Every finding on record at Inspire Behavioral Health

Based on observation, interview and record review, the facility failed to ensure the safety for three of 12 residents (Resident 36, Resident 48, & Resident 98) who were at risk for elopement (the unauthorized, unsupervised departure of a patient/resident from a healthcare facility when their condition puts them at risk of injury or death) and eloped from the facility when:1. The facility failed to provide appropriate and sufficient supervision to Resident 48, when Resident 48 who is deemed gravely disabled (legal term to describe a condition where a person, due to a mental health or substance use disorder, is unable to provide for their basic needs like food, clothing, or shelter) eloped from the locked facility on 10/27/25, when Houskeeper A (HA) failed to follow protocol of ensuring the location of her keys at all times. It was later identified Resident 48 had used HA's keys to exit the locked facility. Resident 48 remained missing until the afternoon of 10/30/25. 2. The facility failed to accurately assess Resident 98's elopement risk on admission on [DATE] and provide the appropriate and sufficient supervision to Resident 98 when she eloped from the facility on 5/24/24. 3. The facility failed to accurately assess Resident 36's elopement risk on 2/20/25 and provide the appropriate and sufficient supervision to Resident 36 when Resident 36 eloped on 10/25/25 after being inaccurately assessed as low risk for elopement and allowed to go on a community walk outside the facility.These failures resulted in Resident 48 to be unaccounted for, causing the facility to fail in providing basic needs of food, medications, and shelter to Resident 48 for approximately three days. These failures had the potential for Resident 48 to be fatally injured, dehydrated (having lost a large amount of water from the body.), or withdraw from medications prescribed by his Physician causing medical and/or psychological deterioration (such as muscle stiffness, headache, dizziness, depression, anxiety, agitation or nausea) These failures had the potential to contribute to Resident 98's elopement on 5/24/24 due to an inaccurate elopement risk assessment.These failures contributed to Resident 36's elopement due to an inaccurate risk assessment reflecting a low risk for elopement. Facility staff allowed Resident 36 to go on a community walk based on the inaccurate assessment.These failures required immediate correction to prevent similar occurrence of elopement due to inaccurate elopement risk assessments at the facility, and staff not accounting for their keys to the locked facility exit doors.On 10/28/25, at 5:40 p.m. 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) was identified and declared, in the presence of the facility's Administrator and Director of Nursing related to the failure to provide adequate supervision, accurately assess Residents risk for elopement, and ensure facility staff kept their keys secured and accounted for at all times.On 10/31/25, at 4:17 p.m., the IJ was removed after the Administrator submitted an acceptable IJ Removal Plan (IJRP, a plan with interventions to immediately correct the deficient practices), and after the survey team verified and confirmed the corrective actions while onsite.1. During an observation on 10/27/25 at 8:30 a.m., in Resident 48's room, Resident 48 was not present in his room. During an observation on 10/27/25 at 8:33 a.m., in Station 1 hallway, Resident 48 was not found in the hallway. Resident 62 who was in the hallway spoke loudly to no one in particular, watch out everyone people are stealing keys around here. During an observation on 10/27/25 at 8:35 a.m., in Station 1 activity room, Resident 48 was not found in activity room. During a review of facility self-reported incident 2653540, dated 10/27/25, incident indicated, At around 0710am, staff reported that [Resident 48] was not found in the facility during shift report. Per staff from noc [night] shift, [Resident 48] had his PRN [as needed] medication at around 5:30am and he was reassessed for the effectiveness of PRN medication at around 6:30am. During shift change report, staff were unable to find [Resident 48] Staff Initiated the search for resident in the facility and in the neighborhood . [Resident 48] is not found at this time. During a review of Resident 48's Facesheet (A facesheet is a summary document containing a Resident's personal and demographic information, including contact details and medical history) dated 10/27/25 indicated, Resident 48 had a diagnosis of Schizoaffective Disorder, Bipolar Type (a mental health condition that combines symptoms of schizophrenia and bipolar disorder, this condition is characterized by both psychotic symptoms (seeing things, hearing voices, disorganized thinking or speech) and mood swings (bipolar disorder) simultaneously.) since admission on [DATE]. The Facesheet indicated, Resident 