVN 2, LVN 2 stated Resident 33 received the insulin glargine this morning (on 8/4/2026 at 9:22 a.m.). LVN 2 stated the Physician's order indicated to administer insulin glargine at bedtime, not in the morning. LVN 2 stated another (unnamed) nurse informed her to give Resident 33's insulin glargine in the morning because the resident's regular (short acting) insulin was pending delivery from pharmacy. LVN 2 stated she should have called the doctor and clarified the order before administering insulin glargine in the morning. LVN 2 stated she was not aware that regular insulin was available in the emergency drug supplies. During interviews on 8/4/2026 at 2:08 PM and 8/4/2026 at 3:18 PM with the Director of Nursing (DON) stated LVN 4 should have called [Resident 33's] Physician and pharmacy to use the regular insulin in the emergency supplies, instead of administering [Resident 33's] insulin glargine at the wrong time. The DON stated insulin glargine was a long-acting insulin, and regular insulin was a short-acting one. The two insulins were not interchangeable, and the long-acting insulin should not be used to replace regular insulin. During a subsequent interview on 8/5/2026 at 1:12 PM with the DON, the DON stated nurses needed to check for the right resident, right medication, right dose, right route, and right time, prior to medication administration. During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration - General Guidelines dated 3/2024, the P&P indicated medications shall be administered in accordance with the orders of the attending physician.

Based on observation, interview and record review, the facility failed to store dented cans in the designated area, discard food items that were beyond the use by date, label food in the pantry, refrigerator and freezer with use by date, and store small milk cartons in a dry bin.These deficient practices had the potential for harmful bacteria growth and cause food-borne illness (food poisoning) to facility residents.Findings:During a concurrent observation and interview on 8/4/2026 with the Head [NAME] (HC), in the kitchen, the following were observed:-At 8:55 a.m., during an inspection of pantry one, one dented can of cranberries was not stored in a separate area within the pantry. one mayonnaise container with a use by date of 6/12/2026, one mustard container with a use by date of 2/17/2026, one tamarin container with a use by date of 6/5/2026, and one bag of chocolate chips with a use by date of 5/18/2026 were observed. The HC stated the dented can of cranberries should have been placed in a separate area, under the sign, Dented Can. The HC stated she was unaware the items (mayonnaise, mustard, tamarin and chocolate chips) were outdated and expired.-At 10:10 a.m., during an inspection of refrigerator one, two large cubes of butter were observed without expiration or use by dates, and a large bin with six heads of lettuce without a use by date. The HC stated she was unaware the butter should have been dated and stated staff should have labeled the food items with use by dates.-At 10:20 a.m., during an inspection of kitchen, the HC stated staff did not label one onion powder container with the open, expiration or use by date. -At 10:25 a.m., during an inspection of freezer one, the HC stated staff did not label one bag of frozen fish sticks with a use by date. -At 10:35 a.m., during an inspection of refrigerator two, several small milk cartons were observed in a tub with water. The HC stated the night shift did not remove the ice from the bin, and the ice melted with the milk cartons inside.During a concurrent observation and interview on 8/6/2026 with the HC in the kitchen, the following were observed:-At 10:05 a.m., during an inspection of refrigerator two, several small milk cartons in tub with melted ice water were observed. The HC stated the night shift did not remove the ice from the bin, and the ice melted with the milk cartons inside.During a review of the facility's Policy and Procedure (P&P) titled, Food Storage Principles, dated 4/2020, the P&P indicated the facility requires staff to handle and store dry foods in a manner that maintains the integrity of the packaging until the items are ready to use. The P&P indicated staff to label and date dry food items with the expiration date or date of receipt, and to rotate foods using a first in-first out system. During a review of the facility's P&P titled, Storing Dry Foods, dated 4/2020, the P&P indicated the facility requires staff to store damaged canned goods in a separate and distinct area of the storeroom, away from other food items. The P&P indicated staff to label this area exclusively for damaged goods and return damaged goods to the vendor.During a review of the facility's P&P titled, Procedure for Freezer Storage, undated, the P&P indicated the facility requires staff to label and date all frozen food, and staff should refer to Freezer Storage Guidelines for the recommended storage time of foods.

Based on interview and record review, the facility failed to maintain accurate medical records for one of seven sampled residents (Resident 4), when on 7/30/2026 Resident 4 missed dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) and the facility documented the resident was transported to dialysis. This failure had the potential to result in miscommunication between staff and a delay in the provision of care or interventions for Resident 4.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease (ESRD- irreversible kidney failure), dependent on renal dialysis and congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of Resident 4's Order Summary Report, dated 6/24/2026, the Order Summary Report indicated, on 6/25/2026, Resident 4 had a Physician's Order to undergo dialysis on Tuesday, Thursday, Saturday, with a chair time at 5:40 a.m. and the Social Services Director (SSD) was to provide transportation for the resident.During a review of Resident 4's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 4 had moderate cognitive (ability to think and reason) impairment. The MDS indicated Resident 4 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) from staff for oral and toileting hygiene, personal hygiene, upper body dressing, moving from sitting on the side of bed to lying flat on bed, and moving from lying on the bed to sitting on the side of the bed.During a review of Resident 4's Progress Note dated 7/30/2026, the Progress Note indicated Resident 4 left for dialysis on 7/30/2026 at 4:51 a.m. via gurney accompanied by transportation in stable condition. During a review of Resident 4's Care Plan titled, Resident 4 has had two missed scheduled dialysis treatments, placing him at risk for fluid overload, electrolyte imbalance (excess of sodium and potassium), uremia (waste products in the blood), and other complications related to inadequate dialysis treatments dated 8/4/2026, the Care Plan indicated Resident 4 missed two dialysis treatments.During an interview on 8/6/2026 at 12:37 p.m. with the Social Services Director (SSD), the SSD stated she was responsible for arranging transportation to and from dialysis treatments. The SSD stated she called the transportation company and was informed that they did not see transportation scheduled for Resident 4 (on 7/30/2026).During a telephone interview on 08/06/2026 at 1:37 p.m., with a representative of the transportation company (HNE 1), HNE 1 stated it was the facility's responsibility to call and schedule appointments for transportation. The last appointment for Resident 4 was on 7/28/2026 and no other transportation appointments were scheduled until 8/4/2026. During an interview on 8/6/2026 at 3:36 p.m., with the Director of Nursing (DON), the DON stated on 7/30/2026, transportation was not arranged and Resident 4 missed dialysis, however the facility documented Resident 4 was transported to dialysis. Staff were supposed to document in real time. Documentation was supposed to represent what actually occurred with the resident. During a review of the facility's Policy and procedure (P&P) titled, Documentation Guidelines dated 11/2021, the P&P indicated documented in the legal health record will follow these basic rules: 1. Record applicable observations, psychosocial and physical manifestations, incidents, unusual occurrences, and abnormal behavior. 2. Promptly record as the events or observations occur; complete, concise, descriptive, factual, and accurately describe services provided to/for the resident.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was completed accurately for one of 19 sampled residents (Resident 10).This deficient practice resulted in incorrect data transmitted to the Centers for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and delivery of necessary care and services for Resident 10.Findings:During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 10's diagnoses included hypertension (HTN, high blood pressure), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 10's Physician's Order, dated 2/18/2026, the Physician's Order indicated to administer Lasix (a diuretic drug to treat fluid retention caused by heart disorder) 20 milligrams (mg, metric unit of measurement used for medication dosage and/or amount) by mouth twice a day (9:00 a.m., and 5:00 p.m.) to Resident 10 for bilateral lower extremity (both legs) edema (swelling).During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 had the ability to understand and be understood by others. The MDS indicated Resident 10 had moderate cognitive (ability to think and reason) impairment. The MDS indicated, Resident 10 required supervision (resident requires verbal cues and/or contact guard assistance as resident completes activity) from staff with eating, oral hygiene, and toileting hygiene. The MDS indicated an x was marked under section N0415 (High-Risk Drug Classes) A (Antipsychotic-[a drug used to treat mental health conditions]) and did not indicate an x was marked for N0415 (G, Diuretic). During a review Resident 10's Medication Administration Record (MAR) dated 5/9/2026 to 5/15/2026, the MAR indicated Resident 10 received Lasix 20 mg by mouth twice a day. The MAR did not indicate Resident 10 received any antipsychotic medication. During a concurrent interview and record review on 8/4/2026 at 3:46 p.m., with the Minimum Data Set Nurse (MDSN) 1, Resident 10's MDS, dated [DATE], was reviewed. MDSN 1 stated Resident 10's MDS assessment was completed inaccurately. MDSN 1 stated there should have been no x marked on MDS Section N0415 (High-Risk Drug Classes) A (Antipsychotic) because Resident 10 did not receive any antipsychotic medication during the 7-day look back period (the specific time frame within which certain resident conditions and events are assessed) before the Assessment Reference Date (ARD, observation end date) of 5/15/2026. MDSN 1 stated there should be an x marked on MDS Section N0415 (G, Diuretic) because Resident 10 received Lasix during the 7-day look back period before the ARD of 5/15/2026. Resident 10's MDS Section N0415 observation assessment period was from 5/9/2026 to 5/15/2026. MDSN 1 stated Resident 10's MDS assessment that was transmitted to the CMS did not accurately reflect Resident 10's current medications during the ARD of 5/15/2026. MDSN 1 stated inaccuracy of MDS assessment could affect the resident's plan of care.During a review of the facility's Policy and Procedure (P&P) titled, Minimum Data Set Accuracy, dated 10/2023, the P&P indicated the facility shall establish a system in which MDS accuracy is checked to assure that each patient receives an accurate assessment by staff [NAME] are qualified to assess relevant care areas and are knowledgeable of the resident's status, needs, strengths and areas of potential or actual decline.

Based on interview and record review, the facility failed to ensure a written Notice of Proposed Transfer and Discharge Form was provided to the resident's responsible party (RP-resident's representative acting on behalf of the resident) for one of four sampled residents (Resident 45).This deficient practice had the potential to compromise Resident 45's due process rights related to transfer.Findings:During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was initially admitted to the facility to the facility on 4/4/2026 and readmitted on [DATE]. The admission Record indicated Resident 45's diagnoses included dementia (a progressive state of decline in mental abilities), bronchitis (an inflammation of the large breathing tubes in the lungs), and Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 45's Minimum Data Set (MDS, a resident assessment tool), dated 7/8/2026, the MDS indicated Resident 45 was able to understand and be understood by others. The MDS indicated Resident 45's cognitive (ability to think and reason) skills for daily decision making were moderately impaired. The MDS indicated Resident 45 required supervision (helper provides verbal cues or contact guard assistance as resident completes activity) from staff with oral hygiene, toileting hygiene, and upper body dressing.During a review of Resident 45's Physician order, dated 7/24/2026, the Physician order indicated Resident 45 was transferred to the General Acute Care Hospital (GACH) for increased confusion.During a concurrent interview and record review on 8/6/2026 at 9:26 a.m., with the Social Service Director (SSD), Resident 45's Notice of Proposed Transfer and Discharge Form, dated 7/24/2026, was reviewed. The Notice of Proposed Transfer and Discharge Form did not indicate Resident 45's RP received and signed the Form. The SSD stated she was not familiar and was still in the process of learning the Notice of Proposed Transfer and Discharge Form.During an interview on 8/6/2026 at 9:53 a.m., with the Director of Nursing (DON), the DON stated there was no evidence that Resident 45's RP was provided with the Notice of Proposed Transfer and Discharge Form, when Resident 45 was transferred to the GACH on 7/24/2026. The DON stated it was important to provide a written notice of Proposed Transfer and Discharge to the resident's RP so they would know the reason why the resident was transferred to the GACH and their right to make an appeal if they felt it was an inappropriate transfer or discharge.During a review of the facility's Policy and Procedure (P&P) titled, Transfer and Discharge, dated 12/2016, the P&P indicated at least 30 days prior to transfer or discharge. In cases when the resident's urgent medical needs require more immediate transfer, provide the notice as soon as practicable before transfer or discharge. The facility will notify the resident, family member, surrogate, or resident representative in writing and in a language and manner they understand the reason for transfer and explain the resident's right to appeal the transfer or discharge.

Based on observation, interview and record review, the facility failed to ensure PRN (as needed) Ativan (brand name for lorazepam, a psychotropic drug [any drug that affects brain activities associated with mental processes and behavior], or medication, that treats anxiety disorders [excessive fear or worry that interfere with daily life) order had a limit of 14 days, as per regulation, for two of 10 sampled residents (Resident 10 and Resident 84). This deficient practice had the potential for unnecessary chemical restraints for Residents 10 and 84. Findings: a. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 10's diagnoses included hypertension (HTN, high blood pressure), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 had the ability to understand and be understood by others. The MDS indicated Resident 10 had moderate cognitive (ability to think and reason) impairment. The MDS indicated, Resident 10 required supervision (resident requires verbal cues and/or contact guard assistance as resident completes activity) from staff with eating, oral hygiene, and toileting hygiene. During a review of Resident 10's Physician's Order, dated 5/20/2026, the Physician Order indicated to administer Lorazepam 0.5 milligrams (mg, metric unit of measurement used for medication dosage and/or amount) by mouth every six hours PRN to Resident 10 for anxiety manifested by inability to inability to relax as evidenced by pacing in the hallway. During an interview on 8/6/2026 at 10:15 a.m., with Registered Nurse (RN) 1, RN 1 stated it was important to put a stop date for psychotropic PRN medication orders because long term use of psychotropic medication could cause adverse effects (undesired effect of a drug) to the resident that would endanger the resident's health and safety. During an interview on 8/6/2026 at 10:30 a.m. with the Director of Nursing (DON), the DON stated Resident 10's Lorazepam 0.5 mg PRN order should have had a stop date of 14 days as per federal regulations. After 14 days, the prescriber needed to come and assess Resident 10 if the Lorazepam PRN order should be continued or place an order for a routine. The DON stated the prescriber should document his or her rationale including the medical justification for the continuation of the medication. The DON stated within the 14 days period, the licensed nursing staff should document the number of behaviors manifested by the resident. The DON stated if there was no assessment and rationale for the continuation of Resident 10's Lorazepam order after 14 days, then the medication would be considered as unnecessary medication. b. During an observation on 8/4/2026 at 9:44 a.m., Licensed Vocational Nurse (LVN) 2 administered 1 tablet of lorazepam 1 milligram mg. by mouth to Resident 84. During a review of Resident 84's admission Record, the admission Record indicated Resident 84 was admitted to the facility on [DATE] with diagnoses including anxiety disorder. During a review of Resident 84's Physician's order, dated 7/31/2026, the order indicated to give lorazepam 1 mg. every 4 hours as needed to Resident 84 for anxiety manifested by restlessness and agitation. During concurrent interviews on 8/5/2026 at 11:22 a.m., with RN 1 and the DON, RN 1 stated Resident 84's PRN Ativan order did not have a stop date. The DON stated PRN psychotropic drugs should have even limited to 14 days. During a review of the facility's Policy and Procedure (P&P) titled, Psychoactive Medication Management, dated 7/2017, the P&P indicated based on a comprehensive assessment of a resident, the facility must ensure that PRN orders for psychotropic drugs are limited to 14 days, except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan that includes measurable objectives and timeframes to meet the language and communication for one of five sampled residents (Resident 1).This had the potential to result in inaccurate resident identification, delay in care and services, medication administration errors, treatment errors, and failure to ensure resident preferences for Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's diagnoses included Diabetes Mellitus Type II (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertensive heart disease (a heart problem caused by having high blood pressure for a long period of time), and sensorineural hearing loss, bilateral (hearing loss in both ears caused by damage to the inner ear or the nerves that carry sound signals to the brain).During a review of Resident 1's History and Physical (H&P) dated 6/18/2026, the H&P indicated Resident 1 did not have the capacity to make own medical decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/21/2026, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 1 used a manual wheelchair and was dependent (helper does all the effort) on staff for activities of daily living and mobility. During a concurrent interview and record review on 8/5/2026 at 2:10 p.m. with the Social Services Director (SSD), Resident 1's undated care plan titled Impaired social interaction, cognitive impairment, communication deflicts [defects], hearing loss, cultural language [NAME][r]s, behavioral health, was reviewed. The care plan indicated the intervention was to facilitate individualized activities tailored to the resident's preference and abilities. The SSD stated the care plan lacked measurable objectives, individualized care and interventions, and timeframes tailored to the resident's assessed needs and preferences. The SSD stated Resident 1's communication board was available on the table for Resident 1's use, however, she did not document this intervention in the care plan.During an interview on 8/6/2026 at 8:30 a.m. with the Director of Nursing (DON), the DON stated Resident 1 had hearing loss and the care plan should include goals and the use of a communication board as an intervention for Resident 1. The DON stated the interventions listed in the care plan were not appropriate because the care plan did not document Resident 1's language or identify resources used to facilitate communication. The DON stated without measurable goals or timeframes, the facility could not demonstrate whether staff implemented interventions, understood expectations, reduced communication barriers, or evaluated outcomes.During a record review of the facility's policy and procedure (P&P) titled, Comprehensive Plan of Care, dated 12/2016, the P&P indicated the facility was committed to developing a comprehensive, person-centered care plan including goals, measurable objectives, and timetables to meet each resident's medical, nursing, mental, and psychosocial needs. The P&P indicated the care plan must describe the services provided or arranged by the facility, ensure these services are delivered by qualified personnel, and reflect culturally competent, and trauma informed practices. The P&P indicated interventions should address the underlying causes of the identified problem area(s), when possible, rather than focusing solely on symptoms or triggers. The P&P indicated the facility conducts ongoing assessments and revised care plans as information about the residents and their conditions changes.

Based on interview and record review, the facility failed to complete an assessment for change of condition (COC, a sudden change in resident's normal physical, mental, or behavioral state) and document the specific needs of the resident the facility could not meet, attempts to meet resident needs and interventions prior to transfer to general acute care hospital (GACH) for one of four sampled residents (Resident 45).This deficient practice had the potential for an inappropriate transfer and compromised continuity of care for Resident 45. Findings:During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was initially admitted to the facility to the facility on 4/4/2026 and readmitted on [DATE]. The admission Record indicated Resident 45's diagnoses included dementia (a progressive state of decline in mental abilities), bronchitis (an inflammation of the large breathing tubes in the lungs), and Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 45's Minimum Data Set (MDS, a resident assessment tool), dated 7/8/2026, the MDS indicated Resident 45 was able to understand and be understood by others. The MDS indicated Resident 45's cognitive (ability to think and reason) skills for daily decision making were moderately impaired. The MDS indicated Resident 45 required supervision (helper provides verbal cues or contact guard assistance as resident completes activity) from staff with oral hygiene, toileting hygiene, and upper body dressing.During a review of Resident 45's Physician order, dated 7/24/2026, the Physician order indicated Resident 45 was transferred to the GACH for increased confusion.During a concurrent interview and record review on 8/5/2026 at 1:47 p.m., with Registered Nurse (RN) 1, Resident 45's Progress Notes, dated 7/24/2026, was reviewed. RN 1 stated there was no COC assessment or Situation, Background, Assessment and Recommendation ([SBAR] - a communication tool used by healthcare workers when there is a change of condition among the residents) completed on 7/24/2026 to address Resident 45's increased confusion. RN 1 stated an SBAR gives us a clinical background or the events that took place about Resident 45's COC or any prior condition that occurred in the past related to the resident's present COC. RN 1 stated without a COC assessment there would be a communication breakdown. RN 1 stated the licensed nurse should have assessed Resident 45's confusion if it was an acute (condition begins suddenly, develops fast, and lasts for a short time) change from Resident 45's baseline level of mentation (process of thinking, reasoning, and cognition). RN 1 stated RN 2 worked on 7/24/2026 and did not complete a change of condition assessment or an SBAR. RN 2 no longer worked at the facility. RN 1 stated Resident 45's confusion could have been attributed to her diagnosis of dementia. RN 1 stated the facility did not provide interventions to address the COC prior to sending the resident to the GACH.During an interview on 8/5/2026 at 3:40 p.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated she did not complete Resident 45's COC assessment or an SBAR because she was told by RN 2 that she would do so. LVN 5 stated Resident 45's confusion was not new. LVN 5 stated Resident 45's needs could have been met at the facility by ruling out the cause of resident's confusion by ordering laboratory tests (a medical analysis of a body sample [blood, urine, tissue] to check health, diagnose diseases and monitor chronic conditions).During a concurrent interview and record review on 8/6/2026 at 9:53 a.m., with the Director of Nursing (DON), Resident 45's Progress Notes, dated 7/20/2026 to 7/24/2026, were reviewed. The DON stated there was no documentation of Resident 45's increased confusion from 7/20/2026 to 7/23/2026 until it was identified on 7/24/2026. The DON stated the licensed nurses should have documented at least 72 hours to determine Resident 45's increased confusion since Resident 45 had a diagnosis of dementia. Nurses should have documented when the increased confusion started and what interventions were provided for the increased confusion prior to transfer to the GACH. The DON stated by not monitoring, completely assessing, and documenting the necessity of Resident 45's transfer had the potential to result in an inappropriate discharge of the resident to the GACH.During a review of the facility's Policy and Procedure (P&P) titled, Transfer and Discharge, dated 12/2016, the P&P indicated the facility does not transfer or discharge a resident unless the transfer or discharge is necessary to meet the resident's welfare and the resident's welfare cannot be met in the facility. Supporting information is documented in the resident's medical records.During a review of the facility's P&P titled, Quality of Care, dated 11/2019, the P&P indicated the facility will provide all treatments and care to all residents based on comprehensive assessments, professional standards of practice, the comprehensive person-centered care plan, and the resident's choice.During a review of the facility's Charge Nurse Job Description, the Charge Nurse Job Description indicated to ensure that required documentation is complete and is in compliance with regulations and standards as well as polices and procedures.

Based on interview and record review, the facility failed to ensure the responsible party (resident representative-individual acting on behalf of the resident) for one of five sampled residents (Resident 45) was notified in a timely manner of resident's change of condition (COC, a change in resident's normal physical, mental, or behavioral state).This deficient practice had the potential to result in violating Resident 45's right for the responsible party to be notified of changes.Findings:During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was initially admitted to the facility to the facility on 4/4/2026 and readmitted on [DATE]. Resident 45's diagnoses included dementia (a progressive state of decline in mental abilities), bronchitis (an inflammation of the large breathing tubes in the lungs), and Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 45's Attestation of Responsible party, dated 4/4/2026, the Attestation of Responsible Party indicated Resident 45's Responsible Party 1 (RP 1) signed the admission agreement and attested to be the Responsible Party and to make medical decisions for Resident 45.During a review of Resident 45's Minimum Data Set (MDS, a resident assessment tool), dated 7/8/2026, the MDS indicated Resident 45 was able to understand and be understood by others. The MDS indicated Resident 45's cognition (ability to think and process) was moderately impaired. The MDS indicated Resident 45 required supervision (helper provides verbal cues or contact guard assistance as resident completes activity) from staff with oral hygiene, toileting hygiene, and upper body dressing.During a review of Resident 45's physician order, dated 7/24/2026, the physician order indicated to transfer Resident 45 to the general acute care hospital (GACH) for increased confusion.During a concurrent interview and record review on 8/5/2026 at 1:47 p.m., with Registered Nurse 1 (RN 1), Resident 45's Progress Note, dated 7/24/2026, was reviewed. RN 1 stated there was no COC assessment or Situation, Background, Assessment and Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents) completed on 7/24/2026 to address Resident 45's increased confusion. RN 1 stated without a COC assessment, there would be a communication breakdown among facility staff.During an interview on 8/6/2026 at 9:53 a.m. with the Director of Nursing (DON), the DON stated the facility did not notify Resident 45's responsible party for Resident 45's COC on 7/24/2026. The DON stated Resident 45's admission Record had other emergency contact names, but the facility did not attempt to notify them. The DON stated by not knowing the resident's COC, the resident's responsible party could become stressed and panicked. The DON stated for any resident's COC, the facility should notify the responsible party in a timely manner to ensure transparency and for the responsible party to be involved in decision making.During a review of the facility's policy and procedure (P&P) titled, Change of Condition, dated 8/2017, the P&P indicated the facility shall promptly notify the resident, his or her attending physician, and resident representative of changes in the resident's medical or mental conditions and or status. Cross Reference: F627

Based on observation, interview, and record review, the facility failed to implement its policy and procedure (P/P) titled Abuse and Neglect Prohibition Policy, dated 6/2022, which indicated the facility prohibited abuse for all residents, for one of four sampled residents (Resident 1), who lacked the ability to consent and had severe cognitive impairment (a profound decline in thinking, memory, and reasoning, that prevents independent living). Resident 2, who had a history of sexually inappropriate behaviors sexually assaulted Resident 1.This deficient practice resulted in Resident 2 forcing penile-vaginal penetration onto Resident 1 on 1/17/2026. A sexual assault examination conducted at General Acute Care Hospital (GACH 2), on 1/17/2026, after the incident, indicated Resident 1 had brown ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) to the left medial (middle) anterior (front) labia minora (inner skin folds of the female external genitalia). Findings: a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 1's diagnoses included spastic quadriplegic cerebral palsy (the most severe form of cerebral palsy, characterized by significant stiffness and limited movement in all four limbs, the trunk, and the face), depression, and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). The admission Record indicated Resident 1 was conserved (deemed by a court to be incapable of managing their own personal needs, finances, or safety, necessitating the appointment of a conservator to act on their behalf). During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 had severe cognitive impairment (a profound decline in thinking, memory, and reasoning, that prevents independent living). The MDS indicated Resident 1 required partial to moderate assistance from staff for dressing her lower body, and to transition from a sitting to standing position, or to walk distances of 10 feet to 50 feet.During a review of Resident 1's progress note, dated 1/17/2026, the progress note indicated Resident 1 was observed engaging in sexual intercourse with Resident 2. The progress note indicated Resident 2 was asked to leave the room, and Resident 1 was observed lying on her bed with her lower body garments down. The progress note indicated Resident 1 did not respond when asked if she was in pain or if she knew what had happened. During a review of Resident 1's Change of Condition (COC) assessment, dated 1/17/2026, the COC assessment indicated an unidentified CNA informed the charge nurse that a male resident (Resident 2) was in Resident 1's room. The COC assessment did not indicate what occurred in the room prior to the residents being separated. The COC assessment indicated Resident 1 received a vaginal exam but did not specify what the exam entailed. Resident 1's physician was notified of the incident and ordered Resident 1 to be transferred to a GACH for further evaluation. During a review of Resident 1's physician order, dated 1/17/2026, the order indicated to transfer Resident 1 to the emergency room for evaluation and treatment related to an observed sexual act. During a review of Resident 1's Facility to Hospital Transfer Form, dated 1/17/2026, the form indicated Resident 1 was transferred to GACH 2 on 1/17/26 at 3:27 p.m. due to a sexual act.During a review of Resident 1's GACH 2 record titled Adult/Adolescent Sexual Assault Examination - Narrative Addendum, dated 1/17/2026, the record indicated an addendum was made to the section of the assessment titled Sexual Acts Described by the Patient. The addendum indicated Resident 1 resided in a nursing facility, and per Law Enforcement and facility staff, Resident 1's roommate ran out of her room asking for help. The record indicated facility staff found Resident 2 on top of Resident 1, forcing penile-vaginal penetration.During a review of Resident 1's GACH 2 record titled Adult/Adolescent Sexual Assault Examination - Anogenital Examination Female, dated 1/17/2026, the record indicated Resident 1 had brown ecchymosis to the left medial anterior labia minora.During a review of Resident 1's GACH 2 record titled Sexual Assault Aftercare Instructions, dated 1/17/2026, the record indicated Resident 1 received the following:a. A sexual assault examination.b. Collection of a sexual assault kit (a standardized kit used by medical professionals to collect and preserve physical, forensic evidence from a survivor's body or clothing after a sexual assault).c. Preventative treatment for sexually transmitted infections (STI, an infection spread between people through direct contact during vaginal, anal, or oral sex): chlamydia, gonorrhea, and syphilis.d. Emergency contraception (medication to prevent pregnancy after unprotected sex). During a review of Resident 1's progress note, dated 1/18/2026, the progress note indicated Resident 1 returned to the facility on 1/17/2026 at 11:45 p.m. During a review of Resident 1's progress notes, dated 1/18/2026 at 3:03 p.m., the progress note indicated Resident 1 was being monitored for alleged assault. The progress note indicated Resident 1 complained of abdominal pain.During an observation on 1/21/2026 at 8:26 a.m., Resident 1 was observed exiting her room. An attempt was made to interview Resident 1, but Resident 1 refused to speak and walked away. b. During a review of Resident 2's General Acute Care Hospital (GACH) 1 Emergency Department (ED) note, dated 12/23/2025, the ED note indicated Resident 2 was admitted to GACH 1 on 12/23/2025 for evaluation of confusion, frequent wandering, and walking around more than usual. The ED note indicated Resident 2 had a history of depression (a common, serious mood disorder characterized by persistent, intense feelings of sadness, emptiness, or a loss of interest in activities), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 2's GACH 1 nursing narrative note, dated 12/25/2025, the note indicated Resident 2 was aggressive towards staff. The note further indicated Resident 2 displayed noticeably sexually inappropriate behavior, and began to masturbate (the deliberate self-stimulation of one's own genitalia to produce sexual pleasure) while looking at a Certified Nursing Assistant (CNA) that was present in his room. The note indicated Resident 2 was placed on precautions for sexually inappropriate behavior. During a review of Resident 2's GACH 1 physician order, dated 12/25/2025, the order indicated Resident 2 was placed on general precautions for sexually inappropriate behavior. The order indicated it was discontinued on 12/29/2025 due to Resident 2's discharge from GACH 1. During a review of Resident 2's GACH 1 nursing narrative note, dated 12/29/2025, the note indicated on 12/29/2025 at 4:40 p.m., Licensed Vocational Nurse (LVN) 1 provided report (a critical, organized exchange of patient information between nurses to ensure continuity of care, safety, and efficient management) to the facility. The note indicated Resident 2 was discharged from GACH 1 on 12/29/2025 at 5:23 p.m. During a review of an untitled and undated facility document, completed by Registered Nurse (RN) 1, the document indicated a summary of the nursing report provided to RN 1 by LVN 1. The document indicated Resident 2 had sexually inappropriate behavior. During a review of Resident 2's admission summary, dated [DATE], written by RN 1, the admission Summary did not indicate Resident 2's sexually inappropriate behavior or interventions to address the resident's sexually inappropriate behavior. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included metabolic encephalopathy (a broad term for brain dysfunction caused by systemic illness, chemical imbalances in the blood, or toxins, rather than structural brain damage) and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 1/2/2026, the MDS indicated Resident 2 was usually understood and usually understood others. The MDS indicated Resident 2 had moderate cognitive impairment (noticeable memory or thinking changes that exceed normal aging but do not severely impact daily life). The MDS indicated Resident 2 required partial to moderate assistance from staff (staff do less than half of the effort to complete the task) for toileting hygiene, getting dressed, and mobility while in and out of bed. The MDS indicated Resident 2 did not have impairments to any extremities. During a review of Resident 2' progress note, dated 1/17/2026, the progress note indicated Resident 2 was observed engaging in sexual intercourse with another resident (Resident 1). The progress note indicated Resident 2 stated he had sexual intercourse with Resident 1 because she didn't tell [him] not to. The progress note indicated Resident 2 stated Resident 1 did not give consent for sexual intercourse.During a review of Resident 2's progress notes, dated 1/18/2026, the progress note indicated Resident 2 was transferred to GACH 3 for further evaluation. During a review of Resident 2's GACH 3 Emergency Physician Note, dated 1/18/2026, the note indicated Resident 2 was brought to GACH 3 following one episode of non-consensual sexual abuse. The note indicated Resident 2 stated he had sexual intercourse with another resident because she did not object. Resident 2's diagnoses included sexual behavior, danger to others, and assault.During a review of Resident 2's GACH 3 Physician Note, dated 1/21/2026, the note indicated Resident 2 was admitted to the behavioral health unit for a psychiatric admission and psychiatric hold (an involuntary 72-hour detention for mental health evaluation when a person is deemed a danger to themselves or others, or gravely disabled due to mental illness) for danger to others and grave disability (someone unable to meet their basic needs due to a mental health issue). During an interview on 1/12/2026 at 8:34 a.m., with Resident 4 (Resident 1's roommate), Resident 4 stated on 1/17/2026, she was asleep when the incident occurred between Resident 1 and Resident 2. Resident 4 stated she saw Resident 2 come into their room multiple times prior to the incident. Resident 4 stated Resident 2 would make flirtatious faces at Resident 1 and attempt to talk to her. Resident 4 stated she would yell at Resident 2 and ask him to leave their room.During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 4's diagnoses included chronic obstructive pulmonary disorder (COPD, a chronic lung disease causing difficulty in breathing) and type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had some difficulty with daily decision making in new situations, but did not exhibit inattention, disorganized thinking, or altered level of consciousness (ALOC, a state of reduced alertness, confusion, or lack of awareness).During an interview on 1/21/2026 at 11:05 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 1/17/2026, Resident 1's roommate (Resident 3) ran into the hallway requesting staff assistance. CNA 1 stated Resident 3 gestured staff to enter the room quietly. CNA 1 stated she entered the room without announcing herself and observed Resident 1's privacy curtain drawn. The foot of Resident 1's bed was visible. CNA 1 stated she observed shoes and jeans at the foot of the bed, and overheard moaning from behind the curtain. CNA 1 stated she pulled the curtain open and observed Resident 2 on top of Resident 1. CNA 1 stated the residents were facing each other and actively engaged in sexual intercourse. CNA 1 stated Resident 2 jumped from Resident 1's bed and ran out of the room. CNA 1 stated Resident 1 had her incontinence brief and pants pulled down to her knees. CNA 1 stated as soon as Resident 2 left the room, Resident 1 curled into a fetal position (lying on the side with the back curved, head bowed forward, and arms and legs drawn in toward the chest) and refused to talk. CNA 1 stated Resident 1 was placed on 1:1 monitoring (a high-level safety intervention in healthcare where a dedicated staff member provides continuous, direct, in-person supervision to a single patient) after the incident occurred. During an interview on 1/21/2026 at 11:50 a.m., with CNA 2, CNA 2 stated on 1/17/2026, she was assigned to Resident 1's care. CNA 2 stated she entered the room and observed Resident 1 lying in her bed with her incontinence brief and pants pulled down. CNA 2 stated she was familiar with Resident 1 and described her as childlike and soft-spoken. CNA 2 stated she was the CNA assigned to perform 1:1 monitoring after the incident occurred, and stated Resident 1 did not talk until she was transferred to GACH 2 later that day. CNA 2 stated she was assigned to Resident 1 the following day, 1/18/2026, and described Resident 1 as less expressive and more withdrawn than usual. CNA 2 stated Resident 1 also complained of pain to her lower abdominal region requiring pain medication. CNA 2 stated Resident 1 was not able to verbalize the cause of the pain but pointed to her lower abdomen with facial grimacing. CNA 2 stated she was also familiar with Resident 2, and stated Resident 2 had a habit of wandering around the facility. During a telephone interview on 1/21/2026 at 2:06 p.m., with LVN 2, LVN 2 stated on 1/17/2026, he was the charge nurse assigned to Resident 1's care. LVN 1 stated he performed a physical assessment of Resident 1 after the incident occurred. LVN 1 stated he observed redness to Resident 1's genital region (the externally visible reproductive and urinary organs). During a concurrent interview and record review, on 1/26/2026 at 11:03 a.m., with the Registered Dietician (RD), Resident 2's care plan titled Resident has a nutritional problem related to. sexually inappropriate behavior., dated 12/30/2025, was reviewed. The RD stated she reviewed Resident 2's admission paperwork which indicated Resident 2 had sexually inappropriate behavior. The RD stated she included the behavior problem in her care plan but did not notify any other staff. The RD stated the care plan interventions only addressed the resident's nutritional risks and did not address his behavior. The RD stated that developing interventions for the sexually inappropriate behavior were not within her scope as the dietician. The RD stated she assumed nursing staff were already aware of Resident 2's behavior since it was documented by nursing staff. Two attempts were made to reach Resident 2's admitting nurse, Registered Nurse (RN) 1, by telephone on 1/26/2026 at 11:26 a.m. and 1:28 p.m. RN 1 was not reachable by telephone for an interview. During an interview on 1/26/2026 at 1:50 p.m., with the Director of Nursing (DON), the DON stated RN 1 was aware of Resident 2's sexually inappropriate behavior upon his admission to the facility. The DON stated a care plan should have been developed to ensure all staff were aware of Resident 2's behavior and interventions were in place to address it. The DON stated this would include behavior monitoring to identify patterns in frequency, and identification of potential for escalation in the behavior. The DON stated the RD was also a department head and should have notified the multidisciplinary team of the behavior to ensure that the team was aware and a plan of care was developed. During an interview on 1/26/2026 at 1:55 p.m., with the Assistant Director of Nursing (ADON), the ADON stated there was no documentation in Resident 2's medical record indicating staff, aside from RN 1 and the RD, were aware of his inappropriate sexual behavior. The ADON stated there was also no documentation in Resident 2's medical record indicating any interventions were implemented to address the behavior, including the development of a care plan or behavior monitoring. The ADON stated the incident that occurred on 1/17/2026 was preventable. The ADON stated staff should have monitored Resident 2 for sexually inappropriate behavior and monitored his whereabouts more frequently. The ADON stated staff should have also notified Resident 2's psychologist (a person who specializes in the study of mind and behavior) to determine if modifications were needed to his plan of care. The ADON stated these interventions were important for the safety of Resident 1, and all other facility residents.During a review of the facility's policy and procedure (P&P) titled Protection of Resident, dated 12/2017, the P&P indicated the facility was to provide a safe resident environment from abuse. The P&P indicated risk for abuse may increase when a resident exhibited wandering into others' rooms and sexually aggressive behavior, and indicated staff should monitor for those behaviors. During a review of the facility's P&P titled Resident Safety, dated 4/2021, the P&P indicated residents were to be evaluated upon admission to identify circumstances that pose a safety risk. The P&P indicated Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) members were to assess the resident's safety risk (including behavioral issues) and develop a resident-centered care plan to mitigate safety risk factors.During a review of the facility's P&P titled Abuse and Neglect Prohibition Policy, dated 6/2022, the P&P indicated it was the facility's policy to prohibit abuse for all residents through prevention of occurrences. The P&P indicated staff were to do all that was in their control to prevent occurrences of abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property for all residents. The P&P defined sexual abuse as non-consensual sexual contact of any type, including sexual assault. The P&P indicated that to prevent occurrences of abuse, staff were to assess, care plan, and monitor residents with needs and behaviors that could lead to conflict. The P&P indicated indicators of potential sexual abuse included bruises around the breast, genital area, or inner thighs. During a review of the facility's P&P titled Comprehensive Plan of Care, dated 12/2026, the P&P indicated it was the facility's policy to provide each resident with a comprehensive plan of care to meet their needs, including psychosocial needs. The P&P indicated the interdisciplinary team (IDT), including the RD, was to discuss and prioritize the resident's needs and develop goals and approaches for each problem and/or condition identified. During a review of the facility's job description titled Registered Nurse - Supervisor, dated 5/2017, the job description indicated the RN was to work collaboratively with the IDT to develop an individualized plan of care for each resident, and coordinate care to meet their individualized needs. The job description indicated the RN was to demonstrate sound clinical judgement in the implementation of the nursing aspects of interdisciplinary resident plan of care. During a review of the facility's job description titled Registered Dietician, dated 5/2017, the job description indicated the RD was expected to maintain two-way communication with the ADM and nursing services. The job description indicated the RD was expected to concern his/herself with the safety of all residents to minimize the potential for accidents. The job description indicated the RD was to ensure residents received the highest quality of service, in a caring and compassionate atmosphere, recognizing the individuals' needs and rights.