48 had a conservator (a person appointed by a court to manage the health care and financial affairs of an adult who is unable to do so themselves due to mental illness, dementia, or other incapacitating conditions) appointed to him. During a review of Resident 48's Inpatient Psychiatry admission Note dated 4/5/24 indicated, Pt [patient] is well known to [inpatient psychiatric facility] .given his history of non-compliance with medications in the community. However, when patient restabilizes on his medications and is attempted to be placed in a lower-level care, he often AWOLs [Absence without official leave: leaving without approval from the facility] and relapses on methamphetamines [a powerful, highly addictive synthetic stimulant drug that affects the central nervous system] and stops taking his medications. [Resident 48] again presents for hospitalization due to his aggressive and threatening behavior at his residence and is no longer welcomed back and is unable to care for himself. During a review of Resident 48's Reappointment Letters for Conservatorship dated 8/12/25 indicated, Powers of the conservator for a gravely disabled person under chapter 3 (commencing with section 5350), part 1 division 5, of the welfare and institutions code .it is hereby ordered that the conservatee [Resident 48] is still gravely disabled person within the meaning of the law, and the petition for reappointment is granted. Signed by County Superior Court on 7/22/25. During an interview on 10/27/25, at 2:09 p.m., with Certified Nursing Assistant (CNA) I, CNA I stated, she was clocked in for work this morning around 7:07 a.m. and was assigned to be the high risk CNA (she is tasked with monitoring the residents designated as high risk, whether it be a fall risk, or behaviors, she monitors them during her shift). CNA I stated, she did her head count after clocking in and noticed Resident 48 was missing. CNA I stated, she normally sees Resident 48 walking in the hallways in the morning, she then checked the bathroom, phone booth and showers and did not see Resident 48. CNA I stated she then notified the nurse who called the sheriff. CNA I stated, she heard one of the housekeepers lost her keys this morning. During a review of the Facility's head count sheet dated 10/27/25, sheet indicated staff wrote HW [hallway] for end of shift at 7:00 am, indicating Resident 48 was seen in the hallway around 7:00am from the NOC shift CNA. Facility head count sheet indicated, next shift CNA, CNA I charted at 7:00 am AWOL for Resident 48, indicating he was missing, signed by CNA I. During an interview on 10/27/25, at 2:17p.m., with the Director of Nursing (DON), the DON stated, During our initial investigation it was reported to the housekeeping supervisor this morning that the AM housekeeper lost her keys. The DON stated housekeeper (Housekeeper A, HA) was suspended pending the investigation. During an interview on 10/27/25, at 3:35 p.m., the facility Administrator (ADM) stated, around 7:30 a.m., this morning she got a call that Resident 48 was missing. The ADM stated, she instructed staff to search for the nearby area around 8:30 a.m., and was informed staff came back and could not find Resident 48. The ADM also stated, she was also notified at the same time by the housekeeping supervisor (HS) that HA lost her keys. The ADM stated, her protocol for lost keys depends on where the staff loses the key, if they lost the key in the locked area, they are supposed to start a room-to-room search. ADM stated another resident (Resident 62) reported they saw Resident 48 with a set of keys. The ADM stated the missing keys were found outside the Station 1 exit door near the dining room shortly after. The ADM also stated that the housekeepers have lanyards on their keys, and it may have been possible the lanyard was hanging outside her apron and Resident 48 was able to grab it and take the keys. During an interview on 10/27/25, at 4:00 p.m., with the Program Director (PD), the PD stated, she spoke to HA at around 6:15 a.m., this morning. The PD stated, HA last remembered using her keys to open the middle classroom and she was cleaning the phone booth around 7:00 a.m. she was keeping her keys in her apron that morning and realized they were missing. The PD further stated, HA told her she reported to her supervisor (HS) around 6:50-7:00 a.m. that the keys were missing. The PD stated, HA was approached by Resident 48 earlier that morning around 5:40 a.m., when Resident 48 asked HA if her supervisor was going to be here today. The PD stated HA and Resident 48 had no other interactions according to HA. During an interview on 10/27/25, at 4:15 p.m., with the Housekeeping Supervisor (HS) HS stated, she was called around 7:05 a.m this morning by HA who stated she had lost her keys. The HS stated, HA told her she was cleaning, and she had put her keys in her front apron pocket, and she reached in to grab it, and could not