Based on interview and record review the facility failed to ensure a resident was free from physical abuse when was pushed to the floor by another resident and sustained an injury for one of four sampled residents (Resident 1). These deficient practices resulted in Resident 2 on 11/30/2025 pushing Resident 1 to the floor and sustaining a 1.0-inch posterior (back of the head) scalp (skin covering the head) laceration (skin tear) which required evaluation and treatment in a general acute care hospital (GACH). Resident 1 received two staples (a piece of thin wire with a long center portion and two short end pieces) for the scalp laceration. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), type 2 diabetes mellitus (DM-a condition where the body can't properly use or produce insulin [hormone to regulate blood sugar level] leading to high blood sugar levels), and paranoid schizophrenia. During a review of Resident 1's history and physical (H&P), dated 10/25/2025, the H&P indicated Resident 1 was admitted to the GACH for psychiatric evaluation due to increased agitation and aggressive behaviors. The H&P indicated Resident 1 did not have the capacity to make reasonable decisions and required redirection. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/1/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills for daily decision making and able to make needs known. The MDS indicated Resident 1 required partial assistance from staff to lift, hold, support the trunk and limbs, for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's change of condition (COC) form, dated 11/30/2025 at 11:53 p.m., the COC form indicated the charge nurse observed Resident 2 approaching Resident 1 and pushing Resident 1 to the floor. The COC form indicated Resident 1 hit the back of her head on the floor and was bleeding from the head. The COC form indicated the charge nurse placed a towel against Resident1's head to stop the bleeding and immediately called 911. During a review of Resident 1's Skilled Nursing Facility (SNF) to Hospital Transfer form, dated 12/1/2025 at 12:12 a.m., the form indicated Resident 1 was transported to the GACH after another resident pushed her resulting in Resident 1 bleeding from a head due to injury. During a review of Resident 1's GACH emergency room (ER) records, dated 12/1/2025, the ER's records indicated Resident 1 arrived at the ER after Resident 1 was pushed by another resident, Resident 1 fell and hit the back of her head on the ground which caused minor head trauma and a 1.0 inch laceration to the posterior scalp. The ER records indicated two staples were used to staple the laceration. The ER records indicated Resident 1 was discharged back to the facility on the same day (12/1/2025). During a review of Resident 1's head computerized tomography scan (CT - a type of imaging that uses X-ray techniques to create detailed images of the body) dated 12/1/2025, the CT scan indicated there was no acute intracranial abnormality with right parietal (located at the top and back of the head) skin staples. During an interview on 12/5/2025 at 12:30 p.m. with Resident 1, Resident 1 stated she was talking with Resident 4 in the hallway outside Resident 4's room (date and time unknown) when Resident 2 suddenly pushed her for no reason. Resident 1 stated, When I fell, I hit the back of my head on the floor, I had to go to the hospital, and they put two staples in the back of my head. During an interview on 12/5/2025 at 12:50 p.m. with Resident 4, Resident 4 stated a few days ago she witnessed when Resident 2 pushed Resident 1 to the ground. Resident 4 stated Resident 1's head was bleeding. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included bipolar disorder (a mental health condition causing extreme mood swings), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 2's H&P, dated 6/8/2025, the H&P indicated, Resident 2 was admitted to the GACH for psychiatric evaluation due to increase agitation, aggressive behaviors, does not have the capacity to make medical decisions, and requires redirection. During a review of Resident 2's MDS, dated [DATE], indicated Resident 2's cognition (ability to understand) was moderately impaired. The MDS indicated Resident 2 required moderate assistance from staff for all ADLs. During a review of Resident 2's COC, dated 12/1/2025, the COC indicated on 11/30/2025 Resident 2 was physically aggressive towards her peers. The COC indicated on 11/30/2025 at 11:53 p.m., Licensed Vocational Nurse (LVN 1) observed Resident 2 pushing Resident 1. Resident 1 fell and hit the back of her head. During an interview on 12/8/2025 at 3:45 p.m. with the Director of Nursing (DON), the DON stated on 11/30/2025, Resident 2 pushed Resident 1 to the ground which caused Resident 1 to sustain a laceration to the back of her head. The DON stated Resident 1 sustained an injury and was transferred to a GACH, where he received 2 staples to her head. During a review of the facility's P&P titled, Abuse and Neglect Prohibition Policy dated 6/2022, indicated it was the facility's policy to prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all residents and if the suspected abuse was a resident-to-resident incident, the resident who threatened or attacked another resident would be removed from the setting or situation.

Based on interview, and record review, the facility failed to ensure one of five (5) sampled residents (Resident 1), who was confused with diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), suicidal ideations (thoughts, wishes, or preoccupations with death or self-harm), bipolar disorder (a mental condition marked by alternating periods of elation and depression), major depressive disorder (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities) and diabetes mellitus (DM, abnormal blood sugar level), did not elope from the facility on 9/25/2025. The facility failed to: 1. Ensure Resident 1's elopement risk assessment included the resident's cognition (ability to think and process information) and poor judgement (inability to make decision that prioritize safety) as indicated in the facility's Nursing Procedures titled, Wandering (aimlessly walking around) & Elopement (likelihood of resident leaving the facility supervised) Risk Assessment. 2. Follow its Policy and Procedure (P&P) titled, Elopement Behavior Management, which indicated the facility will ensure each resident at risk for elopement was identified, assessed and provided appropriate interventions and supervision. 3. Ensure Resident 1 was reassessed for wandering and elopement risk on 9/24/2025 after Resident 1 had a Change of Condition ([COC] a clinical deviation from a resident's baseline). 4. Ensure Resident 1's physician's recommendation to the Director of Nursing (DON) to initiate a 5150 hold (a hold that allows a qualified person to involuntarily detain a patient for up to 72 hours for psychiatric evaluation if they are a danger to themselves, a danger to others, or gravely disabled [unable to provide for their basic needs] due to a mental disorder), to allow for immediate psychiatric evaluation (a comprehensive assessment conducted by a mental health professional to understand a patient's mental health condition) and stabilization (a short-term care provided for patients struggling with a mental health crisis) was followed. As a result, on 9/25/2025 at 2:40 a.m., Resident 1 eloped from the facility and as of 10/20/2025 (25 days later), Resident 1 had not been found. There was a likelihood for Resident 1 to be exposed to medical complications such as malnutrition (lack of proper nutrition), dehydration (when the body doesn't have enough fluid to function properly), hypoglycemia (low blood sugar), exposure to harsh (severe) environmental conditions such as cold weather, fire, possible motor vehicle accident, self-harm and/or possible death. On 10/9/2025 at 4:26 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of Administrator (ADM), Assistant Administrator (AADM), DON, and Clinical Resource Registered Nurses (RN), due to the facility's failure to ensure Resident 1 did not leave the facility on 9/25/2025. On 10/11/2025 at 3:27 p.m., the facility submitted an acceptable IJ removal plan ([IJRP] interventions to immediately correct the deficient practices). After verification of IJRP implementation through interview, and record review, the IJ was removed on 10/11/2025 at 4:42 p.m., in the presence of the ADM.The IJRP included the following immediate actions: On 9/25/2025, at 2:40 a.m., Elopement Code was activated (Code Green) to alert staff to immediately search for Resident 1 inside and outside the facility and its vicinity was completed. Acute hospitals were contacted to check for Resident 1's presence. The elopement involving Resident 1 was reported to Los Angeles Police Department (LAPD), California Department of Public Health (CDPH), and the local Long-Term Care (LTC) Ombudsman on 9/25/2025. On 9/25/2025, the DON and/or DSD, initiated an in-service for facility nursing staff and Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) every shift on F689 Free of Accident Hazards/ Supervision and Monitoring focused on Elopement and was completed on. On 9/25/2025, the IDT which included Social Worker (SW,) DON and Activities Director (AD) conducted record review and reassessed 65 out of 65 residents for wandering and elopement. A total of 4 residents were identified as high risk for elopement. The IDT updated the plan of care for all 4 residents. On 9/27/2025 and 9/28/2025, the facility's DON and Director of Staff Development (DSD) provided Licensed Vocational Nurse (LVN), door monitor Certified Nursing Assistant (CNA) and CNA assigned to Resident 1 on 9/25/2025, 11:00 p.m., to 7:00 a.m., one on one education on F689 Free of Accident Hazards/ Supervision and Monitoring focused on Elopement. On 9/27/2025, the DON and/or DSD provided staff in-service on regular rounding for patient safety and daily safety huddles. On 9/27/2025 the facility's DSD observed CNAs during their shift when caring for 4 of 4 residents who were at high risk for wandering and with inappropriate behavior. Residents observed receiving adequate supervision accordingly. IDT initiated review of records and reassessment of 4 of 4 residents who were at high risk for elopement and wandering and plan of care updated. This was to ensure residents are provided adequate supervision to prevent residents' elopement incidents. Effective 9/28/2025, the Maintenance Director installed door chimes to notify staff of entry or exit in addition to the door monitor CNA, which was stationed at the entrance/exit 24 hours per day, 7 days per week. On 9/28/2025, the Director of Medical Records/Designee conducted an audit of residents' behavior, elopement and wandering episode to identify residents who had changes in condition, need monitoring and transfer to General Acute Care Hospital (GACH) for behavior management, through record review of assessments and physician's order. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included schizophrenia, suicidal ideations, bipolar disorder, major depressive disorder and DM. During a review of Resident 1's History and Physical (H&P) dated 9/11/2025, the H&P indicated Resident 1 did not have the capacity (ability) to consent (unspecified) due to diagnosis of schizophrenia. During a review of Resident 1's Multidisciplinary Care Conference (also known as IDT) notes dated 9/11/2025 timed 4:00 p.m., the IDT notes indicated Resident 1 presented with multiple chronic (persistent or long lasting) medical and psychiatric conditions including schizoaffective disorder, bipolar type, hypertension (high blood pressure), DM with complications, obesity and neuropathy (nerve disorder). The IDT notes indicated Resident 1 required ongoing support for mood stabilization, pain management, blood pressure and glucose (blood sugar) control. The IDT notes indicated Resident 1 had a history of depressive disorder and suicidal ideations that required monitoring. The IDT notes indicated Resident 1 was recently readmitted to the facility (unspecified date) and had spent a lot of time walking around the facility and out of the patio. The IDT notes indicated Resident 1 had a very short-term attention span (concentration), talked to himself often and was hard to be redirected. During a review of Resident 1's Wandering & Elopement Risk assessment dated [DATE] timed 10:00 a.m., the wandering & elopement risk assessment indicated Resident 1 was not an elopement risk. The wandering and elopement risk assessment did not indicate Resident 1's cognitive level or history of elopement. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/15/2025, the MDS indicated Resident 1 had moderate cognitive impairment (loss). The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues) with activities of daily living (ADLs) such as eating, oral hygiene, toilet use, personal hygiene, showering, upper/lower body dressing and putting off footwear, transfer and mobility. During a review of Resident 1's Order Summary Report dated 9/24/2025 (no time indicated), the order summary report indicated to transfer Resident 1 to a GACH on 9/24/2025 due to agitation and unsafe behavior. During a review of Resident 1's progress notes (behavior note) dated 9/24/2025 at 4:38 p.m., the progress notes indicated Resident 1 was observed with a notable increase in agitation (a state of anxiety or nervous excitement) and unsafe behavior. The progress notes indicated Resident 1 was witnessed by a staff earlier (time unspecified) obtained a cup, walked to the wall-mounted hand sanitizer (a liquid, gel or foam used to kill viruses, bacteria, and other microorganisms on the hands) dispenser (equipment to release hand sanitizer), and intentionally dispensed (released) the sanitizer into the cup. The progress notes indicated Resident 1 attempted to drink the contents (in the cup). The progress notes indicated due to Resident 1's highly concerning behavior, as it demonstrated poor judgment, impulsiveness (doing things suddenly without considering the effects), and risk of self-harm, coupled with the residents' escalating (increasing) agitation throughout the day, the resident was unable to ensure his own safety. The progress notes indicated Resident 1 posed (presented) an imminent (close) danger to himself by attempting to ingest toxic (harmful) substances and required a higher level of psychiatric intervention (action). The progress notes indicated because of Resident 1's impaired judgment, unsafe actions, and ongoing agitation, Resident 1's physician strongly recommended that a 5150 hold be initiated due to danger to himself (Resident) 1, to protect the resident's health and safety, and to allow for immediate psychiatric evaluation and stabilization. At 5:15 p.m., Resident 1's progress notes indicated the DON faxed Resident 1's paper work to the GACH 2 intake (admitting personnel) and indicated the DON will follow up. At 11:30 p.m., the progress notes indicated Resident 1 was monitored for attempting to drink sanitizer and was sitting on a chair close to the nursing station. During a review of Resident 1's Care Plan titled Resident exhibits acute agitation and impaired judgment, as evidenced by attempt to ingest hand sanitizer, dated 9/24/2025, the care plan interventions indicated to document resident's mental status, behavior, interventions, and response on the Close Monitoring Form (form used by the facility to document hourly assessments of the resident), immediately notify the physician (MD) for unsafe behaviors and escalating agitation, if resident attempted self-harm or condition worsens, maintain observation and provide redirection as needed, monitor resident and document every one (1) hour using the Close Monitoring Form. During a review of Resident 1's Close Monitoring Form dated 9/24/2025, the monitoring form indicated on 9/25/2025 at 1:40 a.m., Resident 1 was observed talking to himself while walking down hallways. During a review of Resident 1's progress notes dated 9/25/2025 at 4:40 a.m., the progress notes indicated on 9/25/2025, at 2:40 a.m., while Licensed Vocational Nurse (LVN) 2 was making rounds, Resident 1 was not in his room or bed. The progress notes indicated Resident 1 was last seen at 1:40 a.m. in the hallway asking for towels. The progress notes indicated staff searched for Resident 1 in the unit and the surrounding areas, but Resident 1 was missing. During a review of Resident 1's IDT notes, focus: elopement incident, dated 9/25/2025 (untimed- after Resident 1 had eloped), the IDT notes indicated Resident 1 was identified as high risk for elopement due to the resident's history of unsafe behaviors and psychiatric diagnosis (schizoaffective disorder, bipolar disorder, depression and suicidal ideation). The IDT notes indicated Resident 1's psychiatric history and impulsiveness contributed to the high elopement risk. During an interview on 10/8/2025 at 4:40 p.m. with Resident 1's Nurse Practitioner (NP), the NP stated Resident 1 was placed on 5150 hold because Resident 1 was a danger to himself and needed to be closely monitored. The NP stated, during 5150 hold, nurses were expected to monitor the residents every 15 minutes and when residents had suicidal ideation, residents were placed on one-to-one (1:1) supervision (when a staff member is assigned to directly supervise no more than one resident and the staff stay within very close proximity to ensure constant supervision and immediate intervention for safety reasons, if needed). The NP stated on 9/24/2025 at 5:38 p.m., he (NP) was notified of Resident 1's attempt to ingest hand sanitizer. The NP stated he recommended to the DON a 5150 Psychiatric Emergency Team (PET- are specialized units designed to provide immediate care and support for individuals experiencing severe mental health crises) to conduct a psychiatric evaluation and transfer Resident 1 to the GACH. During a concurrent interview and record review on 10/9/2025 at 1:48 p.m., with LVN 3, the facility's Elopement Behavior Management P&P dated 12/2016, indicating elopement definition as a situation in which a resident with impaired cognition or poor safety awareness or judgment successfully left the facility or a secure area undetected or unsupervised by staff, the Wandering & Elopement Risk assessment dated [DATE] and Resident 1's COC dated 9/24/2025 indicating Resident 1 had an unsafe behavior and demonstrated poor judgement, were reviewed. LVN 3 stated the P&P indicated elopement was a situation where a resident with impaired cognition or poor safety judgement left the facility unsupervised. LVN 3 stated Resident 1's wandering & elopement risk assessment dated [DATE] was done incorrectly. LVN 3 stated the nurses should have conducted Resident 1's elopement risk re-assessment after the COC on 9/24/2025 and placed Resident 1 on a 1:1 supervision because the resident was at risk for elopement. LVN 3 stated the PET should have been called immediately to assess Resident 1. LVN 3 stated if the PET was called immediately and had transferred Resident 1 to a GACH, it could have prevented Resident 1 from eloping from the facility. LVN 3 stated on 9/24/2025, the nurses should have called 911 and sent Resident 1 to a GACH. LVN 3 stated the facility failed to place Resident 1 on a 1:1 supervision to prevent the elopement while waiting for Resident 1 to be transferred to the. GACH During a concurrent interview and record review on 10/9/2025 at 2:00 p.m., with the AADM, the Elopement Behavior Management policy dated 12/2016 was reviewed, which indicated it was the facility's policy to ensure that each resident who was an elopement risk be identified, assessed and provided appropriate intervention, adequate supervision and assistive devices. The AADM stated the definition of elopement in the policy, reflected Resident 1 because the resident was cognitively impaired. The AADM stated Resident 1 was only oriented to self, was confused, and verbalized words that did not make sense. The AADM stated Resident 1 demonstrated poor judgment when he tried to ingest hand sanitizer on 9/24/2025. The AADM stated Resident 1's cognitive level was not assessed during the elopement risk assessment on 9/12/2025. The AADM stated after Resident 1 eloped on 9/25/2025, Resident 1's family member (FM 1) stated Resident 1 had a history of elopement (unspecified). The AADM stated if the facility had obtained Resident 1's prior elopement history from the family or conservator, Resident 1's wandering and elopement risk assessment would have been done accurately. The AADM stated the facility did not re-assess Resident 1's elopement risk assessment after the COC on 9/24/2025. The AADM stated if Resident 1 was reassessed for elopement, proper interventions could have been provided, and the resident would still be at the facility. The AADM stated Resident 1's elopement risk assessment on 9/12/2025 did not address Resident 1's cognitive level. The AADM stated Resident 1 did not have enough monitoring and supervision while waiting for the 5150 transfer orders on 9/24/2025. During a review of the facility's P&P titled, Elopement Behavior Management, dated 12/2016, the P&P indicated it is the facility's policy to ensure that each resident who was an elopement risk be identified, assessed and provided appropriate intervention, adequate supervision and assistive devices. The P&P defined elopement as a situation in which a resident with impaired cognition or poor safety awareness or judgment successfully left the facility or a secure area undetected or unsupervised by staff. The P&P defined hazardous wandering as any behavior initiated by a cognitive impaired individual that is characterized by ambulation that may lead to safety problems or elopement. The P&P indicated the DON and/ or its designee should be responsible for the implementation and enforcement of policy and to monitor compliance through staff participation in quarterly elopement drills. The P&P indicated the assessment should be completed every quarter and with significant change of condition.

Based on observation, interview, and record review, the facility failed to provide care and services to prevent a fall for one of three sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 provided a two-person physical assist (help from two persons) when using a Hoyer Lift (mechanical lift- a device used to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from the bed to a Geri-chair (padded chair to provide comfort and support for people with limited mobility). This deficient practice caused Resident 1 to fall and sustain an acute (immediate) fracture (broken bone) of the right femoral neck (part of the thigh bone below the hip joint). Resident 1 was transferred to a general acute care hospital (GACH) for evaluation and treatment five days after the fall. Findings: During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included paraplegia (paralysis in the lower half of the body), muscle wasting and atrophy (loss of muscle and strength), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated Resident 1 had cognitive impairment and to monitor for safety and function. During a review of Resident 1's Minimum Data Set ([MDS] -a resident assessment tool), dated [DATE], the MDS indicated Resident 1 had the ability to express ideas and wants, and the ability to understand others. The MDS indicated Resident 1 was totally dependent (full staff performance) on staff with a two-person physical assist for transfer (how the resident moves between surfaces) and activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's care plan titled, The resident has an alteration in musculoskeletal status related to paraplegia ., dated [DATE], the care plan indicated interventions to assist Resident 1 with the use of supportive devices (primarily used to assist residents with moving from one place to another and with personal care). During a review of Resident 1's Physical Therapy (PT) Report, Progress Report & Updated Therapy Plan, dated [DATE] - [DATE], the report indicated Resident 1 should be transferred between surfaces using a Hoyer Lift. During a review of Resident 1's Change in Condition Evaluation (COC) report, dated [DATE] at 11:45 a.m., the COC indicated on [DATE], Resident 1 reported to staff that he fell to the floor and hit his knees while being assisted by CNA 1 (Certified Nursing Assistant) during a transfer from bed to chair. During a review of Resident 1's progress note dated [DATE] at 12:14 p.m., the progress note indicated on [DATE], Resident 1 reported that while transferring from bed to chair with CNA 1, he fell to his knees. The progress note indicated Resident 1 had complaints of knee pain and a small skin tear (a traumatic wound that occurs when the layers of the skin separate due to friction, removal of adhesive, or blunt force) to the right knee. The progress noted indicated all findings were reported to the physician, and given an order of an X-Ray (machine that creates an image of the inside of the body), to both knees. During a review of the facility's document titled Risk Management, dated [DATE] at 12:25 pm, the document indicated Resident 1 complained of knee pain at a level of 8 out of 10 (,d+[DATE] on the pain scale [a numerical tool used to assess the intensity of pain] indicates severe pain). During a review of Resident 1's progress note dated [DATE] at 10:08 a.m., the progress note indicated Resident 1 continued to complain of right knee pain at a level of 8 out of 10. Resident 1's physician was notified and ordered Resident 1 be transferred to a general acute care hospital (GACH) for further evaluation. During a review of Resident 1's GACH emergency room (ER) admission record, dated [DATE] at 11:08 p.m., the GACH ER admission record indicated Resident 1 was evaluated for a fall with complaints of pain in the right lower extremity (leg). During a review of Resident 1's GACH records, Resident 1 was admitted to the GACH on [DATE]. The GACH ER X-ray Reports dated [DATE] at 11:00 p.m., and [DATE] at 8:55 a.m., indicated there was an acute fracture through the right femoral neck (part of the thigh bone below the hip joint). Resident 1 was treated for severe pain with medication while in the GACH. Resident 1 was discharged from the GACH on [DATE] with instructions to repeat hip x-ray in four to six weeks to evaluate healing. During a review of Resident 1's facility progress note, dated [DATE] at 4:35 p.m., the progress note indicated Resident 1 returned to the facility from the GACH. During an observation on [DATE] at 11:45 a.m., in Resident 1's room, Resident 1 was observed asleep. The bed was in a high position, the side table was to the right of Resident 1 with a radio, headphones, and a bottle of water on the table. During an interview on [DATE] at 11:45 a.m., with Resident 1, Resident 1 stated on [DATE], CNA 1 was transferring him from the bed to a Geri-chair (a supportive reclining chair that provides more support and comfort than a wheelchair) using a Hoyer Lift without assistance from a second person. Resident 1 stated the battery died on the lift and CNA 1 lowered the resident back on the bed to go get batteries. Resident 1 stated, on the second attempt, he fell to the floor on his knees. Resident 1 stated CNA 1 helped him back into the bed and left the room. Resident 1 stated CNA 1 had not transferred him before. During an interview on [DATE] at 12:03 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on [DATE] around noon, Resident 1's call light was on. LVN 1 stated she went to the room and Resident 1 stated he fell out the bed earlier and CNA 1 put him back in. LVN 1 stated Resident 1 was always transferred using a Hoyer Lift and a required two persons assist. During an interview on [DATE] at 1:00 p.m., with CNA 2, in Resident 1's room, CNA 2 stated there should always be two staff available to lift or transfer a resident for safety reasons. CNA 2 stated CNA 1 had worked at the facility a few months and had never asked her for help with the Hoyer Lift. During an interview on [DATE] at 1:20 p.m. with the Maintenance Supervisor (MS), the MS stated the Hoyer Lift ran on electricity and changing the battery was only for the built in weighing scale used to get a residents' weight. The MS stated if the lift stopped working, it would need to be plugged in to charge before continuing use. During an interview on [DATE] at 3:02 p.m. with the Assistant Administrator (AA), the AA stated Hoyer Lifts should be operated by two people. During a review of the facility's Policy and Procedure (P&P) titled, Fall Prevention Program, dated [DATE], the P&P indicated the facility will make the environment as free of accident hazards as possible. The P&P indicated the facility's priority was resident safety, supervision, and assistance to prevent accidents. During a review of the facility's P&P titled Lifting Procedures Using a Mechanical Lift, dated [DATE], the P&P indicated the facility will protect the safety and well-being of residents and staff. The P&P indicated the facility will promote quality care, use appropriate techniques and devices to lift and transfer residents. During a review of an undated Manufacturer's User Manual titled Protekt 600 Lift Power Patient Lift Model: 33600 the user manual indicated a recommendation to use two persons assist for lifting and transferring procedures. During a review of the facility's Certified Nursing Assistant (CNA) Job Description, undated, the CNA Job Description indicated responsibilities and accountabilities include implementing care according to the care plan. The CNA Job Description indicated helping residents with their ADLs, and proper lifting and transitioning from bed to wheelchair, wheelchair to bed, etc.

Based on observation, interview and record review, the facility failed to ensure two of three sampled residents (Resident 63 and Resident 17) were free from sexual abuse. Resident 8, a resident who exhibited hyper sexually active (increased in sex drive) behavior was observed to have escalating behaviors of inappropriate touching. Resident 8 touched Residents 63 and 17 inappropriately. This failure resulted in Resident 17 becoming upset, screamed, and was frightened when Resident 8 pushed Resident 17, in her wheelchair, into his room and slammed the door shut on 7/18/2023. Resident 17 stated Resident 8 touched her inappropriately. On 6/17/2023, Certified Nurse Assistant (CNA) 3 walked into Resident 63's room and witnessed Resident 8 putting his hand on Resident 63's adult protective brief. Resident 63 was not able to verbalize her emotions due to cognitive (the ability to think and process information) impairment and was not able to express how she felt about the incident. Applying the reasonable person (average person, that is common and have good sense and judgement) concept, fear, emotional and psychological distress would occur after Resident 63 was inappropriately touched. Findings: a. During a review of Resident 8's Admission Record (Face Sheet), the Face Sheet indicated Resident 8 was admitted on [DATE] and readmitted on [DATE] with a diagnoses that included schizophrenia (mental illness that can affect your thoughts, mood and behavior), bipolar disorder (a mood disorder that can cause intense mood swings) and major depressive disorder (a persistent feeling of sadness and loss of interest and can interfere with daily life). During a review of Resident 8's Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 5/10/2023, the MDS indicated Resident 8's cognitive skills was moderately impaired. The MDS indicated Resident 8 was independent with activities of daily living such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair), and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 8's Physician Order dated 6/17/2023, the Physician Order indicated to transfer Resident 8 to the General Acute Care hospital (GACH) for evaluation due to hyper sexually active. During a review of Resident 8's Social Service Progress Notes (SS note), dated 6/19/2023 at 8:11 a.m., the SS Note indicated Resident 8 was transferred to the GACH due to inappropriate sexual conduct, trying to get into a female (Resident 63) bed on 6/17/2023. The SS Note indicated staff returned him to his room immediately and processed his transfer to the GACH for further evaluation. During a review of Resident 8's History and Physical (H&P) dated 6/26/2023, the H&P indicated Resident 8 can make decisions for activities of daily living. During a review of Resident 8's SS Notes, dated 7/12/2023, the SS notes indicated Resident 8 was readmitted back to facility on 6/26/2023. During a review of Resident 8's SS Note, dated 7/12/2023 at 12:34 p.m., the SS note indicated Resident 8's family member was called regarding the need of medication for Resident 8's aggressive behavior, including touching others, screaming, and yelling bad words. During a concurrent interview and record review on 7/21/2023 at 11:56 a.m., with Registered Nurse (RN) 1, Resident 8's Clinical Record (including Change of Condition ([COC] a clinical deviation from a resident's baseline) note, care plan, and Interdisciplinary Team ([IDT] group of different disciplines working together towards a common goal of a resident) meeting notes, and nurses notes) were reviewed. RN 1 stated there was no COC, no IDT meeting conducted, and no plan of care initiated for Resident 8 after resident was found in another female resident's room and attempted to get on top of Resident 63 in her bed on 6/17/2023. RN 1 stated Resident 8 was not being monitored for inappropriate sexual behavior. During a review of Resident 63's Face Sheet, dated 7/2/2023, the Face Sheet indicated Resident 63 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood) vascular dementia (problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to your brain), and schizophrenia. During a review of Resident 63's MDS, dated [DATE], the MDS indicated Resident 63's cognitive skills were moderately impaired and could understand and be usually understood by others. The MDS indicated Resident 63 required supervision with activities of daily living such as dressing, toilet use, personal hygiene, transfer, and bed mobility. During a review of Resident 63's care plan, titled Change of Condition, dated 7/20/2023 (completed 33 days after the incident), the care plan indicated Resident 63 had a COC. A certified nurse assistant reported a male resident was in bed with Resident 63 a few weeks ago (6/17/2023). Care plan goal indicated Resident 63 will be free of any physical distress. Nursing interventions included monitor and document any changes every shift for 72 hours and notify the medical doctor as needed, notify Police Department, notify Department of Health Services (DHS), and provide treatment as needed. During an interview on 7/20/2023 at 4:35 p.m., with CNA 3, CNA 3 stated Resident 8 tried to sexually assault the residents (Resident 63 and Resident 17). CNA 3 stated she saw Resident 8 putting his hands in Resident 63's adult protective brief few weeks ago (around 6/17/2023) and she reported the sexual abuse to the Administrator (ADM) around on 6/17/2023. During an interview on 7/20/2023 at 4:50 p.m., with the ADM. The ADM stated CNA 3 stated she saw Resident 8 inside Resident 63's room and Resident 8 was trying to get on top of Resident 63, but she was able to take Resident 8 out of the room. The ADM stated CNA 3 informed him on unspecified date that there was no inappropriate touching that happened. The ADM was asked for documentation of the incident such as an incident report, change of condition, witness interviews and care plans but the ADM stated there was no COC and no records of abused investigation as the facility thought it was not an allegation of sexual abuse. b. During a review of Resident 17's Face Sheet, dated 7/5/2023, the Face Sheet indicated Resident 17 was originally admitted on [DATE] and was readmitted to the facility on [DATE] with diagnoses of muscle wasting, schizophrenia, and severe protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and major depressive disorder. During a review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 17 has clear speech, the ability to express ideas and wants, and clear comprehension. The MDS indicated Resident 17 required supervision for dressing, eating and personal hygiene. During a concurrent observation and interview on 7/18/2023, at 2:10 p.m., in the hallway, Resident 17 was observed with a facial expression of being frightened, was pushed forcedly in her wheelchair by Resident 8. Resident 17 used her feet to stop Resident 8 from pushing her and screamed in a low voice and said leave me alone R .8, stop R .8. Resident 8 pushed Resident 17 into his room and slammed the door shut. RN 1 arrived and removed Resident 17 from Resident 8's room. Resident 17 stated Resident 8 wanted to put his hand in her adult protective brief, and he put his hands in her adult protective brief on two other separate incidents. Resident 17 stated she did not inform the facility staff regarding the two other incidents of Resident 17 placing his hands in her adult protective brief. During a review of Resident 17's SBAR (an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication) Communication Form dated 7/18/2023, the SBAR form indicated Resident 17 was allegedly inappropriately touched by a male resident. The physician was notified and ordered Resident 17 to transfer to the hospital for evaluation. During a review of Resident 17's Care Plan (CP), dated 7/18/2023. The CP indicated Resident 17 claimed a male resident wheeled her to his room and touched the outside of her briefs. The care plan goal indicated Resident 17 will be able to verbalize feeling safe in the facility daily for seven (7) days. The CP nursing interventions included to separate Resident 17 from Resident 8, provide Resident 17 one-to-one (1:1- when an individual staff member is assigned to directly to a resident) with the Social Service Director (SSD), and monitor for episodes of crying, trembling and verbalization of fear. During a review of Resident 8's SBAR communication form, dated 7/18/2023. The SBAR indicated Resident 8 was having inappropriate sexual behaviors. Resident 8 was observed pushing Resident 17 in her wheelchair to his room and staff intervened before Resident 8 could physically touch Resident 17 inappropriately. During a review of Resident 8's care plan, no title, dated 7/18/2023, the care plan indicated a female resident (Resident 17) claimed that Resident 8 wheeled her to his room and touched the lower front part of her body. During a review of Resident 8 Physician order dated 7/18/2023, Resident 8 was transferred to GACH for inappropriate sexual behavior toward female resident. (Resident 17). During a review of Resident 8 Transfer Record, dated 7/18/2023, Transfer record indicated Resident 8 was transferred to GACH due to inappropriate sexual behavior. During a review of the facility's policy and procedure (P&P) titled Abuse and Neglect Prohibition Policy, dated June 2022. The P&P indicated it is the facility's policy to prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all residents by reporting of incidents, investigations, and the facility's response to the results of their investigations. Sexual abuse is non-consensual sexual contact of any type with a resident includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. Prevention of abuse occurrences includes the supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling of residents while giving care, and care planning and monitoring of residents with needs and behaviors which may lead to conflict or neglect, such as residents who have behaviors such as entering other residents' rooms. When an abuse is identified, the appropriate steps to protect residents from additional abuse will be implemented immediately, which will include conducting a thorough investigation of the alleged abuse, taking steps to prevent further potential abuse, take appropriate action that is reflected in the revised care plan that address the resident's physical, mental psychosocial needs, and reporting the alleged violation and investigating within required timeframe.

Based on observation, interview, and record review, the facility failed to provide nutritional supplements (a product that is added to the diet and contains one or more dietary ingredient (such as vitamin, and herbs) to prevent weight loss for two of six sampled resident (Resident 4 and 23) by failing to: 1. Ensure Resident 4 received House Protein Nutrition ([HPN] a liquid that provides nutrients, including carbohydrates, proteins, fats, vitamins, minerals, and electrolytes) with meals as recommended by the Registered Dietitian ([RD], food, and nutrition expert) and Resident 4's physician's order, to meet the recommended daily nutritional intake and prevent severe weight loss (a loss of greater than 5 percent [%- unit of measurement] in one month). 2. Conduct a comprehensive nutritional assessment for Resident 4 per the facilities policies and procedures(P&P) titled Nutritional Assessment. 3. Ensure Resident 23 received Glucerna (shake used as meal or partial meal replacement to support weight loss plan) per the RD's recommendations and physician's order dated 1/19/2023, to meet the recommended daily nutritional intake and prevent severe weight loss. 4. Ensure Resident 23 received HPN, as ordered by the physician, to meet the recommended daily nutritional intake and prevent severe weight loss. As a result, Resident 4 had a total weight loss of 22 pounds ([lbs] unit of measurement) of the resident's usual weight within 27 days (from 1/6/2023 to 2/3/2023) and placed the resident, already experiencing impaired nutrition, for further decline in nutritional status. Resident 23 had a total weight loss of 8 pounds or 6.8% of the usual weight within 29 days (from 12/6/2022 to 1/3/2023) and placed the resident, already experiencing impaired nutrition, for further decline in nutritional status. Findings: 1. During a review of Residents 4's Face Sheet (admission record), the Face Sheet indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Residents 4's diagnoses included gastro-esophageal reflux disease without esophagitis (heart burn without inflammation of the esophagus) and unspecified severe protein-calorie malnutrition (low energy intake, weight loss, loss of subcutaneous fat, loss of muscle mass, fluid accumulation, and decreased hand grip strength). During a review of Resident 4's Nutritional assessment dated [DATE] at 3:18 p.m., the assessment indicated Resident 4's ideal body weight was 110-130 lbs. During a review or Resident 4's Minimum Data Set ([MDS] a standardized assessment and care planning tool) dated 1/23/2023, the MDS indicated Resident 4 had the ability to understand and be understood by others. The MDS indicated Resident 4 required a one-person assist for bed mobility, transfers, walking in the room, locomotion (moving from place to place), dressing, toilet use, and personal hygiene. The MDS indicated Resident 4 required set up assistance for eating. The MDS indicated Resident 4 was on a therapeutic diet but did not indicate the resident's weight loss. The MDS also indicated Resident 4 had a stage two pressure ulcer. During a review of Resident 4's Care plan titled Nutrition Care Plan dated 12/8/2022, the care plan's interventions indicated the staff will provide Resident 4 with four (4) ounces ([oz], unit of measurement) of HPN three times daily (TID) with meals. During a review of Resident 4's History and Physical (H/P) dated 1/25/2022, the H/P indicated Resident 4 could not make decisions but could make her needs known. During a review of Resident 4's Physician Orders dated 1/19/2023 the orders indicated HPN, 4 oz, TID with meals. During a review of Resident 4's Registered Nurse Assistant (RNA) Admission Weight Log dated 1/6/2023 to 2/3/2023 the log indicated: 1. 1/6/2023 = 115 lbs 2. 1/20/2023 = 100 lbs. 2. 1/27/2023 = 98 lbs. 3. 2/3/2023 = 93 lbs (a total of 22 lbs weight loss in 27 days) During a concurrent observation and interview on 02/06/2023 at 12:27 p.m., with Certified Nurse Assistant (CNA) 4, in Resident 4's room, there were no supplements observed on Resident 4's lunch meal tray. CNA 4 stated he was not aware the resident was supposed to have any supplements. CNA 4 stated he always fed Resident 4 without any supplements. During a concurrent observation and interview 02/07/2023 at 12:41 p.m., with CNA 5 and Resident 4, Resident 4's lunch tray and meal ticket was observed with no HPN as ordered by the physician. CNA 5 stated Resident 4's tray did not have any supplements. CNA 5 stated the resident ate 75% of her lunch. Resident 4 stated she was not aware she was supposed to have supplements and was not given any supplements for over two months. During a concurrent interview and observation on 02/08/2023 at 12:58 p.m., with CNA 6, Resident 4's lunch tray and meal ticket were observed with no HPN. CNA 6 stated Resident 4 ate 60% of her meal and that the resident did not have any supplements on the tray. During a concurrent interview and record review on 02/08/2023 at 2:13 p.m., with Licensed Vocational Nurse (LVN) 2, Resident 4's physician's orders dated 1/19/2023 were reviewed and indicated the resident was to have HPN TID. LVN 2 stated on 2/6/2023, 2/7/2023, and 2/8/2023 she was Resident 4's assigned nurse and did not verify if Resident 4 was served HPN for breakfast and lunch on all three days. LVN 2 stated Resident 4 was at risk for skin breakdown and weight loss, if she did not get the supplements as ordered. During an interview on 02/08/2023 at 3:11 p.m., the Dietary Supervisor (DS) stated he did not have an order in the kitchen to provide HPN for Resident 4. During a concurrent interview and record review on 2/9/2023 at 10:27 a.m., with the RD, Resident 4's Dietary Assessment record was reviewed. The RD stated she could not find a readmission dietary assessment for Resident 4 and did not remember the last time she assessed Resident 4. The RD stated on 1/6/2023 Resident 4 weighed 115 lbs and on 2/3/2023 the resident weighed 93 lbs. The RD stated Resident 4 lost a total of 22 lbs within 29 days. The RD stated Resident 4 should have been given 4 oz of HPN to meet the resident's nutritional needs and prevent weight loss. 2. During a review of Residents 23's Face Sheet the face sheet indicated Resident 23 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 23's diagnoses included dysphagia (difficult or abnormal swallowing) and unspecified protein-calorie malnutrition. During a review or Resident 23's MDS dated [DATE], the MDS indicated Resident 23 had the ability to understand and be understood by others. The MDS indicated Resident 23 only required set up for bed mobility, transfers, walking in room, locomotion, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 23 was on a therapeutic diet but did not indicate the resident's admission weight. During a review of Resident 23's H/P dated 12/8/2022, the H/P indicated Resident 23 had a fluctuating capacity to understand and make decisions. During a review of Resident 23's Physician Orders dated 12/20/2022 the physician orders indicated Glucerna 4 oz TID with meals for nourishment. During a review of Resident 23's Nutritional assessment dated [DATE] at 3:28 p.m., the assessment indicated Resident 23's ideal body weight was 142 lbs. The Nutritional Assessment indicated Resident 23 was to have a fortified puree diet with honey thickened liquids and 4 oz HPN TID. During a review of Resident 23's RNA Admission Weight Log dated 12/6/2022 to 1/3/2023, the log indicated: 1.12/6/2022 = 118 lbs 2. 12/13/2023 = 115 lbs 3. 12/20/2023 = 112 lbs 4. 12/27/2023 = 110 lbs 5. 1/3/2023 = 110 lbs (a total of 8 lbs weight loss in 29 days) During a review of Resident 23's Care plan titled Weight Change dated 1/12/2023, the care plan's intervention indicated to provide Resident 23's diet as ordered by the physician. During an interview on 02/06/2023 at 12:08 p.m. with Resident 23, Resident 23 stated he was worried because he was losing weight. Resident 23 stated he did not receive any shake or supplement on his meal tray. During a concurrent observation and interview on 02/07/2023 at 11:56 a.m., with CNA 5 and Resident 23, in the resident's room, Resident 23's meal tray ticket indicated sugar free shake. There was no HPN, or sugar free shake observed on the tray. CNA 5 stated there was no Glucerna, HPN or shake on Resident 23's lunch tray. Resident 23 stated he did not know what Glucerna, and sugar free shakes were and had not had any. During an interview on 02/07/2023 at 12:42 p.m., with CNA 5, CNA 5 stated Resident 23 ate 60% of his meal. During an observation on 02/08/2023 at 12:28 p.m., of Resident 23's lunch tray, there was no Glucerna on the resident's lunch tray. During an interview on 02/08/2023 at 12:55 p.m., with CNA 2, CNA 2 stated there was no Glucerna or HPN on Resident 23's lunch tray. CNA 2 stated Resident 23 ate 40-50% of his lunch. During an interview and record review on 02/08/2023 at 2:13 p.m., with LVN 2, Resident 23's Physician's Orders dated 12/20/2022 were reviewed. The Physician's Orders indicated Resident 23 will receive 4 oz Glucerna, TID, with meals. LVN 2 stated she did not verify if Resident 23 had Glucerna for breakfast and lunch. LVN 2 stated Resident 23 was at risk for skin breakdown and weight loss if the resident did not get the supplements as ordered. During a concurrent observation and interview on 2/09/2023 at 7:22 a.m., and with CNA 6, four containers were observed on Resident 23's breakfast tray. Two of the containers were labeled nectar thick ([NTK] liquid thicker than water fall slowly from a spoon and are sipped through a straw or from a cup) and the other two containers were unlabeled. CNA 6 stated NTK was thickened juice to prevent Resident 23 from choking. CNA 6 stated there was no Glucerna, sugar free shake, or HPN on the resident's meal tray. CNA 6 stated Resident 23's meal tray ticket indicated sugar free shake. During an interview with LVN 2 on 2/09/2023 at 7:22 a.m., LVN 2 stated LVN 1 informed her days prior that the facility did not have Glucerna. LVN 2 stated she forgot to notify the physician that the facility did not have Glucerna. During an interview with LVN 1 on 2/09/2023 at 8:14 a.m., LVN 1 stated the Central Supply Supervisor (CSS) oversaw the ordering Glucerna for the residents. LVN 1 stated Resident 23's physician ordered Glucerna for the resident. LVN 1 stated Resident 23 did not have an order for HPN. LVN 1 also stated she will get an order for HPN from Resident 23's physician since the facility did not have Glucerna. During an interview with the Dietary Supervisor (DS) on 2/9/2023 at 8:20 a.m., the DS stated there were no additional additives or nutritional value in the nectar thickened fluids. The DS stated Resident 23's meal tray did not have any supplements such as Glucerna and HPN. The DS stated the facility has not had Glucerna in several months. During an interview with CSS on 2/9/2023 at 9:20 a.m., CSS stated he was not responsible for ordering Glucerna, and that it was a nursing responsibility. During an interview with the RD on 2/9/2023 at 9:41 a.m., the RD stated she saw Resident 23 on 12/15/2022 due to the resident's weight of 118 lbs which was below his ideal body weight of 142 lbs. The RD stated Resident 23 had a diagnosis of malnutrition. The RD stated severe weight loss could lead to malnutrition, cause the resident to be bed bound and affect Resident 23's quality of life. The RD stated she recommended a sugar free house protein and Glucerna for Resident 23 and was informed by a staff that the facility did not have Glucerna, in December 2022. The RD stated Resident 23's breakfast tray had no supplements. The RD stated Resident 23's nutritional needs would not be met, and the resident was at risk of further weight loss. The RD also stated that Resident 23's weight loss of 8 lbs was because the resident was not getting the supplements as ordered. During a review of the facility's P&P titled, Nutritional Assessment revised in 2017, the P&P indicated the dietitian in conjunction with nursing staff and healthcare practitioners should conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that placed the resident at risk for impaired nutrition. During a review of the facility's P&P titled House Nourishments Revised on 2/2023, the P&P indicated the purpose of supplementation was to increase protein and/or calories for maintaining nutritional status. The P&P indicated the facility's policy was that all Residents requiring a nourishment as ordered by their physician would receive a house nourishment if the commercial nourishment ordered was unavailable.

Based on interview, and record review the facility failed to provide supervision for one of two sampled residents (Resident 1), who was at high risk for falls. Resident 1 was left unsupervised and was found on the floor by a Certified Nursing Assistant (CNA) 3. As a result, Resident 1 fell , sustained a left [CONDITION(S)] (broken bone), was hospitalized in a General Acute Care Hospital (GACH) from 8/25/22 to 8/28/22, (a total of 3 days), and had a surgical repair of the fractured site. Findings: During a review of Resident 1's Face sheet, the face sheet indicated, Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included, unspecified dementia with behavior disturbance (a mental disorder that affects how a person thinks and behaves), lack of coordination (loss of control of body movements), unspecified mood affective disorder (mental disorder that affects a person's emotional state), anxiety disorder (feelings of uneasiness), and unspecified disorder of bone density and structure ( a disease that weakens bones and are at a greater risk for sudden and unexpected bone fractures), wedge compression fracture (small breaks or cracks in the back bone usually occurs in the front of the spine collapsing and weakens the bone of the spine which gives the bones in the back a wedge shape and affects posture). During a review of Resident 1's History and Physical (H&P), dated 8/28/21, the H&P indicated, Resident 1 was not able to fully understand or make decisions. During a review of Resident 1's fall risk assessment, dated 6/2/22, the fall risk assessment indicated, Resident 1 was not at risk for falls. The fall risk assessment indicated Resident 1 had intermittent confusion, had balance problems while standing. The fall risk assessment also indicated Resident 1 was receiving medications for high blood pressure, and psychotropics (any drug that affects behavior, mood, thoughts, or perception), medications known to cause dizziness and falls. During a review of Resident 1's Post Fall Observation Assessment, dated 6/21/22 indicated Resident 1fell from her bed on 6/21/22 and the fall was witnessed by her roommates. The Post Fall Observation Assessment indicated Resident 1 stated she fell from her bed and hit her arm. During a review of Resident 1's Departmental Notes dated 6/21/22 10:03 pm, the departmental notes indicated Resident 1 was diagnosed with a right upper arm humerus (long bone in the upper arm) fracture. The departmental notes indicated Resident 1 was wearing a sling (a device to limit movement of the shoulder or elbow while it heals) and had a right upper extremity (RUE) skin discoloration and swelling. During a review Resident 1's situation, background, assessment, and recommendation (SBAR) dated 6/21/22, the SBAR indicated, a Certified Nursing Assistant (CNA) notified a Charge Nurse (CN) that Resident 1 complained of RUE pain. The SBAR indicated upon assessment, the CN noted Resident 1's RUE was red, slightly swollen and the resident was unable to raise the RUE without pain. The SBAR also indicated Resident 1's physician was notified and an Xray (quick, painless test that produces images of the structures inside the body, particularly your bones) was ordered. During review of Resident 1's care plan titled At Risk for Falls related to dementia dated 6/22/22, indicated Resident 1 had an actual fall on 6/22/22. The care plan's goal indicated Resident 1's risk for falls will be reduced within 90 days. The care plans interventions indicated call lights in reach, room free of clutter, encourage resident to call for assistance if needed, and monitor side effects for medications. During a review of Resident 1's Physical Therapy Evaluation and Plan of Treatment dated 6/23/22 the Physical Therapy Evaluation and Plan of Treatment indicated Resident 1 was referred to rehabilitation (the process of restoring someone to health through training and therapy after an illness) after a fall in the facility on 6/21/22 that resulted in a right arm fracture. The Physical Therapy Evaluation and Plan of Treatment indicated Resident 1 had a new onset of decrease in functional mobility, strength, coordination, and an increased need for help from others after the fall. During review of an Interdisciplinary Team meeting report ([IDT] team members from different disciplines working together, with a common purpose on a resident's behalf) dated 6/25/22, the IDT indicated, Resident 1 was noted with a red swollen right upper extremity and painful to touch. Charge nurse was made aware. Upon investigation of incident, the resident's roommate heard a loud noise in room and Resident 1 stated, she had fallen and hit arm on the bed rail on the 7-3pm shift. Resident was noticed to have severe pain on right upper extremity and the doctor was aware of Xray results and a new order was received to transfer Resident 1 to the emergency room (ER) for further evaluation. During review of Resident 1's Minimum Data Set [ MDS] an assessment and care screening tool) dated 6/25/22, the MDS indicated, Resident 1 had a severe cognitive (thinking) memory loss and had a major injury, a fracture, from one fall since admission. The MDS indicated Resident 1 required extensive assistance from one staff with bed mobility, transfers, walking, dressing, toilet use, eating and personal hygiene. The MDS indicated Resident 1 used a wheelchair. The MDS also indicated Resident 1 had had a fall since admission with a major injury. The MDS indicated Resident 1 was receiving antipsychotic (medications to treat mental health disorders), antidepressants (medication to treat depression) and opioid (strong pain medication). During a review of Resident 1's SBAR dated 8/24/22, the SBAR indicated, Resident 1 was found on the floor in her room by the charge nurse, and Resident 1 stated I was walking, and I fell on the floor. The SBAR indicated Resident 1 was assessed and complained of pain on left hip when palpated, pain medication was provided, medical doctor notified and an Xray was ordered. The SBAR indicated Resident 1 had a pain rated at 7/10, (with 10 being the highest level of pain). The SBAR also indicated Resident 1 had non-verbal signs of pain including grimacing (facial expression of pain) and moaning/gasping (long, low sound expressing physical or mental suffering) and wincing (to draw back or tense the body from pain). During a review of Resident 1's Departmental Notes dated 8/24/22 and timed 8:45 pm, indicated Resident 1 had an order for Xray of both hips. The Departmental Notes indicated Resident 1 was medicated for pain. During a review of Resident 1's Departmental Notes dated 8/24/22 and timed 10:47 pm, the Departmental Notes indicated Resident 1 had a left [CONDITION(S)]. During a review of Resident 1's Departmental Notes dated 8/25/22, and timed 7:07 pm, the Departmental Notes indicated, Resident 1 had unrelieved pain after given medication and was transferred to a general acute care hospital (GACH) for evaluation/treatment. During a review of the GACH physician's consultation report dated 8/26/22, the consultation report indicated, Resident 1 was scheduled for surgery to repair her hip. During review of an IDT meeting dated 8/28/22, the IDT conference indicated Resident 1 had a left [CONDITION(S)]. Resident 1 stated she was walking and fell on [DATE]. Resident 1 has dementia with behavioral disturbances, [CONDITION(S)] (fragile easy to break bones), depression (feeling hopeless with loss of interest in daily activities) anxiety, and Resident 1 tested positive for the coronary virus ([Covid 19] infection that causes difficulty breathing). Resident 1 was examined by a licensed nurse, noted to have pain in left hip, having facial grimacing (frowning), and doctor made aware. Resident 1 noted with facial grimacing and stating her leg hurt after she was already medicated with [MEDICATION(S)] (strong pain medication) as ordered. The IDT notes indicated 911 was called to transfer Resident 1 to the emergency room for further evaluation. During a review of the Investigative summary dated 8/29/22, the Investigative Summary, indicated Resident 1 was a fall risk and had a previous history of falls. The conclusion statement indicated Resident 1's fall was related to lack of coordination, use of [CONDITION(S)] medications, cognitive dysfunction, stubbornness, and refusing to ask for assistance. During an interview on 8/31/22, at 3:40 pm, with the Director of Nursing (DON), the DON stated, after Resident 1's fall on 6/21/22, Resident 1's physician discontinued the resident's [MEDICATION(S)], to prevent dizziness and falls. The DON stated, CNA 3 was assigned to sit by Resident 1's room to monitor the resident on 8/24/22, and that if Resident 1 made any sound, CNA 3 was supposed to notify a Licensed Vocational Nurse (LVN) or a Registered Nurse (RN) for prompt interventions. The DON stated when Resident 1 fell the second time on 8/24/22 the resident had just been moved to the red zone (designated area for COVID-19 positive residents) and was not monitored. The DON stated a CNA 1 was in Resident 1's room helping a maintenance Supervisor (MS) at the time of the fall on 8/24/22, because MS was putting up an isolation barrier (safety device use to prevent movement from one area of the facility to another). The DON stated MS asked CNA 1 to hand him (MS) a piece of tape, and when CNA 1 turned around, Resident 1, who was on a wheelchair, had fallen by her bedside. During an interview on 9/12/22 at 2:33 pm, with physical therapist (PT) 1, PT 1 stated, Resident 1 was at high risk for falls related to dementia, confusion, and inability to follow instructions. PT 1 stated Resident 1 had two falls on 6/21/22 and 8/24/22, while in the facility. PT 1 stated, before both falls, Resident 1 could stand on her own and walk unassisted, but for the safety of Resident 1, it was better for a staff to always assist the resident. PT 1 stated Resident 1 was able to stand beside PT 1, hold on to the gait belt (assistive device which can be used to help safely transfer a person from a bed to a wheelchair, assist with sitting and standing) and walk. PT 1 stated, after the second fall on 8/24/22, Resident 1 required maximum assist and was totally dependent on staff for all activities. PT 1 stated Resident 1 suffered a definite decline in function. During an interview on 9/12/22 at 3:35 pm, with CNA 3, CNA 3, stated, he was not assigned to monitor Resident 1 on 8/24/22, and that he was standing in the doorway when he saw Resident 1 on the floor. CNA 3 stated Resident 1 was alone, inside her room, on the floor, in front of a wheelchair. CNA 3 stated Resident 1's legs were on the floor and the resident was lying in a fetal position (when the body is curled up on one side with the arms and legs). During an interview on 9/13/22 at 12:40 pm, with LVN 1, LVN 1 stated, she did not witness Resident 1's fall on 8/24/22. LVN 1 stated, CNA 3 notified her about Resident 1's fall. LVN 1 stated, she found Resident 1 lying on the floor, on her back, with her legs stretched out, and her right arm was over her chest. During an interview on 9/14/22 at 9:50 am with LVN 1, LVN 1 stated, Resident 1's fall could have definitely been prevented if Resident 1 was placed on a One-to-one observation (continuous staff observation to prevent falls). LVN 1 stated Resident 1 was not on 1:1 monitoring when the resident fell on [DATE]. During an interview on 9/14/22, at 9:35 am, with RN 1, RN 1 stated, Resident 1 was a high risk for falls prior to her fall on 8/24/22. RN 1 stated, Resident 1 had an unsteady gait, was forgetful, and required one person assist with mobility. RN 1 stated, Resident 1 did not follow instructions and was confused. During a review of the Diagnostic Imaging (a type of test to view the inside of the body to help figure out the causes of an illness or injury and confirm a diagnosis) report dated 8/25/22, at the GACH, the diagnostic imaging report indicated, a left sided [CONDITION(S)]. During a review of a letter from the facility's Administrator titled Letter of Consideration of Intent to Cite dated 9/15/22, the letter indicated Resident 1 had multiple fall risks factors including lack of coordination, confusion, forgetfulness, and unable to make decisions. The letter indicated Resident 1 had a fall on 6/20/22 and sustained a right humeral (upper arm) fracture. The letter also indicated on 8/24/22 Resident 1 was found on the floor by a CNA and x-ray results indicated the resident sustained a left [CONDITION(S)]. According to the letter, on 8/24/22, Resident 1 was placed in an environment unrecognized by her (Resident 1) and that may have caused her to be disoriented. The letter indicated everyone was aware Resident 1 had a tendency to get up. On 8/24/22, staff were moving beds, and the maintenance was taping off areas in the facility. Resident 1 probably was scared, did not understand what all the commotion was about, then the resident got up, fell , and was injured. During a review of the facility's policy and procedure (P/P) titled, Safety and Supervision of Residents, dated 12/2017, the P/P indicated resident supervision was a core component of the systems approach to safety. The P/P indicated the type and frequency of resident supervision was determined by each resident's assessed needs and identified hazards in the environment. The P/P indicated monitoring the effectiveness of interventions included evaluating the effectiveness of interventions, modifying or replacing interventions as needed and evaluating the effectiveness of new or revised interventions. During a review of the facility's P/P titled Falls revised March 2018, the P/P indicated after a first fall, the staff will evaluate falls that occurred in the facility, identify possible causes, including each resident's risk factors, and try relevant interventions to prevent further falls. During a review of the facility's P/P titled, Care Plans - Comprehensive, the P/P indicated, each resident's comprehensive care plan was designed to aid in preventing or reducing declines in the resident's functional status and/or functional levels. The P/P indicated an individualized comprehensive care plans including measurable objectives and timetables to meet each resident's medical, nursing, mental, and psychological needs was developed for each resident. The P/P indicated assessments of residents were ongoing and care plans were revised as information about the resident and resident's condition change.

Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) was free from physical abuse by failing to ensure Certified Nurse Assistant (CNA 1) did not slap Resident 1 in the face on 4/3/2022 after verbalizing he would do so. This deficient practice resulted in Resident 1 being physically assaulted. Resident 1 complained of left facial pain, had a hematoma (collection of blood) to the left preseptal area (an area of the eye) and bruising (blood or bleeding under the skin due to trauma) over the nasal (nose) bridge and left eye, and required a transfer to a general acute care hospital (GACH). Findings: During a review Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1 ' s Minimum Data Set ([MDS], a comprehensive assessment and care screening tool) dated 1/17/2022, the MDS indicated Resident 1 had severe cognitive (ability to learn, reason, remember, understand and make decisions) impairment and required limited assistance (resident highly involved in activity; staff provided guided maneuvering of limbs) to extensive assistance (resident involved in activity, staff provide weight bearing support) for activities of daily living (ADL ' s) such as bed mobility (how resident moves in bed), transfer (how resident moves between surfaces including to and from bed, chair, standing position), walking, dressing toilet use, and personal hygiene. During a review of Resident 1 ' s History and Physical (H&P) dated 4/1/2022, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1 ' s Situation, Background, Assessment and Recommendation ([SBAR], an internal communication form) dated 4/4/2022, the SBAR indicated Resident 1 was a victim of suspected elder abuse and had a swollen and bruised left eye and eyebrow which started on 4/3/2022. The SBAR also indicated the resident had new onset of pain to the left eye. During a review of Resident 1 ' s GACH H&P dated 4/4/2022 and timed 1:56 p.m., the H&P indicated Resident 1 was assaulted at the nursing facility. The H&P also indicated the resident complained of left facial pain, had a hematoma to the left preseptal area (an area of the eye) and bruising over the nasal bridge and left eye. During an interview on 5/17/2022 at 11:27 a.m. with Director of Staff Development (DSD), the DSD stated Certified Nursing Assistant (CNA) 1 was assigned to closely monitor Resident 1 on 4/3/2022 during the 3 p.m.- 11 p.m. shift. The DSD stated during an interview conducted on 4/4/2022 with CNA 1, CNA 1 stated Resident 1 was troublesome, and he (CNA 1) was frustrated with the resident. The DSD stated CNA 1 also stated that he had hard time with the resident during his shift, slapped the resident ' s hands and pushed Resident 1 down to his bed to prevent the resident from falling or walking around. During an interview on 5/18/2022 at 11:54 a.m. and 12:56 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when she entered Resident 1 ' s room on 4/3/2022 at around 10:45 p.m., LVN 1 stated CNA 1 was in the room with the resident and Resident 1 did not have any injuries. LVN 1 stated CNA 1 said if Resident 1 continued to be combative, he (CNA 1) would slap the resident up. LVN 1 stated she was concerned for Resident 1 ' s safety after hearing CNA 1 ' s comment but she did not remove CNA 1 from the resident ' s room immediately. LVN 1 stated she replaced CNA 1 with CNA 2 about 15 minutes later, at 11 p.m. According to LVN 1, CNA 2 called LVN 1 to the resident ' s room around 11 p.m., and she (LVN 1) discovered Resident 1 had a discoloration around his left eye and eyebrow. LVN 1 also stated CNA 1 was the last staff in Resident 1 ' s room prior to the resident ' s injury. LVN 1 also stated that CNA 1 left the facility around 11 p.m. on 4/3/2022. During an interview on 5/19/2022 at 10:27 a.m. with Director of Nursing (DON), the DON stated if staff verbalized, he or she would slap a resident, it would be necessary to investigate further, monitor the resident and not leave the resident alone with the staff for safety due to the possibility of causing harm to the resident. During an interview on 5/19/2022 at 2:18 p.m. with the Administrator (ADM), the ADM stated CNA 1 verbalized he slapped the resident because the resident was restless. ADM stated after careful investigation, ADM substantiated CNA 1 abused Resident 1. During a review of the facility ' s policy and procedure (P&P) titled, Abuse Prevention Program dated 8/2006, the P&P indicated the facility was committed to protecting residents from abuse by anyone including facility staff and staff from other agencies providing services to residents. During a review of the facility ' s P&P titled, Abuse Prevention/Prohibition and Abuse Reporting and Investigation dated 11/2018, the P&P indicated abuse is defined as the willful infliction of injury, involuntary seclusion, physical or chemical restraint not required to treat the resident ' s symptoms, intimidating or punishment with resulting physical harm, pain, or mental anguish. If suspected perpetrator is an employee, the employee would be removed immediately from the care of the resident and immediately suspend the employee pending the outcome of the investigation in accordance with facility ' s policies.

Based on interview and record review, the facility failed to implement their abuse policies and procedures (P&P) for one of three residents (Resident 1) by failing to implement protection from abuse for Resident 1. This deficient practice resulted in Resident 1 sustaining a hematoma (collection of blood to the left preseptal area (an area of the eye) and bruising (blood or bleeding under the skin due to trauma) over the nasal (nose) bridge and left eye, and required a transfer to a general acute care hospital (GACH) . Findings: During a review Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1 ' s Minimum Data Set ([MDS], a comprehensive assessment and care screening tool) dated 1/17/2022, the MDS indicated Resident 1 had severe cognitive (ability to learn, reason, remember, understand and make decisions) impairment and required limited assistance (resident highly involved in activity; staff provided guided maneuvering of limbs) to extensive assistance (resident involved in activity, staff provide weight bearing support) for activities of daily living (ADL ' s) such as bed mobility (how resident moves in bed), transfer (how resident moves between surfaces including to and from bed, chair, standing position), walking, dressing toilet use, and personal hygiene. During a review of Resident 1 ' s History and Physical (H&P) dated 4/1/2022, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1 ' s Situation, Background, Assessment and Recommendation ([SBAR], an internal communication form) dated 4/4/2022, the SBAR indicated Resident 1 was a victim of suspected elder abuse and had a swollen and bruised left eye and eyebrow which started on 4/3/2022. The SBAR also indicated the resident had new onset of pain to the left eye. During a review of Resident 1 ' s GACH H&P dated 4/4/2022 and timed 1:56 p.m., the H&P indicated Resident 1 was assaulted at the nursing facility. The H&P also indicated the resident complained of left facial pain, had a hematoma to the left preseptal area (an area of the eye) and bruising over the nasal bridge and left eye. During an interview on 5/17/2022 at 11:27 a.m. with Director of Staff Development (DSD), the DSD stated Certified Nursing Assistant (CNA) 1 verbalized he was frustrated with Resident 1 and slapped Resident 1 ' s hands and pushed him down to his bed. During an interview on 5/18/2022 at 11:54 a.m. and 12:56 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when she entered Resident 1 ' s room on 4/3/2022 at around 10:45 p.m., Resident 1 did not have any injuries. LVN 1 stated CNA 1 said if Resident 1 continued to be combative, he (CNA 1) would slap the resident up. LVN 1 stated she was concerned for Resident 1 ' s safety after hearing CNA 1 ' s comment but she did not remove CNA 1 from the resident ' s room. immediately. LVN 1 stated at around 11 p.m. when she returned to the room, she (LVN 1) discovered Resident 1 had a discoloration around his left eye and eyebrow. LVN 2 added that she should have followed the facility's abuse policy and sent CNA 1 home as soon as CNA 1 stated he was going to slap Resident 1. During an interview on 5/19/2022 at 2:18 p.m. with the Administrator (ADM), the ADM stated the facility did not tolerate any form of resident abuse. The ADM also state CNA 1 was placed on a do not send list, and would never be allowed to work in the facility again. During a review of the facility ' s policy and procedure (P&P) titled, Abuse Prevention Program dated 8/2006, the P&P indicated the facility was committed to protecting residents from abuse by anyone including facility staff and staff from other agencies providing services to residents. During a review of the facility ' s P&P titled, Abuse Prevention/Prohibition and Abuse Reporting and Investigation dated 11/2018, the P&P indicated abuse was the willful infliction of injury, involuntary seclusion, physical or chemical restraint not required to treat the resident ' s symptoms, intimidating or punishment with resulting physical harm, pain, or mental anguish. If suspected perpetrator is an employee, the employee would be removed immediately from the care of the resident and immediately suspend the employee pending the outcome of the investigation in accordance with facility ' s policies.

Based on observation, interview, and record review, the facility failed to ensure 13 of 45 sampled residents (Residents 2, 4, 9, 18, 34, 38, 41, and 45) were not physically, sexually, and verbally abused. Resident 1 hit Resident 2 on the face on 2/23/2020. The facility did not transfer Resident 1 to the general acute care hospital (GACH) for evaluation and treatment of [REDACTED]. The facility did not implement the care plan to provide a one-on-one (1:1, one staff monitoring one resident) supervision when Resident 1 exhibited actual aggression. . Resident 44 performed non-consensual (not agreed to by one or more of the people involved) oral sex on Resident 45 on 10/26/19 and hit Resident 5 on back of the head on 11/10/19 when Resident 5 refused to engage in a sexual act with Resident 44. Resident 3 wandered into the room of Resident 4 and attempted to pull her pants down on 8/21/19. Resident 10, who was wearing adult brief only, wandered into the room of Resident 9 on 11/16/19 at 4 a.m., and laid on top of the resident (Resident 9). Resident 24 alleged that Resident 38 wandered into his room through a shared restroom and Resident 38 was naked. Resident 24 was not able to verbalize date and time the allegation happened. Resident 34 stated Resident 38 was touching and rubbing him while Resident 41 stated Resident 38 informed him (Resident 41) that Resident 34 was doing sexual acts on him (Resident 38). Resident 34 and 41 were not able to verbalize date and time the allegation happened. Licensed Vocational Nurse (LVN) 1 witnessed Resident 17 and Resident 18 having a verbal altercation, then Resident 17 threw a water pitcher on Resident 18. LVN 1 did not separate the residents because she stated the residents were confused and she had not started her shift yet. This deficient practice resulted in Resident 2 sustaining a cut over the bridge of his nose; Resident 45, 4, 9, 34 and 38 becoming victims of sexual abuse; Resident 5 becoming a victim of physical abuse; and Resident 18 crying due to inability to sleep and a victim of verbal abuse. This deficient practice had the potential to result in other residents being abused and creating an unsafe environment and an environment of fear. On 2/26/2020 at 12:55p.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 and the situation created a need for an immediate corrective action) due to the facility's failure to have a system that ensures physical abuse does not occur and recur. The facility did not have an active Administrator at the time. The Department notified the Director of Nursing (DON) and the Director of Staff Development (DSD) of the serious noncompliance that threatened the health and safety of the residents. On 3/2/2020 at 10:32 a.m., the Department informed the Administrator that the facility had an immediate jeopardy situation regarding the facility's system failure to ensure the residents were not sexually and verbally abused. The Vice President of Operations (VPO) provided a plan of action (POA) to correct and remove the IJ situation starting 2/27/2020 at 5:57 p.m. The Department has not accepted a written POA and has not lifted the IJ to date. Findings: 1a. A review of Resident 1's GACH History and Physical (H/P), prior to admission to the skilled nursing facility (SNF), dated 1/2/2020, indicated Resident 1 was admitted to the GACH due to being extremely paranoid (suspicious, distrustful), delusional (having false or unrealistic beliefs, thoughts or opinions) and persecutory (constantly annoy and bother) with irritability (easily impatient and angered). The H/P indicated a few weeks prior (date not specified), Resident 1 was sent to GACH from a SNF where he was fighting with residents. A review of Resident 1's Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and last re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Interdisciplinary Team ((IDT) a group of professionals working toward a common goal for residents) note, dated 1/13/2020, indicated Resident 1 had a history of [REDACTED]. A review of Resident 1's care plan, dated 1/13/2020 and titled, Trauma-Informed Care, at risk for emotional disturbance due to history of traumatic life events, such as history of multiple fights with others, ETOH (alcohol) and etrahydrocannabinol ((THC) psychoactive drug) abuse, homelessness, no family support and severe mental illness, indicated for Resident 1 to receive psychological consult (an evaluation of a person's mental and emotional state) and follow-up as needed for psychotherapy (a treatment of [REDACTED]. A review of Resident 1's care plan, dated 1/13/2020 and titled, History of Aggressive/Assaultive Behavior, at risk for aggression/assaultive behavior related to paranoid [MEDICAL CONDITION], history of getting into a couple of fights with staff and residents prior to admission, history of erratic, irrational behavior, history of suicidal thoughts of thinking of cutting self with a razor, indicated for the staff to observe and monitor Resident 1's behavior of desire to hurt others every shift, to place Resident 1 on 1:1 supervision once actual aggression is exhibited to promote safety to self and others, and to provide a psychiatric consult for Resident 1. A review of Resident 1's admission physician orders, dated 1/10/2020 and 1/29/2020, indicated the following medications were ordered: 1. [MEDICATION NAME] (an antidepressant (to reduce feelings of hopelessness and sadness) medication) 10 milligrams ((mg) a unit of measurement) by mouth daily for verbalizing feelings of sadness, 2. [MEDICATION NAME] (an antipsychotic (mind altering medications) used to treat mental/mood conditions) 80 mg by mouth twice daily for sudden angry outburst. The physicians' order indicated for the staff to monitor Resident 1's episodes of sudden outburst of anger by hash marks (a form of counting) every shift. 3. [MEDICATION NAME] (an antipsychotic medication used to treat mental/mood conditions) 1 mg and 2 mg by mouth every six (6) hours as needed (PRN) for fourteen (14) days for anxiety (the inability to relax) and agitation (feeling or appearing troubled or nervous). 4. Psychiatric consult and follow-up as needed. A review of Resident 1's H/P, dated 1/30/2020, indicated Resident 1 had a fluctuating capacity to understand and make decisions. A review of Resident 1's Medication Administration Record [REDACTED]. The MAR for 1/30/2020 and 1/31/2020 indicated Resident 1 exhibited 2 episodes of anger outburst as documented by hash marks. A review of Resident 1's care plans with the DON on 2/25/2020 at 3:33 p.m., indicated there were no care plans to address Resident 1's behavioral management and use of behavioral psychoactive medications. A review of Resident 1's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated 2/4/2020, indicated the resident's cognition (thought process) was moderately impaired. A review of a Situation, Background, Assessment and Recommendation ((SBAR) an internal communication form), dated 2/11/2020, indicated Resident 1 was verbally abusive and aggressive towards staff and others. The SBAR indicated Resident 1 was observed pacing up and down the hallways of the facility while being verbally aggressive and disrupting other residents and staff. The SBAR indicated Resident 1 was redirected over seven (7) times that day (2/11/2020) while the resident continued to be verbally aggressive. The SBAR indicated a message was left for Resident 1's physician. A review of Resident 1's nurses' note, dated 2/11/2020 on the 7 a.m. to 3 p.m. shift, indicated there was no documented evidence that Resident 1 was being monitored for being verbally abusive towards staff and residents. A review of Resident 1's nurses' notes, dated 2/22/2020, indicated time entries at 4:15 a.m., 5 a.m., 6 a.m., and 8 a.m. The 4:15 a.m. entry indicated Resident 1 was verbally aggressive and abusive, disrupting his roommate by playing loud music, and Resident 1 stated, I don't give a f*** about everybody and whatever they said. The entry at 5 a.m. indicated Resident 1 was lying in bed naked while yelling obscenities and stated, I would get rid of your mother****ing sorry a**. The nurses' note entry at 6 a.m. indicated Resident 1 was angry, agitated talking loudly to himself, [MEDICATION NAME] was offered; however Resident 1 refused. The 8 a.m. entry indicated Resident 1's physician stated to transfer Resident 1 to the GACH. A review of an SBAR, dated 2/22/2020 and timed at 7:05 a.m. indicated Resident 1 was verbally abusive towards staff and residents. The SBAR indicated Resident 1 was observed pacing the hallways while being verbally aggressive and disrupting other residents and staff by yelling and reciting obscenities (an extremely offensive word or expression). The SBAR indicated Resident 1 refused to stop being disruptive and the DON and Resident 1's physician were notified. The SBAR indicated at 8 a.m. on 2/22/2020, a physician's orders [REDACTED]. A review of Resident 1's physician orders [REDACTED]. A review of Resident 1's nurses' notes, dated 2/22/2020 on the dayshift (7 a.m. to 3 p.m.) and evening shift (3 p.m. to 11 p.m.) indicated Resident 1 was being monitored by staff for being verbally aggressive and abusive. The nurses' note for 2/22/2020, which was reviewed with DON 2 2/25/2020 at 3:33 p.m., indicated there was no documented evidence Resident 1 had been transferred to the GACH. A review of Resident 1's nurses' notes from 2/1/2020 through 2/23/2020 indicated there was no documented evidence of Resident 1 was being monitored 1:1 in accordance with the care plan that addressed the resident's history of aggressive and assaultive behavior and risk for aggression/assaultive behavior. A review of Resident 1's nurses' note, dated 2/23/2020 and timed at 8:30 p.m. indicated Resident 1 walked into Resident 2's room and hit Resident 2 in the face. The nurses' note indicated, when the staff arrived in Resident 2's room, Resident 1 continued to hit Resident 2 while the staff were pulling him off Resident 2. A review of an SBAR, dated 2/23/2020 and timed at 9 p.m. indicated Resident 1 left the facility against medical advice (AMA) after assaulting Resident 2. A review of Resident 1's MAR, for the month of 2/2020, indicated Resident 1 did not have any episodes of anger outburst documented by hash marks from 2/1/2020 through 2/24/2020 (sic). On 2/25/2020 at 8:44 a.m., during an interview, Resident 1's roommate (Resident 46) stated Resident 1 was cuckoo (crazy), noisy, and yelled and cursed loudly. Resident 46 stated Resident 1 hit another resident (Resident 2) the day prior. Resident 46 stated everyone in the facility complained about Resident 1. On 2/25/2020 at 9:35 a.m., during an interview, Certified Nursing Assistant 8 (CNA 8) stated on 2/23/2020, she was standing at Nursing Station 1 when she observed Resident 1 exiting Resident 2's room with a bloody (shirt) sleeve. CNA 8 stated she observed Resident 2 with blood all over his face. CNA 8 stated the paramedics (a health field worker trained to provide emergency services) were called and upon arrival, Resident 2 refused to be transferred to the GACH. Resident 2 received treatment from the paramedics for his injuries. CNA 8 stated the police was notified and when the police arrived at the facility, Resident 2 stated he did not want to press charges against Resident 1. CNA 8 stated according to Resident 2, Resident 1 would stare at Resident 2 during the smoking hours. On 2/25/2020 at 3:33 p.m., during a concurrent interview and review of Resident 1's records, DON 2 was asked how the staff knew how to provide care for Resident 1 when the care plans titled, behavioral management and behavioral psychoactive medication, dated from 1/29/2020 through 2/23/2020, were incomplete. DON 2 stated the staff would call Resident 1's physician and Resident 1 would be placed on 1:1 monitoring. DON 2 stated Resident 1 should have a care plan for behavioral symptoms including behavioral medications. The DON 2 was asked if Resident 1 was transferred to the GACH on 2/22/2020, as ordered by the physician. The DON 2 stated Resident 1 was not transferred to the GACH on 2/22/2020. During a telephone interview, on 2/25/2020 at 4:55 p.m., LVN 7 stated Resident 1 was verbally aggressive and abusive to staff and residents. LVN 7 stated on 2/22/2020, she obtained a telephone order from Resident 1's physician to transfer Resident 1 to the GACH. LVN 7 stated she did not transcribe (record) Resident 1's physicians' order due to having to clock out to leave and endorsed it to the oncoming LVN to transcribe Resident 1's physicians' order. LVN 7 stated Resident 1 had escalating behaviors in which Resident 1 had to be re-directed more than seven (7) times in one day. LVN 7 stated she documented Resident 1's escalating behaviors in the nurses' notes and on the SBAR, and stated she did not complete hash marks or a tally of Resident 1's behavioral episodes in the Resident 1's MAR. On 2/25/2020 at 5:40 p.m., during an interview, LVN 8 stated Resident 1 would always enter Resident 2's room looking for Resident 2's roommate, but Resident 2's roommate was discharged from the facility. LVN 8 stated on 2/23/2020, Resident 2 was lying in bed asleep, began crying after being beaten up by Resident 1. and Resident 1 was separated from Resident 2. LVN 8 stated Resident 2 was bleeding from the bridge of his nose, and she cleaned Resident 2's nose and placed an ice pack, until the paramedics arrived. LVN 8 stated if Resident 1 was told to wait for something, he would point at her and state, I want it now. LVN 8 stated she was afraid when Resident 1 talked to her. On 2/26/2020 at 10:52 a.m., during an interview, CNA 5 stated in the month of 1/2020, Resident 1 was aggressive and would walk around the facility saying, F*** you, in an aggressive manner. CNA 5 stated she would ensure residents who were not able to defend themselves where kept at a distance from Resident 1 and removed from the area to avoid contact with Resident 1. b. A review of Resident 2's GACH's H/P, prior to the admission to the SNF, dated 1/23/2020 indicated Resident 2 had suicidal ideation (desire to kill oneself) without a plan. The H/P indicated Resident 2 required hospitalization for a total of 14 days and was transferred to the SNF on 2/5/2020. A review of Resident 2's SNF Admission Record, indicated Resident 2 was admitted to the facility on [DATE]. Resident 2' [DIAGNOSES REDACTED]. A review of Resident 2's physician's admission orders [REDACTED] 1. [MEDICATION NAME] 60 mg by mouth twice daily for sudden angry outburst. 2. [MEDICATION NAME] (an antidepressant medication) 40 mg by mouth daily for verbalizing feelings of sadness. The physicians' order indicated for the staffs to monitor Resident 2's episodes of sudden outburst of anger by hash marks every shift. 3. [MEDICATION NAME] 2 mg every six (6) hours PRN (as needed) for fourteen (14) days for anxiety. A review of Resident 2's care plan, dated 2/5/2020 and titled, Trauma-Informed Care, at risk for emotional disturbance due to history of traumatic life events such as attack from others, indicated for Resident 2 to receive psychological consult and a follow-up as needed for psychotherapy, psychiatric consult and follow up as needed. A review of Resident 2's care plan, dated 2/5/2020 and titled, History of Suicidal Ideation, at risk for injury to self, history of suicidal thoughts, ideation without a plan, indicated for the staff to maintain a safe environment for Resident 2 and remove possible triggers and objects that may aggravate Resident 2's thoughts and suicidal ideation. A review of Resident 2's H/P, dated 2/6/2020, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's psychologist (a clinical professional trained in mental health) evaluation, dated 2/19/2020, indicated Resident 2 verbalized he was feeling good, seemed calm, was not struggling with anxiety or depression and was looking forward to getting things in order and getting back into the community. A review of a SBAR form, dated 2/23/2020, indicated Resident 2 was hit by another resident (Resident 1), while lying in bed resulting in blood coming from a cut on Resident 2's nose. The SBAR indicated the paramedics provided treatment to Resident 2's injuries. A review of Resident 2's physicians' orders, dated 2/23/2020 indicated for Resident 2 to receive the following after being physically abused by Resident 1: 1. Tylenol (pain relieving medication) 325 mg by mouth every 6 hours as needed 2. An ice pack to the face and head. 3. Psychological monitoring, 1:1 monitoring. 4. Neurological checks (assessment of the mental status, vision, strength, coordination (balance), reflexes (reactions), and sensation (sense of feeling). A review of Resident 2's physicians' orders, dated 2/24/2020, indicated for Resident 2' laceration (deep cut) to the bridge of his nose, to be cleansed and apply an antibiotic (medication used to treat infection) ointment. During an interview on 2/25/2020 at 7:56 a.m., Resident 2 stated two days prior he was asleep in his room when Resident 1 entered his room, hit him seven (7) times on the nose and Resident 1 had to be pulled off him by the staff. Resident 2 stated he had a bloody nose that would not stop bleeding and a cut over the bridge of his nose. Resident 2 stated Resident 1 threatened him by stating If you rat on me I will get you. Resident 2 stated Resident 1 was a gang banger (a member of a violent street gang) that did not belong in the facility. A review of the facility's policy and procedure, dated 11/2018 and titled, Abuse Prevention/Prohibition, indicated the policy indicated a measure of immediate action included the Abuse Coordinator will provide a safe environment for the resident as indicated by the situation and if the suspected perpetrator is another resident, separate the residents so they do not interact with each other until circumstances of the reported incident can be clarified. A review of the facility's policy and procedures dated 9/2018 and titled, Altercations, indicated the facility acts promptly and conscientiously to prevent and address altercations. The policy indicated the facility staff observes residents for aggressive or inappropriate behaviors towards other residents, family members, visitors, or the facility staff.

Based on observations, interviews, and record reviews, the facility failed to ensure that the consultant pharmacists (a professional qualified to prepare and dispense medicinal drugs) conducted thorough [MEDICAL CONDITION] (medications or drugs that affect a person's mental state) medication regimen reviews by reviewing the residents' clinical records, and identifying and communicating the medication regimen irregularities to the physician, the facility's medical director and Director of Nursing (DON) for 24 of 24 sampled residents (Residents 5, 10, 11, 14, 16, 17, 18, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 36, and 37.) The consultant pharmacy did not identify that Resident 17 refused doses of [MEDICATION NAME] (ziprasidone, an antipsychotic medication indicated for the treatment of [REDACTED]. The consultant pharmacist recommended graduate dose reduction (GDR) of [MEDICATION NAME] and [MEDICATION NAME] Sodium on 8/6/19 and 9/10/19. The resident's attending physician discontinued [MEDICATION NAME] and [MEDICATION NAME] Sodium on 9/23/19 due to Resident 17's refusal to take these medications. The consultant pharmacy did not identify that the licensed nurses did not administer four doses of a long acting injectable form of an antipsychotic medication (medication used to treat mental illnesses) from August to November 2019 to Resident 16 and 27. The consultant pharmacy did not identify that the licensed nurses did not monitor the adverse medication antipsychotic effects (unwanted, uncomfortable, or dangerous effects) of antipsychotic medications in 24 of 24 residents receiving antipsychotics (Residents 5, 10, 11, 14, 16, 17, 18, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 36, and 37. These deficient practices resulted in improper recommendation for a GDR of the psychoactive medications. Resident 17 had an increased behavior of yelling and cursing, and physical aggression by throwing a water pitcher to her roommate, Resident 18. Resident 17 and 18 argued every night. Resident 18 cried because it was hard for her to sleep at night. These deficient practices had the potential to result in increased and uncontrolled aggressive behaviors by residents on [MEDICAL CONDITION] medications and increased incidences of verbal and physical altercations between residents. Findings: 1. A review of Resident 17's Face Sheet (admission record) indicated the facility admitted the resident on 5/20/19. Resident 17's [DIAGNOSES REDACTED]. The resident was self-responsible. A review of Resident 17's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/27/19, indicated Resident 17 was able to understand and make herself understood. The MDS indicated Resident 17 was able to make decision and had no cognitive impairment with daily decision-making. The MDS indicated Resident 17 had no impairment in ambulation (walking) in room and she utilized a wheelchair for mobility. A review of Resident 17's History and Physical (H/P), dated 5/30/19, indicated Resident 17 had fluctuating capacity to understand and make decisions. A review of Resident 17's Medication Administration Record [REDACTED] a. [MEDICATION NAME] 40 milligrams (mg, a unit of measurement) capsule by mouth two times a day (BID)for [MEDICAL CONDITION] disorder manifested by sudden anger outburst with no provocation, started on 7/14/19 and stopped on 9/23/19. b. [MEDICATION NAME] Sodium ER (extended release, pill is formulated so that the drug is released slowly over time) 250 mg tablet po (by mouth) three times a day (TID) (for [MEDICAL CONDITION] disorder) manifested by mood swings, started on 5/20/19 and stopped on 9/23/19. A review of Resident 17's Situation, Background, Appearance, Review and Notify (SBAR) Communication Form (a communication tool between members of the healthcare team about a resident's sudden change of condition), dated 5/23/19, indicated Resident 17 had been refusing medications upon admission and care. The facility staff notified Resident 17's physician. A review of Resident 17's Licensed Personnel (Nurse) Progress Notes, dated 7/1/19 (7 a.m. to 3 p.m. shift) indicated the licensed nurse was monitoring the resident due to his refusal to take his medications, agitation, and being verbally abusive to staff. A review of Resident 17's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A review of Resident 17's Psychoactive Summary Sheet (a form used by licensed nurses to document the number of specific behavioral episodes) for the use of [MEDICATION NAME] 80 mg cap by mouth BID indicated the number of sudden anger outburst without provocation episodes the resident exhibited. The summary sheet indicated that from 5/21/19 to 5/31/19, the resident exhibited 20 episodes; from 6/1/19 to 6/30/19, the resident exhibited 106 episodes; from 7/1/19 to 7/31/19, the resident exhibited 148 episodes. A review of the consultant pharmacist's monthly medication regimen review (MRR) document, titled, [MEDICAL CONDITION] & Sedative/Hypnotic Utilization By Resident, For Records Updated Between 7/1/19 and 7/15/19, prepared by the consultant pharmacist, PC 3, indicated Resident 17 was receiving the [MEDICAL CONDITION] medication [MEDICATION NAME] 80 mg, 1 capsule by mouth twice daily for [MEDICAL CONDITION] disorder. The MRR document from 81/19 to 8/6/219, prepared by PC 3, indicated a dose reduction was ordered on [DATE] to [MEDICATION NAME] 40 mg, 1 capsule by mouth twice daily for [MEDICAL CONDITION] disorder. A review of Resident 17's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A review of Resident 17's MAR indicated [REDACTED]. The MAR indicated [REDACTED] a. The morning doses (scheduled at 9 a.m.): 11 doses from 5/21/19 to 5/31/19 28 doses from 6/3/19 to 6/30/19 31 doses from 7/1/19 to 7/31/19 29 doses from 8/1 to 8/31/19 22 doses from 9/2 to 9/23/19 b. The noon doses (scheduled at 1 p.m.): 10 doses from 5/21 to 5/31/19 28 doses from 6/3 to 6/30/19 31 doses from 7/1 to 7/31/19 29 doses from 8/1 to 8/31/19 22 doses from 9/2 to 9/23/19 c. The evening doses (scheduled at 5 p.m.): 11 doses from 5/21 to 5/31/19 27 doses from 6/2 to 6/30/19 15 doses from 7/5 to 7/28/19 7 doses from 8/3 to 8/31/19 16 doses from 9/2 to 9/23/19 A review of Resident 17's Psychoactive Summary Sheet for the use of [MEDICATION NAME] Sodium ER 250 mg by mouth TID indicate the number of episodes the resident exhibited mood swings. The summary sheet indicated that from 5/23/29 to 5/31/19, the resident exhibited 50 episodes; from 6/1/19 to 6/30/19, the resident exhibited 125 episodes; and from 7/1/19 to 7/31/19, the resident exhibited 163 episodes. The August and September 2019 Psychoactive Summary Sheet of Resident 17 was not available in the clinical chart. A review of Resident 17's behavior episodes in the MAR, titled as, [MEDICATION NAME]: Monitor with Hashmark Q (every) Shift for Episodes Mood Swings indicated the resident exhibited 131 episodes from 8/1/19 to 8/31/19 and 123 episodes from 9/1/19 to 9/23/19. A review of Resident 17's Physician and Telephone Orders, dated 9/23/19, indicated to discontinue [MEDICATION NAME] and [MEDICATION NAME] Sodium due to resident's refusal to take the medications. A review of Resident 17's consultant pharmacist's MRR forms, dated 8/6/19 and 9/10/19, indicated a recommendation for a GDR due to the resident's use of [MEDICATION NAME] to manage his behavior, stabilize his mood, or treat a psychoactive disorder. The MRR indicated Resident 17 was last assessed on 8/2/19 and a review of the resident associated behaviors and monitoring parameters indicate no worsening of behaviors, behaviors noted have been none to minimal, and a recommendation was made for GDR. The MRR indicated the physician declined the GDR due to the order made on 9/23/19 to discontinue the [MEDICATION NAME] per resident's refusal to take the medication. A review of the consultant pharmacist's MRR reports from August through November 2019 did not contain any evidence that the medication regimen irregularities, such as refusal of medications and increased episodes of behaviors were identified by the consultant pharmacist or communicated to the facility's nursing or medical staff. On 11/16/19 at 6:58 a.m., during an initial tour of the facility, Residents 17 and 18 were heard cursing and yelling at each other. During a concurrent observation and interview, in the presence of Licensed Vocational Nurse (LVN) 1 and Certified Nursing Assistant (CNA) 3, Resident 18 was observed with tears in her eyes and she stated, It's hard to sleep, she (Resident 17) is always yelling and cursing. I can't sleep, I'm tired. Resident 17 yelled out to Resident 18 to get the F*** out of the room, to shut-up, F***B***. Resident 17 was observed sitting up in bed and grabbing the water pitcher and throwing the water pitcher at Resident 18. The water pitcher hit the divider curtain. Resident 19 stated both Residents 17 and 18 argued every night and it made it difficult to sleep at night. On 11/16/19 at 7:25 a.m., during an interview, LVN 5 stated Resident 18 was not able to sleep during the night on 11/15/19 due to Resident 17's behaviors of yelling and cursing at her (Resident 18). LVN 5 stated it was an ongoing problem with Resident 17. On 11/20/19 at 12:27 p.m., during an interview and record review of Resident 17's MAR, the behavioral hashmarks (the Psychoactive Summary Sheet, a documentation of the number of episodes), and the consultant pharmacist's GDR recommendations and documentations on 8/6/19 and 9/10/19, Registered Nurse (RN) 2 stated Resident 1 refused [MEDICATION NAME] and [MEDICATION NAME] from 5/21/19 to 9/23/19 and the consultant pharmacist's documentation of no worsening behaviors or behaviors noted have been none to minimal, did not reflect the documented episodes of behaviors in the MAR. On 11/27/19 at 3:20 p.m., during an interview regarding the process of the consultant pharmacist reviewing resident charts and making recommendations, the consultant pharmacist (PC 1) stated, I look at the physician orders, and I also check the patient labs to see what has been done, what has to be done, and if there are missing labs. Depending on the facility, they may have a tab in the patient's binder with the tab on the progress notes, and I check for the psych ([MEDICAL CONDITION]) meds, any GDRs that are required, and I check for 14-day PRN (as needed) meds. Those are the ones that I focus on because I know there is a lot of emphasis on these points. Beyond that, I look for any general things that may be out of place, for example, if they need to have food, or if they have an order for [REDACTED].>During the interview with PC 1, on 11/27/29 at 3:20 p.m., the following were discussed: a. Regarding if he knew why the Resident 17's prescribing physician did not respond to the 8/6/19 recommendation, PC 1 stated, That, I don't know why he did not reply. Some doctors may take their time to answer, and that may be out of my hands. b. Regarding if PC 1 knew why the next pharmacist consultant, PC 3, made the same MRR recommendation verbatim, to the prescribing physician, PC 1 stated, Usually if the doctor did not respond to the first request, we make that same request again with the recommendation that following month. c. Regarding that the medications were being refused daily by the resident from 5/21/19 through 9/23/19 and that the behavior monitoring records showed hashmarks of mostly II, III and IIII behavioral episodes per shift from 5/21/19 through 9/23/19, PC 1 stated, We didn't look into it in detail. Usually, the nurses write in the progress notes if the resident was refusing medications, and that wasn't documented, and I didn't see it. 2. A review of the clinical records of Residents 5, 10, 11, 14, 16, 17, 18, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 36, and 37 did not contain any documented evidence that the consultant pharmacist had identified or communicated the medication regimen irregularities, such as missed doses due to refusal of the residents to take the medication and the increased in number of episodes the resident exhibited behaviors. On 11/20/19 at 10 AM, during an interview, the psychiatrist (MD 1) stated that Resident 16 has been under his care since admission to the facility on [DATE]. MD 1 stated that he did not recall ever receiving any recommendations or warnings about the missed doses of Resident 16's injectable antipsychotic or about the failure to properly monitor for adverse effects related to antipsychotics from the facility's consultant pharmacist. On 11/20/19 at 1:06 PM, during an interview, RN 2 stated that the medication regimen irregularities should have been identified by the facility's consultant pharmacist and communicated to the facility's medical and nursing staff, but she is not aware of the facility receiving any communication from the consultant pharmacist specifically about these irregularities. RN 2 stated that she is not aware of any recommendations from the consultant pharmacists other than what is in their monthly report binder and the individual residents' clinical records. On 11/21/19 at 2:26 PM, during a telephone interview, PC 1 stated that he could not find any note from any consultant pharmacist regarding the lack of monitoring for general adverse effects of antipsychotics for Residents 5, 10, 11, 14, 16, 17, 18, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 36, and 37 or any note from PC 2 concerning the facility's failure to administer four doses of a long acting injectable form of an antipsychotic for Residents 16 and 27 from August to November 2019. A review of the pharmacy policy and procedures, titled, Consultant Pharmacy Services, effective date April 2019, indicated, Procedures .The consultant pharmacist will provide pharmaceutical care services, including but not limited to the following .Reviewing the medication regimen (drug regimen review) of each resident at least monthly, incorporating federally mandated standards of care in addition to other applicable professional standards .Communicating to the responsible physician, the facility potential or actual problems detected and other findings relating to medication therapy orders, as well as communicating recommendations for changes in medication therapy and monitoring of medication therapy .Review medication administration records (MARs) .physician orders [REDACTED].

Based on observation, interview, and record review, the facility failed to ensure 13 of 45 residents (2, 4, 9, 18, 34, 38, 41, 45) were not physically, sexually, and verbally abused. Resident 1 hit Resident 2 on the face on 2/23/2020. The facility did not transfer Resident 1 to the general acute care hospital (GACH) for evaluation and treatment of [REDACTED]. The facility did not implement the care plan to provide a one-on-one (1:1, one staff monitoring one resident) supervision when Resident 1 exhibited actual aggression. . Resident 44 performed non-consensual (not agreed to by one or more of the people involved) oral sex on Resident 45 on 10/26/19 and hit Resident 5 on back of the head on 11/10/19 when Resident 5 refused to engage in a sexual act with Resident 44. Resident 3 wandered into the room of Resident 4 and attempted to pull her pants down on 8/21/19. Resident 10, who was wearing adult brief only, wandered into the room of Resident 9 on 11/16/19 at 4 a.m., and laid on top of the resident (Resident 9). Resident 24 alleged that Resident 38 wandered into his room through a shared restroom and Resident 38 was naked. Resident 24 was not able to verbalize date and time the allegation happened. Resident 34 stated Resident 38 was touching and rubbing him while Resident 41 stated Resident 38 informed him (Resident 41) that Resident 34 was doing sexual acts on him (Resident 38). Resident 34 and 41 were not able to verbalize date and time the allegation happened. Licensed Vocational Nurse (LVN) 1 witnessed Resident 17 and Resident 18 having a verbal altercation, then Resident 17 threw a water pitcher on Resident 18. LVN 1 did not separate the residents because she stated the residents were confused and she had not started her shift yet. This deficient practice resulted in Resident 2 sustaining a cut over the bridge of his nose; Resident 45, 4, 9, 34 and 38 becoming victims of sexual abuse; Resident 5 becoming a victim of physical abuse; and Resident 18 crying due to inability to sleep and a victim of verbal abuse. This deficient practice had the potential to result in other residents being abused and creating an unsafe environment and an environment of fear. On 2/26/2020 at 12:55p.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 and the situation created a need for an immediate corrective action) due to the facility's failure to have a system that ensures physical abuse does not occur and recur. The facility did not have an active Administrator at the time. The Department notified the Director of Nursing (DON) and the Director of Staff Development (DSD) of the serious noncompliance that threatened the health and safety of the residents. On 3/2/2020 at 10:32 a.m., the Department informed the Administrator that the facility had an immediate jeopardy situation regarding the facility's system failure to ensure the residents were not sexually and verbally abused. The Vice President of Operations (VPO) provided a plan of action (POA) starting 2/27/2020 at 5:57 p.m. to correct and remove the IJ situation. The Department has not accepted a written POA and has not lifted the IJ to date. Findings: 1a. A review of Resident 1's GACH History and Physical (H/P), prior to admission to the skilled nursing facility (SNF), dated 1/2/2020, indicated Resident 1 was admitted to the GACH due to being extremely paranoid (suspicious, distrustful), delusional (having false or unrealistic beliefs, thoughts or opinions) and persecutory (constantly annoy and bother) with irritability (easily impatient and angered). The H/P indicated a few weeks prior (date not specified), Resident 1 was sent to GACH from a SNF where he was fighting with residents. A review of Resident 1's Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and last re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Interdisciplinary Team ((IDT) a group of professionals working toward a common goal for residents) note, dated 1/13/2020, indicated Resident 1 had a history of [REDACTED]. A review of Resident 1's care plan, dated 1/13/2020 and titled, Trauma-Informed Care, at risk for emotional disturbance due to history of traumatic life events, such as history of multiple fights with others, ETOH (alcohol) and etrahydrocannabinol ((THC) psychoactive drug) abuse, homelessness, no family support and severe mental illness, indicated for Resident 1 to receive psychological consult (an evaluation of a person's mental and emotional state) and follow-up as needed for psychotherapy (a treatment of [REDACTED]. A review of Resident 1's care plan, dated 1/13/2020 and titled, History of Aggressive/Assaultive Behavior, at risk for aggression/assaultive behavior related to paranoid [MEDICAL CONDITION], history of getting into a couple of fights with staff and residents prior to admission, history of erratic, irrational behavior, history of suicidal thoughts of thinking of cutting self with a razor, indicated for the staff to observe and monitor Resident 1's behavior of desire to hurt others every shift, to place Resident 1 on 1:1 supervision once actual aggression is exhibited to promote safety to self and others, and to provide a psychiatric consult for Resident 1. A review of Resident 1's admission physician orders, dated 1/10/2020 and 1/29/2020, indicated the following medications were ordered: 1. [MEDICATION NAME] (an antidepressant (to reduce feelings of hopelessness and sadness) medication) 10 milligrams ((mg) a unit of measurement) by mouth daily for verbalizing feelings of sadness, 2. [MEDICATION NAME] (an antipsychotic (mind altering medications) used to treat mental/mood conditions) 80 mg by mouth twice daily for sudden angry outburst. The physicians' order indicated for the staff to monitor Resident 1's episodes of sudden outburst of anger by hash marks (a form of counting) every shift. 3. [MEDICATION NAME] (an antipsychotic medication used to treat mental/mood conditions) 1 mg and 2 mg by mouth every six (6) hours as needed (PRN) for fourteen (14) days for anxiety (the inability to relax) and agitation (feeling or appearing troubled or nervous). 4. Psychiatric consult and follow-up as needed. A review of Resident 1's H/P, dated 1/30/2020, indicated Resident 1 had a fluctuating capacity to understand and make decisions. A review of Resident 1's Medication Administration Record [REDACTED]. The MAR for 1/30/2020 and 1/31/2020 indicated Resident 1 exhibited 2 episodes of anger outburst as documented by hash marks. A review of Resident 1's care plans with the DON on 2/25/2020 at 3:33 p.m., indicated there were no care plans to address Resident 1's behavioral management and use of behavioral psychoactive medications. A review of Resident 1's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated 2/4/2020, indicated the resident's cognition (thought process) was moderately impaired. A review of a Situation, Background, Assessment and Recommendation ((SBAR) an internal communication form), dated 2/11/2020, indicated Resident 1 was verbally abusive and aggressive towards staff and others. The SBAR indicated Resident 1 was observed pacing up and down the hallways of the facility while being verbally aggressive and disrupting other residents and staff. The SBAR indicated Resident 1 was redirected over seven (7) times that day (2/11/2020) while the resident continued to be verbally aggressive. The SBAR indicated a message was left for Resident 1's physician. A review of Resident 1's nurses' note, dated 2/11/2020 on the 7 a.m. to 3 p.m. shift, indicated there was no documented evidence that Resident 1 was being monitored for being verbally abusive towards staff and residents. A review of Resident 1's nurses' notes, dated 2/22/2020, indicated time entries at 4:15 a.m., 5 a.m., 6 a.m., and 8 a.m. The 4:15 a.m. entry indicated Resident 1 was verbally aggressive and abusive, disrupting his roommate by playing loud music, and Resident 1 stated, I don't give a f*** about everybody and whatever they said. The entry at 5 a.m. indicated Resident 1 was lying in bed naked while yelling obscenities and stated, I would get rid of your mother****ing sorry a**. The nurses' note entry at 6 a.m. indicated Resident 1 was angry, agitated talking loudly to himself, [MEDICATION NAME] was offered; however Resident 1 refused. The 8 a.m. entry indicated Resident 1's physician stated to transfer Resident 1 to the GACH. A review of an SBAR, dated 2/22/2020 and timed at 7:05 a.m. indicated Resident 1 was verbally abusive towards staff and residents. The SBAR indicated Resident 1 was observed pacing the hallways while being verbally aggressive and disrupting other residents and staff by yelling and reciting obscenities (an extremely offensive word or expression). The SBAR indicated Resident 1 refused to stop being disruptive and the DON and Resident 1's physician were notified. The SBAR indicated at 8 a.m. on 2/22/2020, a physician's orders [REDACTED]. A review of Resident 1's physician orders [REDACTED]. A review of Resident 1's nurses' notes, dated 2/22/2020 on the dayshift (7 a.m. to 3 p.m.) and evening shift (3 p.m. to 11 p.m.) indicated Resident 1 was being monitored by staff for being verbally aggressive and abusive. The nurses' note for 2/22/2020, which was reviewed with DON 2 2/25/2020 at 3:33 p.m., indicated there was no documented evidence Resident 1 had been transferred to the GACH. A review of Resident 1's nurses' notes from 2/1/2020 through 2/23/2020 indicated there was no documented evidence of Resident 1 was being monitored 1:1 in accordance with the care plan that addressed the resident's history of aggressive and assaultive behavior and risk for aggression/assaultive behavior. A review of Resident 1's nurses' note, dated 2/23/2020 and timed at 8:30 p.m. indicated Resident 1 walked into Resident 2's room and hit Resident 2 in the face. The nurses' note indicated, when the staff arrived in Resident 2's room, Resident 1 continued to hit Resident 2 while the staff were pulling him off Resident 2. A review of an SBAR, dated 2/23/2020 and timed at 9 p.m. indicated Resident 1 left the facility against medical advice (AMA) after assaulting Resident 2. A review of Resident 1's MAR, for the month of 2/2020, indicated Resident 1 did not have any episodes of anger outburst documented by hash marks from 2/1/2020 through 2/24/2020 (sic). On 2/25/2020 at 8:44 a.m., during an interview, Resident 1's roommate (Resident 46) stated Resident 1 was cuckoo (crazy), noisy, and yelled and cursed loudly. Resident 46 stated Resident 1 hit another resident (Resident 2) the day prior. Resident 46 stated everyone in the facility complained about Resident 1. On 2/25/2020 at 9:35 a.m., during an interview, Certified Nursing Assistant 8 (CNA 8) stated on 2/23/2020, she was standing at Nursing Station 1 when she observed Resident 1 exiting Resident 2's room with a bloody (shirt) sleeve. CNA 8 stated she observed Resident 2 with blood all over his face. CNA 8 stated the paramedics (a health field worker trained to provide emergency services) were called and upon arrival, Resident 2 refused to be transferred to the GACH. Resident 2 received treatment from the paramedics for his injuries. CNA 8 stated the police was notified and when the police arrived at the facility, Resident 2 stated he did not want to press charges against Resident 1. CNA 8 stated according to Resident 2, Resident 1 would stare at Resident 2 during the smoking hours. On 2/25/2020 at 3:33 p.m., during a concurrent interview and review of Resident 1's records, DON 2 was asked how the staff knew how to provide care for Resident 1 when the care plans titled, behavioral management and behavioral psychoactive medication, dated from 1/29/2020 through 2/23/2020, were incomplete. DON 2 stated the staff would call Resident 1's physician and Resident 1 would be placed on 1:1 monitoring. DON 2 stated Resident 1 should have a care plan for behavioral symptoms including behavioral medications. The DON 2 was asked if Resident 1 was transferred to the GACH on 2/22/2020, as ordered by the physician. The DON 2 stated Resident 1 was not transferred to the GACH on 2/22/2020. During a telephone interview, on 2/25/2020 at 4:55 p.m., LVN 7 stated Resident 1 was verbally aggressive and abusive to staff and residents. LVN 7 stated on 2/22/2020, she obtained a telephone order from Resident 1's physician to transfer Resident 1 to the GACH. LVN 7 stated she did not transcribe (record) Resident 1's physicians' order due to having to clock out to leave and endorsed it to the oncoming LVN to transcribe Resident 1's physicians' order. LVN 7 stated Resident 1 had escalating behaviors in which Resident 1 had to be re-directed more than seven (7) times in one day. LVN 7 stated she documented Resident 1's escalating behaviors in the nurses' notes and on the SBAR, and stated she did not complete hash marks or a tally of Resident 1's behavioral episodes in the Resident 1's MAR. On 2/25/2020 at 5:40 p.m., during an interview, LVN 8 stated Resident 1 would always enter Resident 2's room looking for Resident 2's roommate, but Resident 2's roommate was discharged from the facility. LVN 8 stated on 2/23/2020, Resident 2 was lying in bed asleep, began crying after being beaten up by Resident 1. and Resident 1 was separated from Resident 2. LVN 8 stated Resident 2 was bleeding from the bridge of his nose, and she cleaned Resident 2's nose and placed an ice pack, until the paramedics arrived. LVN 8 stated if Resident 1 was told to wait for something, he would point at her and state, I want it now. LVN 8 stated she was afraid when Resident 1 talked to her. On 2/26/2020 at 10:52 a.m., during an interview, CNA 5 stated in the month of 1/2020, Resident 1 was aggressive and would walk around the facility saying, F*** you, in an aggressive manner. CNA 5 stated she would ensure residents who were not able to defend themselves where kept at a distance from Resident 1 and removed from the area to avoid contact with Resident 1. b. A review of Resident 2's GACH's H/P, prior to the admission to the SNF, dated 1/23/2020 indicated Resident 2 had suicidal ideation (desire to kill oneself) without a plan. The H/P indicated Resident 2 required hospitalization for a total of 14 days and was transferred to the SNF on 2/5/2020. A review of Resident 2's SNF Admission Record, indicated Resident 2 was admitted to the facility on [DATE]. Resident 2' [DIAGNOSES REDACTED]. A review of Resident 2's physician's admission orders [REDACTED] 1. [MEDICATION NAME] 60 mg by mouth twice daily for sudden angry outburst. 2. [MEDICATION NAME] (an antidepressant medication) 40 mg by mouth daily for verbalizing feelings of sadness. The physicians' order indicated for the staffs to monitor Resident 2's episodes of sudden outburst of anger by hash marks every shift. 3. [MEDICATION NAME] 2 mg every six (6) hours PRN (as needed) for fourteen (14) days for anxiety. A review of Resident 2's care plan, dated 2/5/2020 and titled, Trauma-Informed Care, at risk for emotional disturbance due to history of traumatic life events such as attack from others, indicated for Resident 2 to receive psychological consult and a follow-up as needed for psychotherapy, psychiatric consult and follow up as needed. A review of Resident 2's care plan, dated 2/5/2020 and titled, History of Suicidal Ideation, at risk for injury to self, history of suicidal thoughts, ideation without a plan, indicated for the staff to maintain a safe environment for Resident 2 and remove possible triggers and objects that may aggravate Resident 2's thoughts and suicidal ideation. A review of Resident 2's H/P, dated 2/6/2020, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's psychologist (a clinical professional trained in mental health) evaluation, dated 2/19/2020, indicated Resident 2 verbalized he was feeling good, seemed calm, was not struggling with anxiety or depression and was looking forward to getting things in order and getting back into the community. A review of a SBAR form, dated 2/23/2020, indicated Resident 2 was hit by another resident (Resident 1), while lying in bed resulting in blood coming from a cut on Resident 2's nose. The SBAR indicated the paramedics provided treatment to Resident 2's injuries. A review of Resident 2's physicians' orders, dated 2/23/2020 indicated for Resident 2 to receive the following after being physically abused by Resident 1: 1. Tylenol (pain relieving medication) 325 mg by mouth every 6 hours as needed 2. An ice pack to the face and head. 3. Psychological monitoring, 1:1 monitoring. 4. Neurological checks (assessment of the mental status, vision, strength, coordination (balance), reflexes (reactions), and sensation (sense of feeling). A review of Resident 2's physicians' orders, dated 2/24/2020, indicated for Resident 2' laceration (deep cut) to the bridge of his nose, to be cleansed and apply an antibiotic (medication used to treat infection) ointment. During an interview on 2/25/2020 at 7:56 a.m., Resident 2 stated two days prior he was asleep in his room when Resident 1 entered his room, hit him seven (7) times on the nose and Resident 1 had to be pulled off him by the staff. Resident 2 stated he had a bloody nose that would not stop bleeding and a cut over the bridge of his nose. Resident 2 stated Resident 1 threatened him by stating If you rat on me I will get you. Resident 2 stated Resident 1 was a gang banger (a member of a violent street gang) that did not belong in the facility. A review of the facility's policy and procedure, dated 11/2018 and titled, Abuse Prevention/Prohibition, indicated the policy indicated a measure of immediate action included the Abuse Coordinator will provide a safe environment for the resident as indicated by the situation and if the suspected perpetrator is another resident, separate the residents so they do not interact with each other until circumstances of the reported incident can be clarified. A review of the facility's policy and procedures dated 9/2018 and titled, Altercations, indicated the facility acts promptly and conscientiously to prevent and address altercations. The policy indicated the facility staff observes residents for aggressive or inappropriate behaviors towards other residents, family members, visitors, or the facility staff. 2a. A review of Resident 44's Admission Record (Face Sheet) indicated the facility initially admitted Resident 44 on 8/21/19 and readmitted him on 10/28/19, with [DIAGNOSES REDACTED]. A review of Resident 44's MDS, dated [DATE] indicated Resident 44 has moderately impaired mental cognition. A review of Resident 44's Licensed Personnel Progress Note, dated 10/26/19 and timed at 7:45 a.m., indicated a staff notified LVN 1 that Residents 44 and 45 walked into Resident 45's room after talking about having sex while in the dining room. The progress note indicated upon entering Resident 45's room, LVN 1 observed Resident 44 performing oral sex on Resident 45 and LVN 1 immediately separated both residents. A review of the facility's investigation interviews, dated 10/28/19 and timed at 3 p.m., indicated Residents 44 and 45 engaged in consensual (both parties consenting or agreeing) sexual activity on 10/28/19 (sic). A review of the physician's telephone order, dated 10/28/19 and timed at 4 p.m., indicated an order to transfer Resident 44 to a GACH for medical clearance and a psych (psychiatric, a branch of medicine that deals with mental, emotional, and behavioral disorders) evaluation. A review of a facility's document titled, Resident Transfer and Referral Record, dated 10/28/19, indicated the facility transferred Resident 44 to GACH for sexually inappropriate behavior and a psych evaluation. A review of Resident 44's GACH's H/P, dated 10/29/19, indicated the resident was verbally abusive towards staff and residents and was sexually inappropriate by removing his clothes in common places. b. A review of Resident 45's Admission Record indicated the facility initially admitted Resident 45 on 7/10/18 and readmitted him on 5/6/19, with [DIAGNOSES REDACTED]. The Admission Record indicated Resident 45's was conserved (had a court appointed guardian). A review of Resident 45's H/P, dated 11/9/19, indicated the resident had no capacity to understand and make decisions. A review of a Situational, Background, Assessment and Response (SBAR, an internal communication tool) form, dated 10/26/19, indicated Resident 45 received fell ation (oral stimulation of the penis) from Resident 44. A review of the physician telephone order, dated 10/28/19 and timed at 10:05 a.m., indicated to transfer Resident 45 to GACH for sexual preoccupation (tendency to become obsessed with thoughts about sexual behaviors). On 11/16/19 at 10:24 a.m., during an interview, Resident 45 stated he had engaged in sexual activity with another resident. Resident 45 stated he was not able to recall who the resident was. On 11/16/19 at 11:05 a.m., during an interview, the Social Services Designee (SSD) stated Resident 45 has no mental capacity to make decisions. c. A review of Resident 5's Admission Record indicated the facility initially admitted Resident 5 on 8/6/18 and readmitted the resident on 1/27/19, with [DIAGNOSES REDACTED]. A review of Resident 5's H/P, dated 1/28/19, indicated the resident had no mental capacity to understand and make decisions. A review of the document titled, Incident/Accident Report, dated 11/10/19 and timed at 5:05 a.m., indicated Resident 5 was involved in a physical altercation with his roommate, Resident 44. The report indicated Resident 44 slapped Resident 5 behind the head randomly, and there was no conflict between Residents 44 and 5 were noted. The report indicated Resident 44 was seen making physical contact with Resident 5 while in the hallway. The report did not specify what type of physical contact. On 11/16/19 at 7:30 a.m., during a concurrent interview with LVN 4 and CNA 8, LVN 4, the author of the Incident/Accident Report dated 11/10/19, stated Residents 44 and 5 were roommates. LVN 4 stated, I heard a hit, on 11/10/19 at 3 a.m. (when Resident 44 slapped Resident 5 behind his head). CNA 8 stated Resident 44 hit Resident 5 on the head. Both LVN 4 and CNA 8 stated Resident 44 has the behavior of striking out, swings at residents and nurses, curses all the time, and that Resident 44's behavior started from nowhere. LVN 4 stated Resident 44 was transferred to GACH (date not mentioned) after hitting Resident 5 on the head. On 11/16/19 at 10:29 a.m., during an observation and interview, Resident 5 was sitting on his bed, rocking back and forth while looking down. Resident 5 stated, I did not want to be with him (Resident 44). Resident 5 stated he did not want to engage in a sexual act with Resident 44 so Resident 44 hit the back of his (Resident 5) head. d. A review of Resident 3's Admission Record indicated the facility admitted the resident on 7/19/19. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's MDS, dated [DATE], indicated the resident had impaired cognition for daily decision-making. The MDS indicated Resident 3 was able to understand and make herself understood. A review of the facility's Interview Record, dated 8/21/19, indicated CNA 7 stated she walked into Resident 4's room after hearing the resident's door being closed. CNA 7 stated she saw Resident 3 trying to pull down Resident 4's pants, while Resident 4 was stating continuously, Get off me, it hurts. The Interview Record indicated CNA 7 separated the residents and escorted Resident 3 back to her room. A review of a facility's undated document titled, Witness Statement/Interview, indicated Resident 4 told Resident 3 not to kiss her. The document indicated Resident 4 gave a statement that She (Resident 3) tried to pull down her pants one time, but I told her (Resident 3) that I don't want to do it. A review of an undated document titled, Multi-IDT (Interdisciplinary Team (coordinated group of experts from different fields who work together toward a common goal)) Conference, indicated Resident 3 had episodes of constantly talking and verbalizing profanities (obscene language), displayed sexual innuendos (hint, suggestive) particularly to other male residents, and displayed sexual preoccupied behavior manifested by stripping/undressing in public. The IDT's plan was to transfer Resident 3 to a facility that would able to provide services needed to decrease sexual inappropriate behavior and managed it appropriately, and thoroughly investigate incidents occurred. e. A review of Resident 4's Admission Record indicated the facility admitted the Resident on 6/6/19, with [DIAGNOSES REDACTED]. The Admission Record indicated Resident 4 was conserved. A review of Resident 4's MDS, dated [DATE], indicated the resident had moderately impaired cognition. A review of Resident 4's H/P, dated 10/25/19, indicated the resident had no capacity to understand and make decisions. On 11/16/19 at 11:45 a.m., during an interview, Registered Nurse (RN) 1 stated residents were not allowed to engage in sexual activities due to the facility did not have private rooms and condoms (a device worn over a male reproductive organ or inserted into the female reproductive organ to prevent infection and pregnancy). RN 1 stated both residents must consent and if residents were caught engaging in sexual activity, they were immediately separated. RN 1 stated the facility does not allow informed (permission granted with the knowledge of possible consequences) sexual activity. On 11/16/19 at 3:04 p.m., during a concurrent interview with the Administrator and DON, the Administrator stated the facility did not have a policy to address the residents' sexual activity and protection from STDs and/or pregnancies. The DON was not able to state how sexually active residents were supervised and protected from STDs and/or pregnancies. f. A review of Resident 9's Admission Record indicated the facility admitted the resident on 5/1/19 with [DIAGNOSES REDACTED]. A review of Resident 9's MDS, dated [DATE], indicated the resident was able to understand and be understood by others, and had no memory problems. The MDS indicated Resident 9 was impaired in bilateral (both) lower extremities and was dependent of a one-person physical assist in activities of daily living, such as eating, toilet, personal hygiene, and bed mobility. A review of Resident 9's Care Plan for Activities of daily living, dated 5/2019, indicated Resident 9 was dependent (required assistance) in bed mobility (changing positions in bed), and transfers to and from bed. On 11/17/19 at 11:40 a.m., during an interview, Resident 9 stated on 11/16/19 at 4 a.m., Resident 10, who was only wearing adult briefs, entered his room and laid on top of him. Resident 9 stated he yelled for help and the staff members went into his room and removed Resident 10 from on top of him. Resident 9 stated the staff was aware of Resident 10's (wandering, to walk without purpose and permission) behavior because it was not the first time it happened. Resident 9 stated he felt uncomfortable, unsafe and helpless (in the facility). On 11/17/19 at 12:07 p.m., during an interview, the DSD stated all the staff members are responsible to monitor Resident 10 for his wandering behavior. On 11/17/19 at 1:52 p.m., during an interview, the DON stated the residents should feel safe in the facility. The DON stated Resident 9 did not have the capacity to protect himself from other residents. On 2/29/2020 at 1:32 p.m., during an interview, Resident 9 stated a male resident (Resident 10) climbed on top of him (Resident 9) and started rubbing on him. Resident 9 stated he called for help and a nurse (not identified) saw what happened. Resident 9 stated he pushed the male resident off him and that the facility just did not care. During the interview, Resident 9 became very angry and started to raise his voice. Resident 9 did not state when the incident happened. g. A review of Resident 10's Admission Record indicated the facility readmitted the resident on 9/24/19 with [DIAGNOSES REDACTED]. A review of Resident 10's MDS, dated [DATE], indicated Resident 10 has severely impaired cognition. On 11/17/19 at 1:35 p.m., during an interview and a concurrent review of the comprehensive care plans, the DON stated she did not and had not informed the physicians of Residents 3, 4, 44, and 45's inappropriate sexual behavior. The DON stated the comprehensive care plans were not revised and/or updated for Residents 3, 4,10, 44 and 45. The DON stated she did not know if Residents 3, 4,10, 44 and 45 had a life threatening [MEDICAL CONDITION]. On 3/2/2020 at 4:52 p.m., during an interview and record review with RN 1, RN 1 stated Resident 10 did not have an assessment and a care plan for inappropriate sexual behavior. h. A review of Resident 24's Admission Record indicated the facility admitted the resident on 7/2/19 with [DIAGNOSES REDACTED]. A review of Resident 24's H&P, dated 7/24/19, indicated the resident had the capacity to understand and make decisions. On 2/29/2020 at 1:45 p.m., during an interview ,Resident 24 stated that one week ago (date not specified), a male resident (Resident 38) with female features wandered (walking without purpose and permission) in his room through a shared restroom, with his pants down and private parts exposed. Resident 24 stated he told the male resident to get the *F* out of my room. Resident 24 stated he was really upset, and he could not get up and walk because his left leg is amputated below the knee (TRUNCATED)

Based on observation, interview, and record review, the facility failed to provide supervision with one-person assist in walking to prevent falls for one of three sampled residents (Resident 1). Resident 1, who was confused with an unsteady gait (walk) and required monitoring and supervision and was preoccupied with smoking cigarettes with a behavior of looking for cigarette butts on the ground, was left unsupervised in the patio and had an unwitnessed fall. This deficient practice resulted in Resident 1 falling in an isolated area ( not visited by many) behind the facility's kitchen sustaining injuries to the face and shoulder with bleeding. Resident 1 required a transfer to a general acute care hospital (GACH) for evaluation and treatment. Findings: On 9/17/19 at 7:12 a.m., during an unrelated complaint investigation, Resident 1 was observed in the hallway with an unsteady gait, pacing back and forth unsupervised, outside room [ROOM NUMBER], bleeding from the left side of the face, left shoulder and left hand. On 9/17/19 at 7:15 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1's nurse left before the end of her shift on 9/17/19 and there was no one monitoring the residents. On 9/17/19 at 7:20 a.m., during a concurrent observation and interview, Resident 1 who was confused, was pacing back and forth unsupervised while requesting to be taken to the emergency room (ER) for treatment. Resident 1 also requested for the nurses to cover his bleeding injuries to the left side of his face and left shoulder. On 9/17/19 at 7:25 a.m., during an interview, LVN 2 stated who was assigned to Resident 1 LVN 3 had a tendency of leaving the facility before the end of her shift without endorsing the care of all residents in Station 2 to the incoming nurse. LVN 2 stated that for over a year, LVN 3 had never endorsed the care of residents to her because when she clocked in at 6:57 a.m., LVN 3 had already clocked out. LVN 2 stated Resident 1 was confused and had a tendency of wandering around and picking up cigarette butts from the patio to smoke. LVN 2 stated a Certified Nursing Assistant (CNA) usually stayed with Resident 1 in the facility, to prevent falls and injuries. On 9/17/19 at 7:33 a.m., during a concurrent observation and interview, Resident 1 who was confused with an unsteady gait was pacing back and forth the hallway in Station 2 requesting to be taken to the ER, for the bleeding wounds to be covered and for pain medications. Registered Nurse (RN 1) stated Resident 1's injuries would be covered after the resident was medicated. On 9/17/19 at 8:33 a.m., during an interview, Resident 2 stated Resident 1 was observed walking from the patio area bleeding from the injuries on his face and shoulder. According to Resident 2, Resident 1 had an unwitnessed fall on 9/17/19 outside the patio and sustained injuries. On 9/17/19 at 8:40 a.m., during a concurrent observation and interview, Resident 1 whose wounds were still opened and bleeding, continued to pace back and forth and walked out to the patio area asking the Surveyor to come with him. Resident 1 stated I will show you how I fell . Resident 1 who remained unsupervised walked to the back of the facility's kitchen to a secluded area, out of staff's visual field and pointed at a rough concrete area stating, This is how I fell . Resident 1 stated he picked up a cigarette butt to smoke and fell over hurting himself. Resident 1 stated he often went behind the building because it had a lot of butts for him to smoke. According to Resident 1, the staff never followed him to this secluded area. On 9/17/19 at 9:02 a.m., during an interview, RN 1 stated Resident 1 had an unsteady gait and had the tendency of wandering in and out of the facility. RN 1 stated Resident 1 liked to pick cigarette butts. RN 1 stated Resident 1 might have lost his balance when he tried to pick up a cigarette butt to smoke . The cigarette butt was not lighted and Resident 1 did not have a lighter on him. RN 1 stated the LVN or CNA assigned to Resident 1 was not in the facility when the resident had a fall. According to RN 1, Resident 1 could not smoke unassisted and had to be monitored and supervised to prevent cigarette burns, falls and injuries. On 9/17/19 at 10:25 a.m., during an interview, the Director of Nursing (DON) stated LVN 3 was supposed to endorse Resident 1's care to the incoming nurse before leaving the facility early. The DON stated Resident 1 was not supervised at the time of the fall on 9/17/19 and LVN 3 was supposed to supervise Resident 1 to ensure the resident did not go out to the patio unassisted. On 9/17/19 at 3:33 p.m., during an interview, the administrator (ADM) stated LVN 3 had a history of [REDACTED]. The ADM stated LVN 3 was the type of nurse who would endorse residents' care to another nurse (any nurse working on the same shift as LVN 3) working the same shift as her and without waiting for the incoming nurse. A review of Resident 1's Admission Face sheet indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's history and physical (H/P) report, dated 6/7/19, indicated Resident 1 had a fluctuating capacity to understand and make decision (could sometimes understand and make decisions). A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 6/12/19 indicated Resident 1 was usually able to understand and be understood by others. The MDS indicated Resident 1 had delusions (believed in things that could not be true), required a one-person physical assist moving to or from a bed, chair to a standing position, with walking, dressing, and toilet use. The MDS indicated Resident 1 was receiving antipsychotic and antidepressant medications (medications for mental disorders). A review of Resident 1's care plan, dated 6/6/19 indicated Resident 1 was at risk for falls related to poor balance, use of medications and diagnosis. The staff's interventions included to orient the resident to the environment each time changes were made, provide an environment that supports minimized hazards over which the facility had control, keep Resident 1's call light within reach, and monitor Resident 1 for side effects of medication, provide activities that enhances mobility if not in conflict with the resident's medical condition. A review of Resident 1's Safe Smoking assessment dated [DATE] indicated Resident 1 was not able to light and hold a cigarette without endangering himself. A review of Resident 1's care plan, dated 8/13/19 indicated Resident 1 was at risk for hazards, injuries [MEDICAL CONDITION] to smoking cigarettes and smoked multiple times a day. The staff's interventions included to reassess Resident 1's physical and cognitive ability (thought process) to smoke, determine if the resident could smoke safely without harm to self or others, provide precautionary measures and supervision during smoking, provide designated smoking area, offer and provide Resident 1 with a fire-retardant (a substance that is used to slow or stop the spread of fire or reduce its intensity) apron during smoking. A review of Resident 1's Licensed Nurse Weekly Summary dated 9/16/19 indicated Resident 1 required supervision with movement and transfer. A review of an untimed Situation Background Assessment and Recommendation ((SBAR) an internal communication form), dated 9/17/19 indicated Resident 1 had a fall with an abrasion (scrapping of skin) to the head and shoulder. It indicated Resident 1 did not have increased confusion or disorientation (sic). The SBAR indicated Resident 1 had abrasions (areas damaged by scraping or wearing away) on the left upper eyebrow measuring 4 centimeters ((cm) unit of measurement) by 2.5 cm, on the left cheek bone measuring 5 cm by 3.5 cm, left shoulder measuring cm 5 by 4 cm, and left hand. According to the SBAR, Resident 1 had pain to the head and shoulder rated at 10 out of 10 (a rate of 10 indicated worst pain). The SBAR indicated Resident 1 was brought to the nurses' station by another resident (Resident 2) after falling outside. The SBAR indicated Resident 1's abrasions were cleaned and the resident was sent to the ED for evaluation. A review of Resident 1's post-fall assessment indicated on 9/17/19 at approximately 7:05 a.m., Resident 1 who had impaired balance and impaired safety awareness was bending over outside looking for cigarettes on the ground and had a fall that resulted in injuries. A review of a Resident Interview report dated 9/17/19 and timed at 10:35 a.m., indicated another resident (Resident 2) reported Resident's unwitnessed fall, after not being supervised in an unknown location on 9/17/19 at an unknown time. The Interview Report indicated Resident 1 had a habit of picking up cigarette butts on the ground to smoke and might have fallen while attempting to pick up a cigarette butt. A review of Resident 1's Emergency Department (ED) Physician Documentation dated 9/17/19 and timed at 9:21 a.m., indicated Resident 1 felt lightheaded, lost consciousness (the state of being awake and aware of one's surroundings) and fell on the left side. The ED note indicated after the fall, Resident 1 vomited multiple times and repeatedly stated, Can I go to a different place? A review of Resident 1's GACH H/P, dated 9/17/19 and timed at 4 p.m. indicated Resident 1 was smoking in the facility when the resident had a fall that resulted in a large abrasion to the left side of the resident's face and bilateral knees. A review of Resident 1's GACH Discharge Notes dated 9/19/19 indicated Resident 1 was admitted to the GACH on 9/17/19 after a fall while smoking in the facility. This note indicated Resident 1 sustained abrasions to the left side of his face, both knees and palms of the hands and Resident 1's injuries were cleansed with antibiotic soap daily. A review of the facility's follow-up letter to the Department, dated 9/23/19 indicated on 9/17/19 Resident 1 had a fall incident and was sent to a GACH for evaluation and was readmitted back to the facility on [DATE]. A review of the facility's policy titled, Smoking by Residents, dated of 9/2018, indicated the facility would provide a safe environment that allowed residents who wished to smoke to do so safely. It also indicated Residents who required assistance and or monitoring for smoking safety were not allowed to smoke unaccompanied and unsupervised. A review of the facility's policy titled, Safety and Supervision of Residents with a revised date of 12/2007, indicated residents would be supervised and assisted to prevent accidents. A review of the facility's policy titled, Routine Resident Checks, with a revised date of 7/2013,indicated the staff would make routine residents' checks every two help maintain resident safety and well-being.

Based on interview and record review, the facility failed to develop and implement a baseline care plan at admission that contained specific interventions directing staff to implement needed care and supervision for one of four sampled residents, (Residents 1 and 2). Resident 1, who required supervision while smoking, smoked marijuana in his room on 1/1/2020 and kept two cigarettes given by staff at his bedside. The facility did not implement the care plan interventions to supervise the resident while smoking and to offer provide safe storage for smoking devices. Resident 1 had a history of [REDACTED]. Resident 2, who had a history of [REDACTED]. The facility did not develop a care plan at admission with interventions implemented to address how the facility would manage their risk to commit suicide, their need for a psychiatric evaluation (an evaluation of the causes, the symptoms, the course and the consequences of a psychiatric disorder to formulate a [DIAGNOSES REDACTED]. This deficient practice had the potential to result in death for Resident 1 and 2 and for other residents with suicidal ideation. A pattern of the facility's failure to ensure staff supervise Resident 1 and 2 with a history of suicidal ideation and who verbalized suicidal ideation, constituted 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) situation and need for an immediate corrective action. The systems failure resulted in an immediate threat to the health and safety for other residents in the facility. On 1/7/2020 2:28 p.m., the Department declared an Immediate Jeopardy regarding the facility's failure to supervise residents with history of suicidal ideation and who verbalized ideations of suicide and was not evaluated by a psychiatrist after 30 days, and to implement the facility's policy and procedure, titled Suicide Threats. The Department notified the facility's Vice President of Operations ((VPO 1 and 2) who were acting as 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 1/7/2020 at 6:03 p.m., VPO 1 provided an acceptable written plan of action (POA) which included the following: On 1/7/2020 at 6:03 p.m., the facility's VPO, provided an acceptable written plan of actions (POA) which included the following: 1. Resident 2 was immediately placed on one-to-one (1:1) supervision (one staff monitoring one resident) for verbalizing suicidal ideation and transferred to the GACH via 911. Resident 2's care plan was reviewed and update to address the resident's suicidal ideation. 2. Resident 1's care plan was reviewed and updated to address the resident's suicidal ideation. 3. The Director of Staff Development (DSD) conducted an in-service to staff regarding the importance of providing close supervision and monitoring of residents with suicidal ideation, including proper assessment, initiation of a care plan to address suicidal risk and implementing a monitoring log. 4. Facility will obtain a psychiatric clearance for residents being admitted with suicidal history. 5. New Admissions will be reviewed by IDT within 24 to 72 hours to check residents for care plan completion, addressing suicidal ideation, and ensure monitoring logs are in place (monitoring every 15 to 30 minutes for 72 hours). 6. Resident identified as expressing threats of suicide will be placed on 1:1 monitoring and psychiatric consultation or transfer for emergency evaluation will be implemented. On 1/9/2020 at 10:52 a.m., the Department lifted the Immediate Jeopardy after an on-site verification and confirmation that the facility implemented the POA. Findings: a. A review of Resident 1's general acute care hospitals (GACH) emergency room (ER) history and physical (H/P), prior to admission to the facility, dated 11/25/19, indicated GACH admitted the resident for suicidal ideation and for verbalizing a desire to die by overdosing (taking a dangerous or an excessive amount of medications on medications) on medication, cutting his wrist or getting shot by the police. A review of Resident 1's GACH H/P, dated 12/2/19, indicated Resident 1 continued to have auditory hallucinations (seeing things and hearing voices that are not there) telling him to harm himself and verbalize [MEDICAL CONDITION] by overdosing. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's history and physical (H/P), dated 12/6/19, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's baseline care plan, dated 11/30/19 (sic), indicated the resident had a history of [REDACTED]. for suicide. A review of Resident 1's admission orders [REDACTED]. A review of Resident 1's Safe Smoking assessment dated [DATE], indicated the resident required supervision while smoking. A review of Resident 1's care plan, dated 12/9/19, and titled Smoking, At Risk for Hazards/Injury, related to smoking, as evidenced by smokes multiple times a day and prefers to smoke without supervision, indicated for the staff to provide precautionary measures and supervision during smoking schedule if possible, and offer and provide safe storage for smoking devices. A review of a Situation, Background, Assessment and Recommendation ((SBAR) an internal communication tool) form, dated on 1/1/2020, indicated at 10 a.m., Resident 1 was allegedly smoking marijuana in his room. According to the SBAR, Resident 1 stated marijuana calmed him down and he had [MEDICAL CONDITION]. The SBAR indicated Resident 1 had two (2) containers of marijuana. On 1/7/2020 at 7:25 a.m., during an observation, Resident 1 walked out of his room with an unused and unlit cigarette behind his right ear. Resident 1 was asked how the cigarettes were supplied in the facility, Resident 2 stated the staff outside in the smoking area gave him two (2) cigarettes on the day before and he kept an extra cigarette in his drawer at his bedside. Resident 2 stated he was not allowed to have a cigarette(s) in his room and stated that he did not want to get the staff in trouble. A review of the facility's supervised smoking hours indicated the listed smoking hours were as follow: 8 a.m. to 8:30 a.m. 10 a.m. to 10:30 a.m. 12:30 p.m. to 1 p.m. 2 p.m. to 2:30 p.m. 4 p.m. to 4:30 p.m. 5:30 p.m. to 6 p.m. 7:30 p.m. to 8 p.m. On 1/7/2020 at 10:01 a.m., during an interview, the Director of Staff Development (DSD), stated on 1/1/2020, Resident 1 had ordered food for delivery to the facility. When the delivery person arrived at the facility, he went into Resident 1's room and closed the door. The DSD stated the staff became suspicious of Resident 1's room door being closed, when the staff smelled marijuana coming from Resident 1's room. According to the DSD, the staff intercepted Resident 1 from smoking marijuana in his room. A review of Resident 1's Medication Administration Record (MAR), dated for 1/2020, indicated from 1/1/2020 through 1/7/2020, Resident 1 verbalized nine (9) behavioral episodes of sadness, exhibited 15 behavioral episodes of the inability to relax and exhibited 12 behavioral episodes of anger outburst as indicated by hash marks (a form of counting). The MAR indicated Resident 1 was administered 1 mg of [MEDICATION NAME] on 1/1/2020 at 9 a.m. and on 1/2/2020 at 8:30 a.m., for feeling anxious. Upon review of Resident 1's clinical record on 1/7/2020, there was no documented evidence the facility developed and implemented a care plan with interventions to address how the facility would manage the resident's suicidal risk and the need for a psychiatric evaluation. b. A review of Resident 2's GACH's H/P, prior to admission to the facility, dated 11/8/19, indicated that for the past few days, Resident 2 had positive [MEDICAL CONDITION] with an increased desire to hurt himself by scratching his arms. The H/P indicated Resident 2 required hospitalization for a total of 11 days and was transferred back to the facility on [DATE]. A review of Resident 2's Admission Record indicated the resident was initially admitted to the facility on [DATE] and last re-admitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 2's admission orders [REDACTED]. A review of Resident 2's H/P, dated 11/22/19, indicated the resident had a fluctuating capacity to understand and make decisions. A review of Resident 2's care plan, dated on 11/26/19 and titled Mood State, decline in interest or pleasure doing things previously enjoyed, indicated for the staff to monitor the resident for changes in mental status. Resident 2's care plan had an option to select the intervention for the staff to monitor the resident for signs of suicidal ideation or harmful acts or behaviors, but this option was not selected as a specific intervention for the staff to implement on the resident. A review of a SBAR form, dated 12/5/19, indicated Resident 2 verbalized feelings of suicidal ideation by planning to scratch himself. According to the SBAR, on the same day at 5:26 p.m., the staff called Resident 2's Psychiatrist's (a physician who specializes in the [DIAGNOSES REDACTED]. A review of a nurses' note, dated 12/6/19 at 12:15 p.m., indicated Resident 2 approached the nurses' station and verbalized feelings of suicidal ideation when the staff redirected Resident 2. The staff informed the resident that a telephone call was placed on 12/5/19 to the transfer coordinator and the facility was waiting for a return call from the hospital for bed availability for Resident 2. A review of Resident 2's MAR, dated for 12/2019, indicated on 12/14/19, Resident 2 exhibited behavioral two (2) episodes of anger outburst, the inability to relax and mood swings as indicated by hash marks. A review of Resident 2's MAR dated for 1/2020, indicated the resident exhibited nine (9) behavioral episodes of mood swings as indicated by hashmarks from 1/1/2020, through 1/7/2020. The MAR indicated Resident 2 exhibited one (1) behavioral episode of sudden anger outburst on 1/7/2020. Upon review of Resident 2's clinical record on 1/7/2020, there was no documented evidence the facility developed and implemented a care plan with interventions to address how the facility would manage the resident's suicidal risk and the need for a psychiatric evaluation. On 1/7/2020 at 12:10 p.m., during an interview, the Director of Nursing (DON) and the Registered Nurse Supervisor (RNS) 1 stated a care plan is initiated upon admission within 48 hours for residents with a history of [MEDICAL CONDITION]. On 1/7/2020 at 12:38 p.m., during an interview Licensed Vocational Nurse (LVN) 1 stated there were no residents currently in the facility who were at risk for suicide or had a history of [REDACTED]. LVN stated a at risk for suicide care plan is developed within 48 hours and if a resident verbalized suicidal ideation, the resident would be placed on 1:1 monitoring by the staff. On 1/7/2020 at 12:45 p.m., during an interview, LVN 2 stated Resident 2 was the only resident in the facility who was at risk for suicide. LVN 2 stated when suicidal risk residents are admitted to the facility, they are monitored by the staff for 72 hours, a psychiatric eval is conducted and a care plan is developed. LVN 2 stated the purpose of a suicidal risk care plan is for the staff to determine when residents are improving. LVN 2 stated residents with suicidal risk who verbalized suicidal ideation are placed on 1:1 monitoring by the staff. On 1/7/2020 at 1:08 p.m., during a concurrent interview and record review, the facility's VPO and the DSD stated upon admission, residents who are at risk for suicide are care planned, monitored by the staff for 72 hours, and the resident's behavior is documented on the MAR. On 1/7/2020 at 1:35 p.m., during an interview in the presence of the DSD, Resident 2 stated he had thoughts of suicide that told him to kill himself. Resident 2 stated he requested to go to the hospital after being asked how he would kill himself. Resident 2 stated he had informed the staff a few times about his [MEDICAL CONDITION] and he was not being monitored by the staff. Resident 2 stated his thoughts were telling him to get help and stop scratching himself. On 1/7/2020 at 1:48 p.m., during an observation and interview, Resident 2 was sitting in a chair next to the nurses' station. When Resident 2 walked away, he passed the surveyor in the hallway and stated that he was going to the bathroom. At 1:49 p.m., the surveyor observed RNS 1, LVN 2 and LVN 3 sitting at the nurses' station, when LVN 2 stated Resident 2 was placed on 1:1 monitoring by the staff effective immediately. RNS 1, LVN 2 and LVN 3 did not respond when asked where Resident 2 was. At 1:50 p.m., RNS 1 returned Resident 2 back to the nurses' station. RNS 1 located Resident 2 down the hallway, pass the back of the nurses' station (Station 2). On 1/7/2020 at 3:23 p.m., during a telephone interview, RNS 2 stated on 12/5/19, Resident 2 verbalized a desire to commit suicide, he was transferred to the GACH and he returned to the facility on the same day. RNS 2 stated she could not sure if Resident 2 was being monitored by the staff every 15 to 30 minutes on 12/5/19 and could not recall if she documented Resident 2's hospital transfer. The RNS 2 stated upon admission, a care plan is initiated for residents at risk for suicide. A review of the facility's plan of action to remove the immediate jeopardy situation, on 1/7/2020 at 4:30 p.m., indicated there were four residents identified as at risk for suicide. On 1/9/2020 at 10:46 a.m., during a telephone interview, Resident 2's Psychiatrist stated residents who verbalized [MEDICAL CONDITION] required staff supervision and monitoring for safety precautions in addition to daily mental inquiry and screening on residents. The Psychiatrist stated it was dangerous to have suicidal residents in the facility without any staff monitoring. A review of the facility's revised policy dated 9/2010 and titled Care Plans, Comprehensive indicated an individualized comprehensive 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 policy indicated the comprehensive care plan is based on a thorough assessment that includes but is not limited to The Minimum Data Set (MDS (a care screening and assessment tool)) each resident's comprehensive care plan is designed to incorporate identified problem areas, incorporate risk factors associated with identified problems.

Based on observation, interviews and record review, the facility failed to ensure residents who had a history upon admission of eloping (leaving unsupervised, undetected without authorization) would have a plan created and implemented to prevent elopement. The facility failed to ensure the resident's whereabouts were supervised for one of three sampled residents (Resident 1). Resident 1, who had a history of [REDACTED]. The facility failed to address Resident 1's elopement as an elopement and to notify the Department, but documented Resident 1's elopement as the resident signing out against medical advice (AMA). The inaccurate documentation led to the facility avoidance to implement new interventions to prevent this failure and put other resident's at risk. This deficient practice resulted in Resident 1 eloping on 11/6/19, and wandering the streets. Resident 1 was later found by the police on 11/6/19 at 3:05 p.m. (approximately 4 hours after eloping from the facility) wandering the streets and was admitted into a psychiatric urgent care (clinic for individuals with an urgent mental health need) and placed on a 5150. The urgent care was located approximately 10-15 miles away from the facility and this deficient practice had the potential for Resident 1 to have been seriously harmed. On 11/8/19 at 2:10 p.m., the facility had a total of four (4) residents (Resident 1, Resident 2, Resident 3, and Resident 4) identified as a high elopement risk. The facility had a systemic failure that resulted on Resident 1 elopement. The facility did not communicate to the staff of Resident 1's risk for elopement. The facility did not implement its policies to ensure residents who were at risk for elopement were supervised. The facility did not document that Resident 1 had eloped. These failures resulted in an Immediate Jeopardy ((IJ) a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident), which was declared under F 689. The facility's Administrator (ADM) and Director of Nursing (DON) were notified of the immediacy and seriousness to the resident's health and safety. On 11/8/19 at 6:55 p.m., the facility submitted an acceptable Plan of Action (POA) and the IJ was lifted on 11/9/19 at 3:38 p.m., after the team verified the POA was implemented through observation, interview and record review as follows: 1. The DON called the Urgent Care Mental Health Clinic Registered Nurse on 11/8/19, who stated Resident 1 was safe and unharmed in their facility. 2. Registered Nurse 2, who admitted Resident 1 into the facility, received a one to one in- service and corrective actions, by the clinical nurse consultant about the importance of implementing interventions and supervision to residents who were assessed a high risk for elopement upon admission to prevent elopement on 11/8/19. 3. The Director of Nursing received one to one in-service and corrective action by the clinical nurse consultant about the importance of reviewing new admission with interdisciplinary team members at least within 24 hours to 72 hours to ensure the facility provided and implemented proper interventions for residents who have history of elopement and/or identified who are deemed at high risk for elopement on 11/8/19. 4. In-service will be provided by the clinical nurse consultant to all staff on all shifts regarding of the importance to provide interventions and a monitoring process for residents who were at risk for elopement and/or with history of elopement incident for safety and to prevent recurrence of the situation. 5. Current residents were assessed for elopement risk using Elopement Risk Assessment by the Director of Nursing/designee to identify residents who were at risk on 11/8/19. 6. Registered Nurse/ licensed designee will evaluate residents on admission to see if a resident is at risk for elopement based on the elopement risk assessment record. Elopement risk assessment will be completed within four hours upon admission. 7. Residents who were deemed high risk for elopement will have a photograph and resident's profile will be maintained in the clinical record and elopement binder. Resident who were deemed high risk for elopement will be place on close activity monitoring at least every 15-30 minutes for 72 hours, within 4 hours from admission or until evaluated and proper interventions are in placed as ordered by the physician. Information will be relayed to all licensed staff. 8. Residents who are deemed high risk for elopement will wear a green band to identify risk for elopement to alert the staff to enhance monitoring and supervision by staff within 4 hours of admission. 9. Director of Nursing/Designees will review resident's clinical records upon admission; to ensure elopement care plans and preventive measures will be put in place. 10. Medical records/Designees will conduct monthly audits of resident clinical records for presence of elopement risk assessment, plan of care and prescribed appropriate device to prevent elopement. 11. Director of Nursing/ Designee will review facility's elopement binder weekly to ensure records are updated and necessary interventions are in place. 12. Director of staff development will conduct monthly Code Green (an emergency code used denote an activation of an emergency plan; missing resident) drills to staff members in accordance to facility policies and procedures. 13. Elopement incident will be reported to the local State Agencies. 14. Findings from the clinical record audits will be presented to Quality Assurance Committee monthly for the first three months for further evaluation and recommendation; quarterly thereafter if no negative trends are found. Findings: A review of Resident 1's clinical records indicated the following: An Admission Face Sheet indicated Resident 1 was recently admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. A Nursing Admission Assessment, dated 11/5/19, indicated Resident 1's cognition (ability to think and reason) was marked as alert, verbal, and oriented. An Elopement Risk Assessment, dated 11/5/19 indicated Resident 1 was scored as a high risk for elopement. The assessment included Resident 1 had a history of [REDACTED]. A Baseline Care Plan, dated 11/5/19, indicated the facility did not have a goal or documented interventions to prevent Resident 1 from eloping from the facility. A physician's order, dated 11/5/19, indicated orders to administer [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]) 10 milligrams ((mg) unit of measurement) twice daily, for sudden angry outburst. A Licensed Personnel Progress Note, dated 11/6/19 and timed at 7:30 a.m., indicated Resident 1 was in the facility. At 3:30 p.m., on the same day (11/6/19) the note indicated the police was notified because Resident 1 had left the facility. At 4:20 p.m., on 11/6/19, the note indicated Resident 1's family member (FM1) was contacted and a message left that Resident 1 had eloped from the facility and FM1 was asked to call the facility in case she had information about Resident 1's whereabouts. A Medication Administration Record [REDACTED]. The facility's census (a daily record of all residents who are occupying beds in a facility) dated 11/7/19, indicated Resident 1 left the facility against medical advice (AMA) (sic) On 11/8/19 at 9:40 a.m., during an interview, Certified Nurse Assistant 2 (CNA 2) stated the staff was supposed to call a code green (an emergency code used denote an activation of an emergency plan; missing resident) from the overhead page when a resident was missing. CNA 2 stated code green warned all the staff to look for a missing resident. CNA 2 stated Resident 1, who was a new admission, went missing on 11/6/19. CNA 2 stated she was unable to find Resident 1 on 11/6/19, around 12:15 p.m. CNA 2 stated she immediately notified Licensed Vocational Nurse 1 (LVN 1) and CNA 3 and both she and CNA 3 went looking for Resident 1. CNA 2 stated she did not hear the code green announcement for resident 1. CNA 2 stated the ADM checked the video surveillance camera (camera used to remotely monitor an area or building by transmitting recorded images to a central control room) and the video surveillance showed Resident 1 was last seen going to the smoking patio area. CNA 2 stated the video surveillance camera showed the Activity Assistant 1 (AA1) who was watching the smoking patio area, walked away from the smoke patio. CNA 2 stated Resident 1 could have jumped over the fence of the smoking patio area. CNA 2 stated the facility was located in a high crime area and Resident 1 could have been killed. On 11/8/19 at 10:09 a.m., during an interview, the DON stated when residents elope the staff would search for the resident in other resident's rooms, bathrooms, and drive within a five-mile radius during a code green. The DON stated the facility did call a code on 11/6/19, but she called it Code Grey (sic). The DON was not aware of the code to call in the event a resident eloped, and she continued to repeat the code as being Code Grey instead of Code Green (an emergency code used denote an activation of an emergency plan; missing resident). The DON stated the staff should call the local hospitals and notify the State Ombudsman (patient advocate) and the Department of Public Health (DPH) as soon as the facility becomes aware that a resident was missing within one to two hours. The DON stated the facility would document the elopement situation, the time, where/when the resident was last seen in the resident's medical records. The DON was asked what the facility's protocol was for residents who wanted to leave against medical advice (AMA) and she stated the staff would call the physician and obtain an order to discharge the resident AMA and the resident would sign an AMA form before leaving. The DON reviewed Resident 1's physician's orders and stated there was no physician order to discharge Resident 1 AM[NAME] The DON stated she did notified Resident 1's primary physician (Physician 1) by telephone that Resident 1 had left the facility. The DON stated if a resident left the facility without permission and staff's knowledge, then the resident eloped from the facility. The DON recanted (deny; recall) and stated Resident 1 eloped and did not sign out AMA, as was initially indicated and documented. The DON stated she was aware that a surveyor was in the building the morning Resident 1 eloped, but they did not inform the surveyor of Resident 1's elopement. The DON was asked was a Code Green called the morning Resident 1 eloped and the DON stated, I do not know why a Code Green was not called, I do not know what to say. The DON stated on 11/6/19, at approximately 11 a.m., RN 1 informed her Resident 1 was not in the building. The DON stated Resident 1 was admitted to the facility on [DATE] at 10 p.m. and Resident 1's Elopement Risk Assessment indicated Resident 1 had a score of 12, which was a high risk for elopement. The DON stated the facility should have been proactive (creating or controlling a situation) as Resident 1 had a history of [REDACTED]. risk. DON stated residents who were at risk for elopement could have a wanderguard (a bracelet that activates an audible alarm and temporarily locks exterior doors when the patient approaches an exit) and their picture taken and filed on the elopement binder. DON stated the elopement binder was not updated for resident 1 because he was admitted at night. DON stated intervention should have been implemented the following day. DON stated she did not had a change to look at Resident's 1 medical records. The DON stated the facility did not notify the Ombudsman and/or DPH of Resident 1's elopement, as per the facility's policy. The DON stated, We should have done the proper thing and report the resident's (Resident 1) elopement, but instead we decided to indicate the resident went AMA and that was an omission. On 11/8/19 at 10:53 a.m., during an interview, Licensed Vocational Nurse 1 (LVN1) stated during lunch time (11a.m-12 p.m.), on 11/6/19, CNA 2 notified her she did not know where Resident 1 was. LVN 1 stated she notified RN 1, who asked CNA 2 to look for Resident 1 and RN 1notified the ADM and the DON. LVN 1 stated it was obvious Resident 1 had eloped from the facility because Resident 1 was not in the facility. LVN 1 stated she was not notified of Resident 1 being a high risk for elopement and had she known she would have monitored Resident 1's whereabouts closely. On 11/8/19 at 11:19 a.m., during an interview, Registered Nurse 2 (RN 2) stated the facility would usually take pictures of the residents who were elopement risk and would put them in an elopement binder. RN 2 stated she did admit Resident 1, but she did not take Resident 1's picture because she did not have time. RN 2 stated she did not place a Wander guard (a bracelet that activates an audible alarm when a resident approaches an exit door) on Resident 1 either, although she was aware Resident 1 was an elopement risk. RN 2 stated she was aware Resident 1 was a high risk for elopement. RN2 stated on 11/6/19 RN1 told her Resident 1 had left the facility. RN2 stated she knew Resident 1 did not leave the facility AMA, because the staff would not have called the police looking for the resident. On 11/8/19 at 11:35 a.m., during an interview, RN 1 stated CNA 1 notified her Resident 1 had left the facility. RN 1 stated she notified the administrator and the DON. RN1 stated the staff had told her Resident 1 wanted to leave the facility. RN 1 stated she did not call a code to look for Resident 1, but stated she should have called a code, to inform the staff to assist with the search of a resident. RN1 stated during the morning shift report, on 11/6/19, she was not notified Resident 1 was at risk for elopement. On 11/8/19 at 11:43 a.m., during an interview, AA1 stated she monitored residents in the smoking patio to keep the residents safe. AA1 stated she kept residents in the smoke patio calm and would tell the residents not to go around the corner of the building where she could not see them. AA1 stated she did not know Resident 1, nor did she see Resident 1. On 11/8/19 at 12:07 p.m., during a telephone interview, FM 1 stated Resident 1 was at a psychiatric urgent care. FM 1 stated the police called her and allowed her to speak to Resident 1. FM 1 stated, The resident (Resident 1) was out of his mind, confused, and talking trash (slang for verbally disrespecting another person). On 11/8/19 at 1:03 p.m., during an interview, the Director of Staff Development (DSD) stated she provided an elopement in-service the first quarter of the year and when something happened. When asked when the last time a resident eloped from the facility the DSD stated the facility did not had any elopement cases that year (sic). The DSD stated she worked on 11/6/19 and no codes for an eloped resident was called. The DSD stated she provided in-services after an elopement incident to remind the staff of the code used, as well as the policies and procedures. When asked what the process was when a resident went missing, the DSD stated staff does a head count, look for the resident and call a code green. The DSD stated the code green was announced on the overhead page and the staff would immediately know what to do when the code green was called. The DSD stated she did not see Resident 1 on 11/6/19, but during the morning huddle at approximately 10 a.m., on 11/6/19 the staff mentioned Resident 1 was a new admission. The DSD stated during the morning huddle it was not mentioned that Resident 1 was an elopement risk. The DSD stated she was in the facility on 11/6/19 but a code green for Resident 1 was not called. On 11/8/19 at 1:57 p.m., during an interview, the ADM stated Resident 1 was supposed to go to another facility because Resident 1 needed a locked facility. On 11/8/19 at 2 p.m., during an interview, the DON stated the business office marketer (a person or company that advertises and promotes) made the decision to bring Resident 1 to the facility. The DON stated Resident 1 was scheduled to arrive at the facility on 11/6/19 but the marketer changed the admitted and Resident 1 arrived earlier, on 11/5/19. The DON stated she was supposed to approve Resident 1's admission to the facility, but did not. The DON stated she was not aware Resident 1 was a high risk for elopement prior to admission, because had she known, the DON stated she would not have accepted Resident 1. On 11/8/19 at 2:02 p.m., during an interview, the ADM stated when she was notified Resident 1 was not in the facility, she went out and looked for Resident 1 but she could not find him and the police was notified. The ADM stated the camera showed Resident 1 going to the smoke patio at 11:15 a.m., on 11/6/19 while AA1 was in the patio, but the camera did not capture what happened in the patio. On 11/8/19 at 2:20 p.m., during an observation, the facility's smoking patio had a locked metal fence with a concrete wall which was approximately five (5) feet tall. Outside the facility's entrance door was a main street with high car traffic and on the end of the street were two rail road crossing tracks with warning construction signs. On 11/12/19 at 8:39 a.m., during a telephone interview, Physician 1 stated the DON sent him a text message that Resident 1 had left the facility AMA and the police was notified. On 11/13/19 at 10:10 a.m., during an interview, Security 1 stated he was by the facility's front door on 11/6/19 and at approximately 12 p.m. RN 1 told him the staff was looking for Resident 1. Security 1 stated he was not notified of Resident 1's admission the night before and did not know what Resident 1 look liked. On 11/13/19 at 10:30 a.m., during an interview, the maintenance supervisor (MS) stated he checked the alarms on all the facility's doors from Monday-to- Friday. The MS stated on 11/7/19 Security 1 told him Resident 1 had eloped and he immediately checked all the facility's door alarms and they were all working. The MS stated he was in the facility on 11/6/19, but he did not hear a code green called because had he heard the code green, he would have helped look for Resident 1. On 11/13/19 at 2:01 p.m., during an interview, CNA 3 stated on 11/6/19, within 30 minutes to an hour after they noticed Resident 1 was missing, he drove around with Security 1 to find Resident 1. CNA 3 stated they did not find Resident 1. CNA 3 stated the facility did not call the code green for Resident 1. CNA 3 stated Resident 1 could get harm because there was rail road construction zone near the facility. On 11/13/19 at 3:20 p.m., during an observation of the facility's surveillance video with the DON, she stated on the day of the incident (11/6/19), Resident 1 was observed wearing dark shoes, dark pants, and a facility's gown and walking to the smoking patio at 12:14 p.m. while AA1 was seen walking out of the smoking patio. At 12:21 p.m., at 11/6/19 AA1 left the smoking patio, but Resident 1 was not seen again on the video. A review of the facility's Emergency Preparedness Program titled, Nursing Home Command System Guidebook, dated (YEAR) indicated immediate response for a missing resident was to confirm a missing resident incident occurred, activate lockdown procedures, notify state survey agency, and coordinate with law enforcement. A review of the facility's policy titled, Unusual Occurrence Reporting dated 12/2007 indicated the facility was to report unusual occurrences that interfered with the welfare, safety or health of residents to the appropriate agencies as required by current federal and state regulation within 24 hours of each occurrence. A review of the facility's policy titled, Wandering and Elopement, dated 11/2018, indicated the purpose was to enhance the safety of residents of the facility, to help identify residents who are at risk for elopement and minimize possible injuries as a result from elopement. The policy indicated all residents would be assessed upon admission and residents at risk for elopement and preventive interventions would be documented in the resident's medical records. According to the policy, residents who were deemed to be high risk for elopement would have a photograph maintained in their medical record. The policy indicated residents at risk were identified with a history of wandering or elopement prior to admission, and who were assessed to be at risk for wandering or elopement. The policy indicated if staff member noted a resident missing and could not find the resident in the facility must alert other facility staff immediately. The licensed nurse/designee would call a code and organize a search immediately. In the event the resident could not be located, charge nurse would notify the administrator, DON, attending physician, and responsible party. The administrator/Designee would contact law enforcement. The licensed nurse most familiar with the incident would document and record how the elopement occurred in the resident's clinical record. The facility would make the necessary reports to state agencies. The policy indicated the facility would establish a resident's identification information to alert staff members to provide extra monitoring on their whereabouts. A review of the facility's policy titled, Safety and Supervision of Residents, dated 12/2017 indicated the purpose was to keep resident safety and supervision and assistance to prevent accidents. The policy indicated staff should use various sources to identify risk factors for resident, including the information obtained from the medical history, physical exam, and observation of the resident. A review of the facility's policy titled, Admissions Policies, dated 12/2006, indicated the purpose was to establish uniform guidelines for personnel to follow in admitting residents to the facility. The policy objective was to provide uniform guidelines in the admission of residents, admit residents who could be adequately cared for by the facility, and assure that appropriate medical and financial records were provided to the facility prior to or upon the resident's admission. A review of the facility's policy titled, Baseline Care Plan, dated 6/2019, indicated the baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon admissions, which would address resident specific health and safety concerns to prevent the decline or injury, such as elopement or fall risk and would identify needs for supervision, behavior interventions, and assistance with activities of daily living as needed.

Based on observation, interview, and record review, the facility failed to ensure residents were protected and free from abuse for two of three sampled residents (Residents 1 and 3). Resident 2, who had a history of [REDACTED]. Resident 2, who had escalating (increasing or becoming more intense) angry outburst behavior toward staff and peers for over two weeks that was not reported to Resident 2's physician, continued to escalate and threaten other residents. Resident 2 was heard yelling and was observed physically attacking Resident 3 and the facility's staff. These deficient practices resulted in Resident 2 injuring Resident 1 on 9/28/19 before attacking the facility's staff members and Resident 3 on 10/2/19. Resident 1 required a transfer to the emergency room of a general acute care hospital (GACH) on 9/28/19 and was diagnosed with [REDACTED]. Resident 3 sustained scratches (scrape of the skin) to the right cheek and two of the facility's staff members were hit in the back and scratched. The residents in the facility felt unsafe and fearful of Resident 2, but he remained unsupervised. A pattern of the facility's failure to protect and ensure residents were free from physical abuse, fear, and mental anguish and thus, constituted an immediate jeopardy (IJ) situation and need for an immediate corrective action. On 10/2/19 at 2:28 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 prevent abuse, protect the residents from abuse, and implement the facility's abuse prevention and protection policy and procedure. The Department notified the administrator (ADM) and Director of Nursing (DON) of the serious noncompliance that threatened the health and safety of Residents 1, 2 and 3 and the potential to affect the other residents in the facility. On 10/2/19 at 6:05 PM, the ADM and DON provided an acceptable written plan of action which included the following: 1. Resident 2 was immediately separated from Resident 1. 2. The licensed nurse assessed Resident 1 for possible injury and reassured her safety and reported the incident to Resident 1's attending physician. 3. Resident 2 was placed on one-one-one (1:1) supervision (one staff monitoring one resident) to prevent further abuse. 4. Resident 2's care plan was reviewed and completed by the DON on 10/2/19 and addressed the resident's aggressive behavior. The DON notified Resident 2's attending physician on 10/2/19. The physician gave orders to monitor Resident 2's aggressive/assaultive behavior manifested by (M/B) hitting/striking out at others every shift and to place Resident 2 on 1:1 supervision with documented monitoring every 15 minutes by a licensed staff until discharge to the GACH for further evaluation and intervention. 5. The DON/Designee conducted an ongoing in-service to staff regarding the importance of providing close supervision and monitoring for residents with aggressive/assaultive behavior to promote safety. On 10/4/19 at 9:36 a.m., the Department lifted the Immediate Jeopardy after the team verified on-site that the facility implemented the plan of action. Findings: a. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's History and Physical (H/P), dated 5/6/19, indicated Resident 1 had the capacity to understand and make decisions. A review of a Situation, Background, Assessment and Recommendation ((SBAR) an internal communication tool), dated 9/28/19 and timed at 8 a.m., indicated Resident 1 was observed sitting outside on the ground by a sliding door near room [ROOM NUMBER]. The SBAR indicated Resident 1 stated she was attempting to re-enter the facility when Resident 2 pushed her from behind. The SBAR indicated Resident 1 sustained a 2.0 x (by) 0.5 centimeter ((cm) a unit of measurement) laceration to the right forehead and a 3.0 x 2.0 cm laceration to the right elbow. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's GACH emergency room (ER) report, dated 9/28/19, indicated Resident 1 sustained a right wrist fracture and received two sutures to her right [MEDICAL CONDITION]. Resident 1 was diagnosed with [REDACTED]. On 10/1/19 at 3:30 p.m., during a telephone interview, the anonymous caller (AC 1) stated Resident 1 informed her (the AC 1) that Resident 2 pushed her (Resident 1) and that she (Resident 1) had to fight for her life because she was scared and afraid of Resident 2. The AC 1 stated a licensed nurse informed her Resident 2 verbalized wanting to kill Resident 1. On 10/2/19 at 9 a.m., during an observation and interview, Resident 1 had a long discolored closed wound with two sutures to the right forehead and a swollen (enlarged) right hand. Resident 1 stated Resident 2 pushed her from behind and she fell on the ground. Resident 1 began to cry and stated she was afraid to speak about the incident and identify the resident who pushed her. On 10/2/19 at 9:56 a.m., while interviewing Resident 2, loud screams were heard coming from the facility's dining room. Upon arrival to the dining room, the maintenance staff was observed restraining Resident 2 after he attacked Resident 3 and because he was attempting to attack Activities Assistant 1 (AA 1). Resident 3 had a scratch to the right cheek. Resident 1's hands were observed shaking and he was visibly agitated. AA 1 stated Resident 2 chased her around the dining room table, walked towards her with his fists closed, and lifted his fist and table in an attempt to hit her. On 10/2/19 at 10 a.m., loud screams were heard coming from the dining room after Resident 2 punched the Director of Staff Development (DSD) on the right side of her back and scratched Certified Nursing Assistant 1 (CNA 1) on the left side of her neck and both hands. On 10/2/19 at 10:20 a.m., during an interview, AA 2 stated Resident 2 had a history of [REDACTED]. AA 2 stated Resident 1 had a wound on her forehead because Resident 2 had pushed her down. On 10/2/19 at 10:25 a.m., during a concurrent observation and interview, Resident 3 had a scratch to the right upper cheek and the right head area. Resident 3 stated he was scratched by Resident 2 in the dining room this morning while he was trying to defend AA 1 from being attacked. Resident 3 stated Resident 1 told him she was injured after being pushed by Resident 2. On 10/2/19 at 10:35 a.m., during an interview, CNA 1 stated the resident (Resident 2) had been in the facility for two months and easily becomes agitated. CNA 1 stated a week prior, during Resident 2's shower, Resident 2 began yelling and screaming directly in her face. On 10/2/19 at 10:40 a.m., during an observation, 40 minutes after Resident 2's escalating agitated behavior of attacking the staff and resident, Resident 2 was lying in his bed, awake and mumbling to himself. There was no staff present in Resident 2's room to supervise and monitor him. On 10/2/19 at 10:50 a.m., during an interview, the DON stated on 9/28/19, she was notified by a licensed nurse that Resident 1 was pushed by Resident 2 on the outside patio and was sent to the hospital. The DON stated Resident 1 returned to the facility on the same day from the GACH but Resident 2 was not placed on a 1:1 supervision, but should have been to ensure protection of Resident 1 and other residents in the facility. b. A review of Resident 2's GACH's H/P prior to admission to the facility, dated 8/16/19, indicated Resident 2 was admitted to GACH due to aggressive behavior, agitation, negative intrusive (not welcomed or uninvited) thoughts with increased anxiety (define anxiety), impulsive (acting without thought), unpredictable (not expecting) and desiring to hurt himself and others. A review of Resident 2's Facility's Admission Record indicated the resident was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's physician's admission orders [REDACTED]. A review of Resident 2's H/P, dated 8/22/19, indicated Resident 2 had fluctuating (to change continually) capacity to understand and make decisions. A review of Resident 2's nurses' notes, dated from 8/22/19 to 10/3/19, indicated there was no documented evidence the licensed nurses notified Resident 2's physician of Resident 2's escalating anger outbursts, especially on 9/24/19 (two outbursts), 9/25/19 (two outbursts), 9/28/19 (three outbursts), 9/29/19 (four outbursts), and 9/30/19 (three outbursts). A review of Resident 2's care plan, dated 8/23/19 and titled, [MEDICAL CONDITION] manifested by hitting and resisting care indicated for the staff to re-direct Resident 2's attention, monitor side effects daily, and approach the resident calmly. A review of Resident 2's care plan, dated 8/23/19 and titled, Resident is on antipsychotic medication for [DIAGNOSES REDACTED]. every shift and evaluate monthly and implement behavioral interventions. A review of Resident 2's care plan, dated 8/23/19 and titled, Behavioral/Psychoactive Medication Care Plan due to [MEDICAL CONDITION], indicated the staff's interventions included to monitor antecedent (previously existed) behaviors. A review of Resident 2's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED] 9/7/19- 3 episodes 9/8/19- 2 episodes 9/9/19- 2 episodes 9/10/19-2 episodes 9/11/19-2 episodes 9/12/19-2 episodes 9/13/19-2 episodes 9/23/19-5 episodes 9/24/19-2 episodes 9/25/19-2 episodes 9/28/19-3 episodes 9/29/19-4 episodes 9/30/19-3 episodes A review of Resident 2's physician's orders [REDACTED]. A review of an SBAR form, dated 9/28/19 and untimed, indicated Resident 2 was displaying aggressive behavior evident by verbally admitting to pushing a resident (Resident 1). A review of a nurse's note entries, dated 9/28/19 and timed from 3 p.m. to 7 p.m., indicated Resident 2 was monitored for aggressive behavior toward another resident (Resident 1) and was pacing back and forth on the unit, while mumbling to himself and making hand gestures. A review of another SBAR record, dated 10/2/19 indicated Resident 2 had aggressive behaviors towards staff and other residents by attempting to strike staff member and scratch a resident (Resident 3) in the face. c. A review of Resident 3's Admission Record, indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 3's Minimum Data Set (MDS), a care screening and assessment tool), dated 9/2/19, indicated Resident 3's cognition (thought process) was intact. On 10/3/19 at 9:45 a.m., during an interview, Resident 3 stated Resident 2 had been agitated for a week prior to pushing Resident 1 (on 9/28/19). Resident 3 stated Resident 1 was afraid of Resident 2. Resident 3 stated Resident 2's agitation had increased because he was angry and yelling all the time. A review of the facility's policy and procedure, dated 11/2018 and titled, Abuse Prevention/Prohibition, indicated the facility maintains adequate staffing on all shifts to ensure that the needs of each patient are met. The facility involves qualified psychiatrist and other mental health professionals to help facility staff manage difficult or aggressive residents if available. The policy indicated a measure of immediate action included the Abuse Coordinator will provide a safe environment for the resident as indicated by the situation and if the suspected perpetrator is another resident, separate the residents so they do not interact with each other until circumstances of the reported incident can be clarified. A review of the facility's revised policy and procedure, dated 4/2007 and titled, Abuse and Neglect, Clinical Protocol, indicated the management and staff, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations.

Based on observation, interview, and record review, the facility failed to supervise residents with abusive behaviors toward other residents and staff to ensure safety for two of three sampled residents (Residents 1 and 3). Resident 2, who had a history of [REDACTED]. Resident 2, who had escalating (increasing or becoming more intense) angry outburst behavior toward staff and peers for over a two-week period that was not reported to Resident 2's physician, continued to escalate and threaten other residents and staff while remaining unsupervised. These deficient practices resulted in Resident 2 injuring Resident 1 on 9/28/19 before attacking the facility's staff members and Resident 3 on 10/2/19. Resident 1 required a transfer to the emergency room of a general acute care hospital (GACH) on 9/28/19 and was diagnosed with [REDACTED]. Resident 3 sustained scratches (scrape of the skin) to the right cheek and two of the facility's staff members were hit in the back and scratched. The residents in the facility felt unsafe and fearful of Resident 2, but he remained unsupervised in the facility. A pattern of the facility's failure to supervise a resident with escalating abusive behavior, constituted an immediate jeopardy (IJ) situation and need for an immediate corrective action. The systems failed and resulted in an immediate threat to the health and safety for Residents 1, 2, 3 and other residents in the facility. On 10/2/19 at 2:28 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 supervise a resident with abusive behavior, keep residents safe at all times, and implement the facility's policy and procedure, titled Behavioral Assessment, Intervention and Monitoring. The Department notified the administrator (ADM) and Director of Nursing (DON) of the serious noncompliance that threatened the health and safety of Residents 1, 2 and 3 and the potential to affect the other residents in the facility. On 10/2/19 at 6:05 PM, the ADM and DON provided an acceptable written plan of action (POA) which included the following: 1. Resident 2 was immediately separated from Resident 1. 2. The licensed nurse assessed Resident 1 for possible injury and reassured her safety and reported the incident to Resident 1's attending physician. 3. Resident 2 was placed on one-one-one (1:1) supervision (one staff monitoring one resident) to prevent further abuse. 4. Resident 2's care plan was reviewed and completed by the DON on 10/2/19 and addressed the resident's aggressive behavior. The DON notified Resident 2's attending physician on 10/2/19. The physician gave orders to monitor Resident 2's aggressive/assaultive behavior manifested by (M/B) hitting/striking out at others every shift and to place Resident 2 on 1:1 supervision with monitoring every 15 minutes by a licensed staff until discharge to the GACH for further evaluation and intervention. 5. The DON/Designee conducted an ongoing in-service to staff regarding the importance of providing close supervision and monitoring for residents with aggressive/assaultive behavior to promote safety. On 10/4/19 at 9:36 a.m., the Department lifted the Immediate Jeopardy after the team verified on-site that the facility implemented the PO[NAME] Findings: a. A review of Resident 2's GACH's History and Physical (H/P) prior to admission to the facility, dated 8/16/19, indicated Resident 2 was admitted to GACH due to aggressive behavior, agitation, negative intrusive (not welcomed or uninvited) thoughts with increased anxiety (define anxiety), impulsive (acting without thought), unpredictable (not expecting) and desiring to hurt himself and others. A review of Resident 2's Facility's Admission Record indicated the resident was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's physician's admission orders [REDACTED]. A review of Resident 2's H/P, dated 8/22/19, indicated Resident 2 had fluctuating (to change continually) capacity to understand and make decisions. A review of Resident 2's nurses' notes, dated from 8/22/19 to 10/3/19, indicated there was no documented evidence the licensed nurses notified Resident 2's physician of Resident 2's escalating anger outbursts, especially on 9/24/19 (two outbursts), 9/25/19 (two outbursts), 9/28/19 (three outbursts), 9/29/19 (four outbursts), and 9/30/19 (three outbursts). A review of Resident 2's care plan, dated 8/23/19 and titled, [MEDICAL CONDITION] (a mental disorder characterized by a disconnection from reality) manifested by hitting and resisting care indicated for the staff to re-direct Resident 2's attention, monitor side effects daily, and approach the resident calmly. A review of Resident 2's care plan, dated 8/23/19 and titled, Resident is on antipsychotic medication for [DIAGNOSES REDACTED]. every shift and evaluate monthly and implement behavioral interventions. A review of Resident 2's care plan, dated 8/23/19 and titled, Behavioral/Psychoactive Medication Care Plan due to [MEDICAL CONDITION], indicated the staff's interventions included to monitor antecedent (previously existed) behaviors. A review of Resident 2's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED] 9/7/19- 3 episodes 9/8/19- 2 episodes 9/9/19- 2 episodes 9/10/19-2 episodes 9/11/19-2 episodes 9/12/19-2 episodes 9/13/19-2 episodes 9/23/19-5 episodes 9/24/19-2 episodes 9/25/19-2 episodes 9/28/19-3 episodes 9/29/19-4 episodes 9/30/19-3 episodes A review of Resident 2's physician's orders [REDACTED]. A review of a Situation, Background, Assessment and Request ((SBAR) an internal licensed staff communication tool) form, dated 9/28/19 and untimed, indicated Resident 2 was displaying aggressive behavior evident by verbally admitting to pushing a resident (Resident 1). A review of a nurse's note entries, dated 9/28/19 and timed from 3 p.m. to 7 p.m., indicated Resident 2 was monitored for aggressive behavior toward another resident (Resident 1) and was pacing back and forth on the unit, while mumbling to himself, and making hand gestures. A review of another SBAR record, dated 10/2/19 indicated Resident 2 had aggressive behaviors towards staff and other residents by attempting to strike staff member and scratch a resident (Resident 3) in the face. On 10/1/19 at 3:30 p.m., during a telephone interview, the anonymous caller (AC 1) stated Resident 1 informed her (the AC 1) that Resident 2 pushed her (Resident 1) and that Resident 1 had to fight for her life because she was scared and afraid of Resident 2. The AC 1 stated a licensed nurse informed her that Resident 2 verbalized wanting to kill Resident 1. On 10/2/19 at 9 a.m., during an observation and interview, Resident 1 had a long discolored closed wound with two sutures to the right forehead and a swollen (enlarged) right hand. Resident 1 stated Resident 2 pushed her from behind and she fell on the ground. Resident 1 began to cry and stated she was afraid to speak about the incident and identify the resident who pushed her. On 10/2/19 at 9:56 a.m., while interviewing Resident 2, loud screams were heard coming from the facility's dining room. Upon arrival to the dining room, the maintenance staff was observed restraining Resident 2 after he attacked Resident 3 and because he was attempting to attack Activities Assistant 1 (AA 1). Resident 3 had a scratch to the right cheek. Resident 1's hands were observed shaking and he was visibly agitated. AA 1 stated Resident 2 chased her around the dining room table, walked towards her with his fists closed, and lifted his fist and table in an attempt to hit her. On 10/2/19 at 10 a.m., loud screams were heard coming from the dining room after Resident 2 punched the Director of Staff Development (DSD) on the right side of her back and scratched Certified Nursing Assistant 1 (CNA 1) on the left side of her neck and both hands. On 10/2/19 at 10:20 a.m., during an interview, AA 2 stated Resident 2 had a history of [REDACTED]. AA 2 stated Resident 1 had a wound on her forehead because Resident 2 had pushed her down. On 10/2/19 at 10:25 a.m., during a concurrent observation and interview, Resident 3 had a scratch to the right upper cheek and the right head area. Resident 3 stated he was scratched by Resident 2 in the dining room this morning while he was trying to defend AA 1 from being attacked. Resident 3 stated Resident 1 told him she was injured after being pushed by Resident 2. On 10/2/19 at 10:35 a.m., during an interview, CNA 1 stated the resident (Resident 2) had been in the facility for a couple of months and easily becomes agitated. CNA 1 stated a week prior, during Resident 2's shower, Resident 2 began yelling and screaming directly in her face. On 10/2/19 at 10:40 a.m., during an observation, 40 minutes after Resident 2's escalating (becoming more intense) agitated behavior, Resident 2 was lying in his bed, awake and mumbling to himself. There was no staff present in Resident 2's room to supervise and monitor him. On 10/2/19 at 10:50 a.m., during an interview, the DON stated on 9/28/19, she was notified by a licensed nurse that Resident 1 was pushed by Resident 2 on the outside patio and was sent to the hospital. The DON stated Resident 2 returned to the facility on the same day from the GACH but Resident 1 was not placed on a 1:1) supervision, but should have been to ensure protection of Resident 2 and other residents in the facility. b. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's H/P, dated 5/6/19 indicated Resident 1 had the capacity to understand and make decisions. A review of an SBAR form, dated 9/28/19 and timed at 8 a.m., indicated Resident 1 was observed sitting outside on the ground by a sliding door near room [ROOM NUMBER]. The SBAR indicated Resident 1 stated she was attempting to re-enter the facility when Resident 2 pushed her from behind. The SBAR indicated Resident 1 sustained a 2.0 x 0.5 centimeter ((cm) a unit of measurement) laceration to the right forehead and a 3.0 x 2.0 cm laceration to the right elbow. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's GACH emergency room (ER) report, dated 9/28/19, indicated Resident 1 sustained a right wrist fracture and received two sutures to her right [MEDICAL CONDITION]. Resident 1 was diagnosed with [REDACTED]. c. A review of Resident 3's Admission Record, indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 3's Minimum Data Set ((MDS) a care screening and assessment tool), dated 9/2/19, indicated Resident 3's cognition (thought process) was intact. On 10/3/19 at 9:45 a.m., during an interview, Resident 3 stated Resident 2 had been agitated for a week prior to pushing Resident 1 (on 9/28/19). Resident 3 stated Resident 1 was afraid of Resident 2. Resident 3 stated Resident 2's agitation had increased because he was angry and yelling all the time. A review of the facility's revised policy and procedure, dated 3/2015 and titled, Behavioral Assessment, Intervention and Monitoring, indicated behavioral symptoms will be managed appropriately, the Interdisciplinary Team (IDT) will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition including physical or medical changes, emotional, psychiatric and/or psychological stressors, functional, social or environmental factors. The policy indicated safety strategies will be implemented immediately if necessary to protect the resident and others from harm. The policy indicated if the resident is being treated for [REDACTED].

Based on interviews and record review, the facility failed to implement a resident's plan of care, its policies titled, Discharge Summary and Plan; Discharging the Resident, which indicated that the social service designee (SSD) and the interdisciplinary Team ((IDT) group of medical professional that coordinate, collaborate, and plan the delivery of care for residents) would determine if the discharge was appropriate for four of four sampled residents (Residents 1, 2, 3, and 4). Residents 1, 2, 3, and 4, who required assistance with care, were discharged to an unlicensed assisted living facility (UALF) without evaluation if the residents were clinically stable for discharge to a lower level of care and if the UALF was a safe and appropriate placement. Resident 1, who required assistance with all his activities of daily living ((ADLs) such as transfer (movement from one surface to another (i.e. from a bed to a chair)), ambulation (walking), dressing, eating, personal hygiene and bathing) and mobility, had a [DIAGNOSES REDACTED]. and adequate amount of TB medications. Residents 2, 3 and 4, all required assistance with ADLs and medication administration (the giving of medications to another, usually performed by a nurse) and Resident 4 required transportation to and from [MEDICAL TREATMENT] treatment (a treatment that filters and purifies the blood using a machine when the kidney stop functioning). Residents 1, 2, 3, and 4, were discharged to a lower level of care without an IDT assessment and approval and as well as confirmation the residents were clinically clear for a lower level of care placement and the facility was appropriate and safe, as per the facility's policy. These deficient practices resulted in Resident 1, who required medication for TB being discharged to an unlicensed home without any care givers (a person who provides direct care to another) and without receiving TB medications for 18 days. Residents 2, 3, and 4, who all required assistance with care and medications. Resident 4, who had end stage [MEDICAL CONDITION] (([MEDICAL CONDITION]) last stage of long-term (chronic) kidney disease; when the kidneys can no longer support the body's needs to filter waste/water) that required transportation to [MEDICAL TREATMENT] treatment three times a week, being transferred to an UALF and later was discharged and the owner of the home refused to provide the whereabouts of Residents 3 and 4. A pattern of the facility's system failure to implement its policies to ensure residents who were unable to care for themselves and required supervision and/or assistance with care was not discharged to a lower level of care unless their condition had improved, and it was an appropriate and safe placement was identified. The facility discharged Residents 1, 2, 3, and 4 to an UALF run by an untrained person, who stated that she wanted someone to assist in paying her mortgage, without an IDT assessment of the facility to ensure that the discharge and the placement was appropriate and safe to meet the resident's needs, as per the facility's policy. The facility's non-compliance put Residents 1, 2, 3 and 4 at risk for a decline and potential for injury and harm. On 8/7/19 at 1:17 p.m., 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) was declared for F622. The facility's administrator (ADM) and the Director of Nursing (DON) were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 8/7/19 at 5:10 p.m., the ADM and DON provided an acceptable plan of action (POA) for correction of the I[NAME] The POA included the following: 1. Resident 1 was readmitted to the facility on [DATE] for continued TB treatment under the care of the Health Department. 2. The facility's staff will be in-serviced on 8/7/19 of the importance of discharging residents to a safe and licensed environment where residents needs could be met. 3. A facility's staff will visit the UALF within 24 hours to assess the safety and security of Residents 2, 3, and 4. 4. One to One in-service re-education provided to the SSD on 8/7/19 regarding the importance of discharging residents to a safe licensed environment that was able to care for residents who required special treatment and medical observation. 5. Disciplinary/corrective action was given to the SSD effective 8/7/19. On 8/9/19 at 4:24 p.m., after the team verified that the POA was implemented, both the DON and the ADM were notified and the IJ was lifted. Findings: a. A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE] with a recent admission on 6/24/19. Resident 1's [DIAGNOSES REDACTED]., energy and ability to think clearly) disorder. A review of a Community Disease Control and Prevention: [MEDICAL CONDITION] Control Program, dated 3/13/19, indicated a recommendation for [MEDICATION NAME] (anti-TB medication) 300 milligram (mg) every day (QD) to be substituted for Rifambutin 300 mg QD due to a drug to drug interaction with the resident's antipsychotic medications (medication to treat mental disorders). A review of Resident 1's [MEDICATION NAME] Skin Test (TB test (a blood test tells that a person has been infected with TB bacteria)) Report dated 3/14/19, indicated Resident 1 was diagnosed with [REDACTED]. A review of Resident 1's history and physical (H/P), dated 3/16/19, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's care plan, dated 3/14/19, indicated Resident 1 had TB and was undergoing treatment. The nurses' interventions indicated the staff would monitor the resident for signs/symptoms of TB, observe TB precautions, medicate as ordered, follow up with the public health department and follow directions regarding the treatment plan of care. A review of a physician's orders [REDACTED]. antipsychotic medicine that is used to treat [MEDICAL CONDITION]) PO at bed time. A review of Resident 1's care plan, dated 3/15/19, indicated Resident 1 was able to participate in discharge planning process. The staff's interventions included to coordinate discharge goals with rehabilitative therapies, arrange a family conference to establish discharge plan, arrange with scheduling post discharge appointments and services needed, follow up with the resident/family to assure understanding of plan or answer additional questions and offer opportunity for the resident to visit the potential new home or care center. A care plan for Resident 1, dated 3/21/19 indicated Resident 1 required assistance with bed mobility, transfer, ambulation, dressing and personal hygiene. It also indicated Resident 1 was at risk for fluctuating activities of daily living (ADLs) due to TB, muscle weakness of coordination. The staff's interventions included to assist the resident with ADLs, shower as scheduled, administer medications as ordered and observe for side effects, notify the physician of any changes in Resident 1's condition. A review of a physician's orders [REDACTED]. QD and start 300 mg of Rifambutin PO QD due to a drug to drug interaction of [MEDICATION NAME] and quetiapine (an antipsychotic medicine that is used to treat [MEDICAL CONDITION]). A review of a Request for Monthly TB Medical Update, dated 6/4/19, indicated Resident 1 started TB treatment on 3/14/19 and the expected dated of completion of therapy was unknown. It also indicated Resident 1 was currently receiving three TB medications. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 6/20/19, indicated Resident 1 was able to understand and be understood by others. According to the MDS, Resident 1 required supervision with bed mobility and transferring from a bed, to a chair and/or standing position. The MDS indicated Resident 1 required a one-person physical assist with ADLs. According to the MDS, Resident 1 used a cane for ambulation and was receiving antipsychotic (medications to treat mental disorder). A review of an article, by the Centers for Disease Control and Prevention titled, [MEDICAL CONDITION] (TB), indicated taking several medications will do a better job of killing the bacteria and preventing them from becoming resistant. The four common medications include; [MEDICATION NAME] and [MEDICATION NAME] for a minimal of six months, but nine months is recommended because TB bacteria dies slowly. https://www.cdc.gov/tb/publications/faqs/qa_tbdisease.htm. A review of the SSD's note, dated 6/18/19 indicated Resident 1 was assessed for possible placement by the owner of the UALF and she accepted Resident 1 for placement in her home. There was no documented evidence that the IDT team assessed Resident 1 for possible discharge to a lower level of care, as per the facility's policy. A review of an untimed Licensed Nurses Weekly Summary, dated 6/22/19, indicated Resident 1 required supervision with ADLs, eating, bathing, dressing, locomotion (movement around the facility), hygiene and transfers. A review of a Recapitulation (brief summary) of Care Discharge Summary/Guide for Aftercare, dated 6/24/19, indicated Resident 1 was discharged on [DATE] to ALF, because the resident's health had improved. It also indicated Resident 1 was discharged with the following medications and amounts:12 tablets of quetiapine, 50 milligrams; 16 capsules of [MEDICATION NAME] 100 mg; 10 tablets of [MEDICATION NAME] sodium; six (6) tablets of [MEDICATION NAME] 300mg; and four (4) tablets of [MEDICATION NAME] 300mg. [MEDICATION NAME] which had been discontinued on 3/21/19 was still given to Resident 1 upon discharge, instead of Rifambutin 300 mg. A review of a physician's telephone order, dated 6/24/19 and timed at 9:15 a.m., indicated Resident 1 should be discharged to an assisted living (ALF) with home healthcare to follow-up. A review of Resident 1's physician's progress notes indicated there was no documentation by the resident's physician regarding the basis of Resident 1's discharge to ALF on 6/24/19, as stipulated (specified) per the facility's policy. The nurse's progress notes and the SSD's notes had no documentation explaining the sudden need to discharge Resident 1 to a lower level of care. There was no IDT documented to indicate they coordinated, collaborated, and planned the delivery of care to prepare Resident 1 for discharge to a lower level of care. A review of a Licensed Personnel Progress Note, dated 6/24/19 and timed 9:15 a.m., indicated Resident 1 was discharged and picked up by the owner of the UALF at 11 a.m. On 7/13/19 at 9:40 a.m., during an interview, Resident 1 stated that he did not know why the facility decided to discharge him on 6/24/19, because he did not have medications and/or food. Resident 1 stated, I did not consent to the discharge and a lady just came and took me to her home and did not give me my medications or help me shower. Resident 1 stated he was readmitted back to the facility on [DATE]. On 7/13/19 at 10:04 a.m., during a concurrent interview and review of Resident 1's clinical record (nurse's and physician progress notes [REDACTED]. RN 1 stated that Resident 1's physician was notified, and orders received for the resident to be discharged . RN 1 also stated that upon discharge, Resident 1 was transported to the home by the owner of the home. RN 1 stated that Resident 1 was discharged with only a few TB and [MEDICAL CONDITION] medications (Any medication capable of affecting the mind, emotions, and behavior), without any plans of a physician to follow the resident's care. According to RN 1, Resident 1 required assistance in taking his medications and was not able to care for himself. RN 1 stated that failure of completing the TB treatment regimen could lead to complications including death of Resident 1. On 7/13/19 at 10:35 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated that Resident 1 required assistance in taking medications because the resident was not capable of self-medicating. LVN 1 stated Resident 1's TB symptoms could exacerbate (to make worse) if the resident did not take medications as ordered. LVN 1 stated, You don't play with TB, because it could be deadly. On 7/16/19 at 1:03 p.m., during a telephone interview, the SSD stated that Resident 1 was assessed and cleared for discharged for lower level of care. The SSD stated the IDT did not meet to clear Resident 1 for discharge and she had never been to the home to assess safety of the home. The SSD stated she had assumed that Resident 1 could self-medicate and did not know if Resident 1 had enough medications for discharge. The SSD stated she was not aware that Resident 1 was supposed to continue taking TB medicines. The SSD also stated that no arrangements were made for a physician to follow up with the Resident 1 post discharge. According to SSD, not ensuring that Resident 1 was discharged to a place where all his needs could be met, could lead to harm and injury to the resident, as well as exacerbating (the process of making a problem, bad situation, or negative feeling worse) his TB symptoms. On 7/16/19 at 1:30 p.m., during a telephone interview, the DON stated that the facility dropped the ball by not holding an IDT to clinically clear Resident 1 for discharge, not notifying the public health nurse (PHN 1) of Resident 1's discharge, not providing the resident with at least a weeks' worth of medications, not asking a physician to continue seeing Resident 1 after discharge. The DON stated that the facility made a mistake by not assessing the ALF (assisted living facility) to ensure Resident 1's needs could be met. The DON stated that these failures could cause Resident 1's condition to get worse. On 7/16/19 at 1:37 p.m., during a subsequent telephone interview, RN 1 stated Resident 1 was accidentally discharged with the wrong TB medication, [MEDICATION NAME] 300 mg, it was discontinued. RN 1 stated that this could exacerbate the resident's symptoms because the medication was discontinued due to a drug to drug interaction. RN 1 also stated that she was not sure how the facility made the decision on discharging Resident 1 to a lower level of care because Resident 1 required assistance with ADLs and was being monitored by a PHN (PHN 1) from the Health Department for TB. On 7/16/19 at 2:39 p.m., during a telephone interview, Resident 1's physician (MD 1) stated that he was shocked to find out from PHN 1, after PHN 1 had been looking for him, that the facility had discharged Resident 1 to a lower level of care. MD 1 stated that Resident 1 could not make decisions due to his cognitive impairment (thought process), was not stable for discharge and required assistance with all activities of daily living, including taking his medications. MD 1 stated that he did not give discharge orders. According to MD 1, Resident 1 was re-admitted to the facility on [DATE], as soon as he found out the resident was inappropriately discharged . On 7/18/19, at 10:49 a.m., during a telephone interview, the owner of the UALF stated that it was a private home, not an assisted living as indicated by the facility. The homeowner stated that she rents rooms out in her homes to cover her mortgage payments and that the facility's SSD was aware. The homeowner stated that she was not a nurse, was untrained on patient care and does not administer medications nor provide assistance with ADLs to her tenants. The homeowner stated that the SSD told her that Resident 1 was independent and only needed a place to live. The homeowner stated, I call my homes 'H---e of H------y A----s' just because the name sounded nice and not because I provide any type of nursing services. On 7/18/19, at 11:16 a.m., during an interview, PHN 1 stated that Resident 1 was discharged inappropriately without ensuring the resident had enough medications for TB and mental disorders, as well as follow-up care for TB. PHN 1 stated that the facility did not notify her about Resident 1's discharge and did not provide an ongoing physician care. PHN 1 stated that Resident 1 did not take his medications for 18 days after being discharged from the facility and stated not taking TB medications could exacerbate Resident 1's condition and prolong the TB treatment. A review of a Request for Monthly TB Medical Update form, dated 7/25/19 indicated Resident 1 was discharged and was not taking his TB medications during that time (6/24/19 through 7/12/19), for a total of 18 days. b. A review of Resident 2's Admission Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a recent readmission on 4/1/19. Resident 2 had [DIAGNOSES REDACTED]. A review of an H/P, dated 2/1/19, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's care plan, dated 2/1/19, indicated Resident 2 required assistance with bed mobility, transfer, ambulation, dressing, eating, personal hygiene and bathing; related to lack of safety awareness and poor personal hygiene. The staff's interventions indicated to assist Resident 2 with ADLs, provide clean clothing to wear, keep groomed in appearance, maintain good personal hygiene and neat appearance, set up grooming supplies as needed, administer medications as ordered and shower the resident as scheduled. A review of Resident 2's care plan dated 2/1/19, indicated Resident 2 was at risk for injury to self or others related to his [MEDICAL CONDITION] diagnosis. The staff's interventions included to determine triggers and de-escalation (Slowing down an encounter by backing off from immediate intervention or action) techniques, minimize environmental stressors, provide a calm, quiet and supportive environment. A review of Resident 2's physician orders, dated 2/1/19 indicated Resident 2 was receiving medications for the immunocompromised disease and depression. A review of Resident 2's MDS, dated [DATE] indicated Resident 2 was able to understand and be understood by others. The MDS indicated Resident 2 required a staff's assistance with bed mobility, transferring from a bed, chair to a standing position, moving from one location to another, dressing, eating, toilet use and personal hygiene. According to the MDS, Resident 2 used a walker for mobility and was receiving antipsychotic and antidepressants (medications to treat depression). A review of Resident 2's Licensed Nurse Weekly Summary, dated 3/21/19, indicated Resident 2 required supervision with bathing, locomotion and hygiene. A review of an untimed SSD's note, dated 3/28/19, indicated Resident 2 was assessed for placement by the homeowner of the UALF with plans to be discharge there on 4/1/19. A review of Resident 2's Licensed Progress Note, dated 3/28/19 and timed at 12 p.m., indicated Resident 2 had an order to be discharged to an ALF. A review of an untimed progress note, dated 4/1/19, indicated Resident 2 was discharged to the UALF. There were no IDT notes in Resident 2's clinical record indicating Resident 2 was evaluated for discharge, as per the facility's policy. A review of Resident 2's untimed Discharge Summary Record, dated 4/1/19, indicated Resident 2 required assistance with walking, bathing and toilet use. This record indicated Resident 2 was discharged to the UALF with limited amount of medications. On 8/7/19 at 10:41 a.m., during a concurrent interview and record review, the DON stated that Resident 2 was discharged on [DATE] to the UALF. The DON stated that facility did not hold an IDT meeting to clinically evaluate and clear Resident 2 for discharge. The DON also stated without assessing Resident 2, the facility would not know if the resident's needs could be met at UALF. According to the DON, Resident 2 had to be adequately prepared for discharge and information provided on where the resident could continue to get medications. The DON stated that the facility should have also ensured Resident 2 had a physician for post discharge and including addresses of where the resident could to go for help. c. A review of Resident 3's Admission Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 3's physician's orders [REDACTED]. [MEDICATION NAME] (used to treat certain psychiatric conditions (manic phase of [MEDICAL CONDITION] disorder)) 500 mg PO BID (twice a day) for [MEDICAL CONDITION] disorder and [MEDICATION NAME] 40 mg PO BID with meals for [MEDICAL CONDITION]. A review of Resident 3's undated care plan indicated Resident 3 was receiving psychoactive medications (medications to treat mental disorders). The staff's interventions included to monitor and record episodes Resident 3's behavior, administer medications as ordered and monitor for medication side effects. A review of Resident 3's care plan, dated 3/15/19, indicated Resident 3 required supervision with bed mobility, transfer, ambulation (walking), toilet use and bathing. The staff's interventions included to assist with all ADLs, provide clean clothing to wear, keep groomed in appearance, administer medications as ordered and observe for side effects. A review of Resident 3's H/P, dated 3/17/19, indicated Resident 3 had the capacity to understand and make decisions. A review of Resident 3's MDS, dated [DATE] indicated Resident 3 required a one-person physical assist with bed mobility, transferring from a bed, chair to a standing position, moving from one location to another, dressing, eating, toilet use and personal hygiene. According to the MDS, Resident 3 used a wheelchair for mobility and was receiving antipsychotic medication. A review of Resident 3's Licensed Nurse Weekly Summary, dated 4/3/19 indicated Resident 3 required limited assistance in bathing, dressing and hygiene. These notes also indicated Resident 3 required supervision with locomotion and transfers. A review of a SSD's untimed note, dated 4/5/19, indicated Resident 3 was assessed for placement by the homeowner at the UALF with plans for discharge on 4/10/19 to the UALF. A review of an untimed nurse's note, dated 4/10/19, indicated Resident 3 was discharged to the UALF. There was no documented evidence in Resident 3's clinical record that an IDT meeting was conducted to assess if the resident was clinically stable to discharge to a lower level of care prior to discharge, as per the facility's policy. On 8/7/19 at 10:34 a.m., during a concurrent interview and record review, the DON stated that Resident 3 was discharged on [DATE] to the UALF. The DON stated that the facility did not have an IDT meeting to clinically evaluate and clear Resident 3 for discharge, as per the facility's policy. The DON also stated without assessing Resident 3, the facility would not know if the resident's needs could be met at the UALF. The DON agreed that the facility did not adequately prepare Resident 3 for discharge because no information was provided to Resident 3 on where the resident could get medications and/or which physician would follow-up with the resident's care. d. A review of Resident 4's Admission Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with a most recent admission on 5/3/19. Resident 4 had [DIAGNOSES REDACTED]. A review of Resident 4's H/P, dated 2/28/19 indicated Resident 4 had the capacity to understand and make decisions. A review of Resident 4's care plan, dated 2/28/19, indicated Resident 4 required assistance with bed mobility, transfer, ambulation, toilet use and bathing, due to poor physical endurance, and ADL self-performance and support fluctuated on a daily basis. The staff's interventions included to assist with ADLs, provide clean clothing to wear, keep groomed in appearance, administer medications as ordered and observe for side effects. A review of Resident 4's Licensed Nurse Weekly Summary, dated 4/26/19 indicated Resident 4 required supervision with eating, bathing, dressing locomotion, hygiene and transfers. A review of Resident 4's MDS, dated [DATE] Resident 4 was able to understand and be understood by others. According to the MDS, Resident 4 required one staff's assistance with bed mobility, transferring from a bed, chair to a standing position, moving from one location to another, dressing, eating, toilet use and personal hygiene. A review of a progress note, dated 5/3/19 and timed at 10 a.m., indicated Resident 4 would be discharged to the UAFL. A review of another progress note, on the same date, timed at 4:15 p.m., indicated Resident 4 left the facility with all his belongings. A review of Resident 4's clinical record, indicated there was no documented evidence that an IDT was conducted and indicating Resident 4 was ready and prepared for discharge. On 8/7/19 at 10:43 a.m., during a concurrent interview and record review, the DON stated that Resident 4 was discharged on [DATE] to the UALF. The DON stated that facility did not have an IDT meeting to clinically evaluate and clear the resident for discharge. The DON stated this could result in harm to the resident. On 8/7/19 at 10:47 a.m., during an interview, the SSD stated that she failed to visit and checked out the UALF prior to discharging Residents 2, 3, and 4. The SSD stated that there was no IDT meeting done to clinically evaluate the residents for discharge clearance and/or a physician contacted for ongoing care after discharge for the residents. The SSD stated that not having a physician to follow the resident post discharge could worsen the resident's medical condition and result in harm to the residents. On 8/8/19 at 4 p.m., during an interview, the AIT (administrator in training) stated she visited the UALF on 8/7/19 and the homeowner of the UALF stated Residents 3 and 4's whereabouts were unknown and she would not tell him any pertinent information of their location. A review of an Employee Termination Record, dated 8/12/19, indicated that the facility fired the SSD, effective 8/8/19 due to violation of known facility rule or policy. The narrative indicated that the SSD discharged patients without an IDT meeting to an unsafe location without proper documentation and the inability of accepting facility to administer medications to the residents. A review of the facility's policy titled, Discharge Summary and Plan, with a revised date of 11/2014, indicated when a resident's discharge was anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his or her new living environment. The policy also indicated a post discharge plan would be developed by the IDT team with assistance of the resident and his or her family. According to this policy, the SSD would review the plan with the resident and family within twenty-four (24) hours before discharge takes place, and a copy of the plan filed in the resident's medical records. A review of the facility's policy titled, Discharging the Resident, with a revised date of 11/2012, indicated the purpose of the policy was to provide guidelines for the discharge process. The policy indicated the resident would be consulted about the discharge, with information regarding who would provide resident's care. A review of the facility's policy titled, Transfer or Discharge Documentation, with a revised date of 8/2014, indicated when a resident was transferred or discharged , the details of the transfers or discharges would be documented in the medical records. The policy also indicated the reason for the transfer or discharge would be documented in the resident's clinical records by the resident's attending physician.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had the right to be free from abuse, by: 1. Failure to develop a plan of care addressing Resident 2's aggressive behavior with the necessary interventions for the staff to implement and assist in managing Resident 2's behavior. 2. Failure to closely monitor Resident 2 to prevent her from attacking other residents, including Resident 1, who was the roommate and near Resident 2 when Resident 2 was manifesting uncontrolled aggressive behaviors. 3. Failure to develop a plan of care with interventions to protect Resident 1 when Resident 2, who had attacked her roommate, was moved to share the room with Resident 1. 4. Failure to implement interventions to protect Resident 1 when Resident 2 was manifesting aggressive behaviors for several hours. 5. Failure to inform Resident 2's physician when Resident 2 refused to take her controlling-behavior medications throughout the day and nursing staff could not control and manage Resident 2's aggressive behavior. As a result, on 9/5/18, at 5:30 a.m., Resident 2 slapped Resident 1 across her face causing redness to the left side of the face. Resident 1 was scared and afraid. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE] with the most recent re-admitted d 7/26/18. Resident 1 had [DIAGNOSES REDACTED]. A review of the History and Physical (H&P) Exam completed by the attending physician dated 7/27/18, indicated Resident 1 could not understand and make decisions. A review of a Minimum Data Set (MDS - standardized assessment and care-planning tool) dated 7/4/18, indicated Resident 1 was able to understand and be understood by others, required supervision with bed mobility, transferring from a bed and chair to a standing position, dressing, eating, toilet use and personal hygiene. A review of the Situation Background Assessment and Recommendation (SBAR) form dated 9/5/18, indicated at 5:30 a.m., Resident 2 slapped Resident 1 on the face causing redness to Resident 1's left side face. A review of the licensed nursing Progress Notes completed by Licensed Vocational Nurse 1 (LVN 1) dated 9/5/18, for the 11 p.m. to 7 a.m., indicated Resident 2 slapped Resident 1 while Resident 1 slept. Resident 2 hit Resident 1 so hard LVN 1 thought someone had fallen. A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident 2 also had [DIAGNOSES REDACTED]. A review of Resident 2's [MEDICAL CONDITION] Medication Orders dated 8/27/18 included: -[MEDICATION NAME] ([MEDICATION NAME] - treats [MEDICAL CONDITION]) 125 milligram per 5 milliliters (mg/ml) injection intramuscularly (IM - in the muscle) every two weeks for [MEDICAL CONDITION], -[MEDICATION NAME] ([MEDICATION NAME] sodium) 500 mg by mouth two times daily for [MEDICAL CONDITION] disorder (a mental illness that causes dramatic shifts in a person's mood, energy and ability to think clearly), -[MEDICATION NAME] ([MEDICATION NAME] - produce calming effects) 2 mg orally every six hours for anxiety (nervousness), -[MEDICATION NAME] (Ambien - for inability to sleep) 10 mg orally at the hour of sleep, and -[MEDICATION NAME] ([MEDICATION NAME]- for [MEDICAL CONDITION]) 100 mg orally twice a day. A review of Resident 2's licensed nursing Progress Notes dated 8/28/18, indicated at 2:50 p.m., Resident 2 threatened her roommate, Resident 3, and poured juice on Resident 3's bed. Staff moved Resident 2 to another room, Resident 1's room. A review of Resident 2's H&P dated 9/1/18 indicated the resident had a fluctuating capacity to understand and make decisions. A review of Resident 2's MDS dated [DATE] indicated that Resident 2 had memory problems, required limited assistance with transferring, dressing, and personal hygiene. Resident 2's clinical record lacked a plan of care addressing Resident 2's aggressive behavior, which was confirmed by Assistant Director of Nursing (ADON) during interview and record review on 9/12/18, at 7:35 a.m. A review of Resident 2's licensed nursing Progress Notes completed by LVN 1 dated 9/5/18, indicated: -At 12 a.m., Resident 2 was awake, pacing the floor and threw juice on her roommate, Resident 1. Resident 2 refused to take her medications after three attempts. Resident 2 used a water pitcher to throw water on Resident 1. Resident 2 stated, I am crazy. I am the devil's child. Resident 2 was a danger to herself, Resident 1 and the staff. -At 1 a.m., Resident 2 was sitting up in bed up shaking her legs and was monitored. -At 4 a.m., Resident 2 continued to refuse her medications, was walking throughout the facility disoriented and stating she would kill everyone. -At 7:15 a.m., the police came to the facility and arrested Resident 2 for slapping Resident 1 in the face. There was no documented evidence the licensed nursing staff notified the physician about Resident 2 refusing to take her medications and having uncontrolled aggressive behavior which was confirmed by Assistant Director of Nursing (ADON) during interview and record review on 9/12/18, at 7:35 a.m., and by LVN 1 on 9/12/18, at 11:17 a.m. On 9/12/18, at 7:18 a.m., during an interview, LVN 2 stated that Resident 2 was very violent and resistant to care. According to LVN 2, whenever the resident took her medications, she calmed down. On 9/12/18, at 7:35 a.m., during an interview, ADON stated for the safety of other residents, Resident 2 was monitored closely, whenever she displayed aggressive behavior, but the ADON could not provide documentation of strategies and interventions to manage Resident 2's behavior. The ADON stated Resident 2 did not have a care plan to control her behavior before attacking Resident 1. On 9/12/18, at 8:10 a.m., during an interview, Restorative Nursing Assistant 1 (RNA 1) stated Resident 2 was very aggressive towards other residents. Resident 1 was calm and non-aggressive. On 9/12/18, at 9:55 a.m., during an interview a Certified Nursing Assistant (CNA 1) stated that Resident 2 was combative and always ready to fight. On 9/12/18, at 11:17 a.m., during an interview LVN 1 stated staff could not stay with Resident 2 because her behavior could escalate as when agitated, Resident 2 would be left alone to prevent becoming aggravated. LVN 1 also stated that she did not know what behavior management interventions were needed and what approaches were necessary to protect Resident 1. LVN 1 also said Resident 2 refused all her medications for the entire day (9/5/18) and the nurses did not notify the physician. A review of the facility's policy titled, Preventing Resident Abuse, revised on 12/2013, indicated the facility would not condone any form of resident abuse and would continually monitor the facility's policies, procedures, and systems to assist in preventing resident abuse. A review of the facility's policy titled, Abuse Prevention Program, revised on 8/2006 indicated residents would be free from abuse and be protected from all forms of abuse. A review of a facility's policy titled, Care Plans-Comprehensive, revised on 9/2010, indicated that each resident's care plan would be individualized with measurable objectives and timetables to meet the resident's needs. A review of the facility's policy titled, Using the Care Plan, revised on 8/2006, indicated care plans were used to develop each resident's daily care routine and available to the staff responsible for providing care services to the residents. A review of the facility's policy titled, Behavioral Assessment, Intervention and Monitoring, revised on 3/2015, indicated behavioral symptoms would be identified and managed appropriately by assessing and treating the underlying factors that could be managed. It also indicated that nursing staff would document and inform the physician about specific details on the resident's changes in mental status, behavior, and cognition.

Based on observation, interview and record review the facility failed to ensure two of two sampled residents (Resident 1and 2) who were assessed as having a high risk of elopement, were provided continuous, adequate supervision and monitoring by failing to: 1. Ensure the licensed nurse and CNAs were aware of Resident 1's high risk and history of elopement to ensure they provided monitoring to ensure Resident 1's safety. 2. Ensure Resident 1 was supervised and monitored every two hours as indicated in the IDT notes. 3. Implement the facility's Elopement Risk Prevention Program policy and procedure to provide a wander guard, 1:1 Supervision, alternative placement when Resident 1 and 2 exhibited elopement behaviors. Resident 1, who was diagnosed with [REDACTED]. The facility staff could not locate the resident. Unbeknownst to the facility, the following day Resident 1 was located 18 miles away from the facility and was unresponsive. Consequently, this resulted in harm to Resident 1. Resident 1 was admitted to the acute hospital, where he was diagnosed as having blunt head trauma and an intracranial bleed. Resident 1 remains in the acute hospital in a persistent vegetative state and has underwent two brain surgeries. Additionally, Resident 2, who was schizophrenic, severely impaired cognitively, and noncompliant with use of a Wander Guard, wandered from the facility undetected and was found outside without staff supervision on several occasions. This had the potential to result in harm to Resident 2. Findings: On [DATE], an unannounced visit was made to the facility to investigate an entity reported incident which indicated on [DATE], at 10:30 a.m., Resident 1 was missing from the facility and his whereabouts were unknown. The facility was not aware the resident had eloped and had not recognized the elopement for over an hour. A review of the physician's history and physical (H & P) from the GACH dated [DATE], indicated Resident 1 had eloped from the GACH's medical floor, and was found in a coffee shop mumbling to himself. The H & P further noted the resident had difficulty following re-directions, was confused, disoriented and disorganized, had slurred speech, was not quite coherent, and wanders into the streets placing his life at risk. A review of the admission record indicated Resident 1 was admitted to the facility on [DATE], from the general acute care hospital (GACH) with [DIAGNOSES REDACTED]. A review of the admission assessment dated [DATE], indicated Resident 1 was alert, oriented, aggressive and denied sensory problems. A review of the elopement risk assessment dated [DATE], indicated Resident 1 was assessed a score of 13. A total score of 10 or above represents high risk. The assessment also indicated the resident was cognitively impaired with poor decision-making skills, had a history of [REDACTED]. A review of Resident 1's plan of care titled Wanderer/Elopement Risk dated [DATE] indicated Resident 1 had a potential for injury related to wandering, attempts to leave the facility grounds, which posed a danger to himself and others, a history of elopement prior to admission and refusing to wear a wander guard. The listed approaches included to monitor the resident's whereabouts, and to identify and minimize situations that lead to wandering behavior A review of the facility's Interdisciplinary Team (IDT) conference record dated [DATE] indicated Resident 1 had a history of [REDACTED]. The IDT notes also noted Resident 1 was being monitored every two hours for his whereabouts and was placed in a room by the nurses' station for close watch. However, upon further review there was no documented evidence in Resident 1's clinical record to confirm he was monitored every two hours. A review of the facility's internal investigative report indicated on [DATE], at 10:30 a.m., indicated Resident 1 was observed standing in the doorway threshold of his room. On [DATE] at 11:30 a.m., one hour later, the resident was not observed to be in the facility. An internal and external search was conducted but, facility staffs were not able to locate the resident. The facility notified the local authorities and a missing person's report was generated. During an interview on [DATE] at 9:45 a.m., with Employee X, she stated, on the [DATE], she did not observe Resident 1 leaving the facility due to multi-tasking. She further stated on [DATE], the day before Resident 1 eloped, Resident 1 walked towards the receptionist desk and pointed at the main door of the facility. Employee X re-directed the resident back to his room and told the staff sitting at nurses station one that the resident was near the entrance of the facility. Employee X stated she was informed by the DON on [DATE], after the resident eloped, that he was a high risk for elopement. During an interview on [DATE] at 11:00 a.m. the Director of Staff Development (DSD) stated she administered the routine morning medications to Resident 1 on [DATE] at 8:10 a.m. The DSD further stated that she was not aware and had not been informed prior to Resident 1's elopement that he was a high risk of elopement and had eloped from previous health facilities. During an interview on [DATE] at 11:35 a.m., certified nurses' assistant (CNA 1) stated she provided care for Resident 1 on [DATE] and [DATE] from 7 am to 3 pm and was not informed the resident was a high risk for elopement and had eloped from previous health facilities. During an interview on [DATE] at 2:35 p.m., with Family member (FM 1), she stated Resident 1 had a history of [REDACTED]. A year ago the resident eloped from a facility and was found in San Diego California. He had been brutally assaulted, half of his brain was missing and he was not able to talk. FM 1 further stated Resident 1 becomes bored easily. During an interviews [DATE] at 3:48 p.m., 4:05 p.m., and 4:20 p.m., the registered nurse supervisor (RNS) stated that he performed the initial elopement risk assessment on Resident 1 on [DATE]. The RNS further stated that he was not aware that the resident has a history of elopement. However, the elopement risk assessment indicated that Resident 1 had a history of [REDACTED]. The RNS stated that he could not recall notating the elopement risk assessment and believed that he read somewhere in the resident's chart that the potential existed. The RNS stated after a high risk of elopement was determined the physician would be notified, but could not recall if the physician was notified. During an interview on [DATE] at 4:25 p.m., with the Administrator, she was asked if there were any residents who had eloped from the facility prior to [DATE], and he stated back in [DATE] Resident 3 eloped from the facility. Resident 3 walked out the front door and was found one week later downtown Los Angeles at the Mission (a homeless shelter). The Administrator also stated Resident 2 made an attempt to go across the street to the liquor store and was found outside of the facility without supervision. During an interview on [DATE] at 4:32 p.m., the Administrator and the DON were asked how information is communicated to the staff after an IDT meeting. The DON stated the charge nurses are present during the IDT meeting and are responsible for informing the licensed nurses and CNA's of the resident's ongoing conditions and/or changes. The DON stated the staffs were only in-serviced for High Risk Elopement after Resident 1 had eloped from the facility. During a telephone interview on [DATE] at 8:38 a.m., FM 1 stated that she was concerned and afraid that Resident 1 maybe deceased . During a telephone interview on [DATE] at 1:00 p.m., the Administrator stated that Resident 1 has not been located at this time and several attempts were made to locate the resident. During a telephone interview on [DATE] at 4:20 p.m., the DON stated that Resident 1 has not been located and the facility has made daily attempts in locating the resident. 2. A review of the admission record indicated Resident 2 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's elopement assessment dated [DATE] indicated the resident was assessed with [REDACTED]. A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool) dated [DATE] indicated Resident 2 was severely impaired cognitively, was able to ambulate independently and did not exhibit wandering behavior. A review of Resident 2's plan of care titled Behavioral Symptoms: Elopement/Wandering Risk dated [DATE], indicated the resident's elopement risk assessment was scored as a 9, which is not a risk, but identified the resident as having a status or condition that is a risk factor for elopement or wandering. The listed interventions included to apply a Wander guard bracelet and to provide frequent visual check at least every 30 minutes, if noted with wandering guards. A review of Resident 2's plan of care dated [DATE] and titled Non-complaint with Nursing Care and Nursing Intervention indicated Resident 2 refused to use a wander guard due to a tendency to leave the facility to go to the store. The listed approaches included to provide frequent visual monitoring to ensure safety. A review of an updated plan of care for Resident 2 titled Behavioral Symptoms: Elopement/Wandering Risk dated [DATE] indicated the resident was at risk for injury due to elopement/wandering episode to unsafe areas and attempted to leave facility to go to the store. The listed approaches included to provide frequent visual checks at least every 30 minutes, if noted with wandering episodes, apply Wander guard bracelet to alert the staff when the resident attempts to leave the facility unassisted. Provide activities that will divert the resident's attention from wandering. During an interview on [DATE] at 9:45 a.m., Employee X stated on [DATE] Resident 2 eloped from the facility and was witnessed crossing the main street in front of the facility and was witnessed by the central supply clerk. During an interview on [DATE] at 11:58 a.m., the central supply clerk stated that on [DATE] Resident 2 was observed outside of the facility in the driveway. The clerk stated that he had informed the charge nurse. During an interview on [DATE] at 4:30 p.m., the DON stated on [DATE] ([DATE]) Resident 2 had left the facility, attempted to go to the store, was caught and escorted back to the facility. A review of the facility's revised policy dated 2016 and titled Elopement Prevention Program indicated all residents will be assessed of elopement risk upon admission and as needed. The resident who is identified at risks for elopement the implementation will be but not limited to: Wander guard bracelet if applicable to the facility setting. 1:1 supervision. Secured unit placement. Activity re-assessment. Family intervention. Environmental assessment. Medication review. Physical re-assessment. Psychosocial assessment. Evaluation of alternate placement. A review of the facility's undated protocol titled Elopement Prevention Protocol indicated appropriate staff will monitor resident whereabouts including the monitoring of responses/reactions to events/activity in surroundings at the time of wandering and report unusual behaviors to supervisor immediately. Communication such as but not limited to: written notification to appropriate departments regarding resident at risk. Because of the facility's failure to ensure the staff adequately supervised and monitored Resident 1, and provided supervision every two hours for Resident 1, who had a high risk of elopement and had eloped from several facilities in the past, and to ensure all staff were aware of the residents significantly high risk of elopement, had the potential to expose the resident to accidents, dangerous and hazardous incidents, and death. Therefore, an immediate jeopardy was called on [DATE], at 4:35 p.m., with the Administrator and the Director of Nurses. The administrator presented an acceptable plan of correction action to the surveyor on which consisted of the following: 1. Staff will be provided in-service on the elopement protocol. 2. Licensed staff will do elopement assessment upon admission and initiate a plan of care. 3. IDT will meet to give input of possible prevention measures for the resident's safety with accurate plan of care. 4. All prevention measures will be communicated during change of shift. 5. Licensed staff will update elopement assessment is there if the behavior of change such as displaying exiting behavior. 6. All new admissions will be closely monitored at least 72 hours. 7. Facility staff must be familiar with elopement or missing resident drill and know code Green and the code for Elopement or Missing Resident. 8. The clinical staff must be familiar with 1:1 monitoring if the need of the resident to be monitored as 1 staff per 1 resident. 9. The Elopement or Missing Resident drill will be done monthly by the DON or DSD, or RN Supervisor to ensure the effectiveness of the staff knowledge of the protocol. 10. Medical record staff will do weekly audit of the elopement assessment and plan of care. 11. The findings will be reported to the DON for further corrective actions if needed. 12. The front door alarm will be turned on at 5:30 p.m., every day. 13. All staff will be aware and check when alarm goes off. 14. All residents will be photograph in the chart, at the front desk and nursing stations at all times to identify the residents. 15. The photograph will be updated and retake and retaken every 3 months or as needed due to possible physical changes on the resident. On [DATE] at 8:31 p.m. the administrator and the director of nurses were informed the immediate jeopardy was lifted. During a telephone interview on [DATE], with the DON, she stated Resident 1 had been located and is in the general acute care hospital. A review of the acute hospital record indicated Resident 1 was found down at the train station on [DATE], and was admitted with a large epidural hematoma. He underwent surgery for [REDACTED].