find it. The HS stated, HA reported to her that Resident 48 came up to her early in the morning and asked her if HS was working today, and that is the only interaction they had. HS stated, it is her expectation that the housekeepers would keep the keys around their necks and know where the keys are at all times. The HS stated she had to write up the HA for her behavior two times in the past, when she had left open a door to the laundry room leading outside the facility. The HS further stated she gave the HA a warning the first time, then the second time she was found to leave the door open she was suspended for a period of time. During an interview on 10/27/25, at 4:40 p.m., with CNA J, CNA J stated she last saw Resident 48 this morning around 6:30 a.m., walking in the hallway. During an interview on 10/27/25, at 5:05 p.m. with Resident 62, in Residents room. Resident 62 stated he saw Resident 48 with a set of keys that were not his. Resident 62 stated the keys had a black string on them, and he saw Resident 48 put them in his pocket and walk toward the dining room. Resident 62 stated he did not see where Resident 48 got the keys, but he was standing next to the phone room leaning against the wall. During a review of Resident 62's Brief Interview for Mental Status (BIMS- a standardized cognitive screening tool used primarily in long-term care facilities to assess a resident's cognitive function) dated 7/31/25, indicated a score of 14. A score of 13-15 indicates being cognitively intact. During an interview on 10/27/25, at 7:00p.m., with CNA K, CNA K stated he was the CNA for the NOC shift prior to when Resident 48 went missing. CNA K stated he last saw Resident 48 around 6:30 in the hallway. During a review of Resident 48's care plan dated 8/9/25, care plan indicated, Resident is an elopement risk AEB [as evidenced by] resident may leave the facility without permission. Noted with a long history of AWOL from previous placements and substance abuse. The care plan had a goal, Resident will have 0 (zero) episode of attempting AWOL q (every) day. It included interventions such as: Resident will be redirected away from the exit doors when observed standing by the exit doors, Nursing or Program staff will observe for exit seeking behaviors, if observed res (resident) to placed on high risk monitoring and counselling. During a review of Resident 48's Psychiatrist Progress Note dated 8/23/25 indicated, Staff reports 8/21/25 patient attempted to elope from the facility by following staff an [sic] pushing past them through station exit door to main lobby.Patient was seen by me for evaluation.Continue treatment plan. Signed by Medical Doctor (MD) L. During an interview on 10/29/25 at 3:56 p.m., with the Medical Director (MD), the MD stated, it is his expectation that the facility staff supervise all residents in order to prevent elopements. The MD stated staff are taught to be cautious. During an interview on 10/30/25, at 3:19 p.m., with the Conservator (CON), he stated he was the appointed conservator for Resident 48 who makes decisions on his behalf. The CON stated, he was concerned that Resident 48 was missing for so long, because he is considered gravely disabled and he cannot provide food or safety for himself. During an interview on 10/30/25 at 9:44 a.m., with MD L, MD L stated, he is Resident 48's psychiatrist and manages his psychiatric medications. MD L stated it is his expectation that staff supervise the residents in order to prevent elopements from the facility. During a review of Resident 48's Physician Orders dated active on 10/27/25, orders indicated Resident 48 was ordered Divalproex Sodium (a medication used to treat manic phases of bipolar disorder) DR (delayed release) 250 mg. give three tablets by mouth two times per day, Lorazepam (a drug of the benzodiazepine group, used especially to treat anxiety) two mg. 1 tablet by mouth two times a day for agitation, and Zyprexa (atypical antipsychotic medication primarily used to treat schizophrenia and bipolar disorder) 20 mg. q HS (every bedtime), Propranolol HCL (hydrochloride, medication to lower blood pressure) 10 mg 1 tablet by mouth two times a day, hold if BP (blood pressure) < (below) 100/60, PR (pulse rate) < 60. During a review of Medication Guide for Divalproex Sodium by the National Institute for Health (NIH), dated 2022, guide indicated, Do not stop taking Depakote [divalproex sodium] without first talking to your healthcare provider. Stopping Depakote suddenly can cause serious problems [such as anxiety, nausea, vomiting, irritability, depression and insomnia]. During a review of Medication Guide for Zyprexa by the National Institute for Health (NIH), dated 2009, guide indicated, To prevent serious side effects [such as headaches, nausea, brain zaps [electrical like pain sensation] anxiety, mood swings], do not stop taking ZYPREXA suddenly. If you need to stop taking ZYPREXA, your doctor can tell you how to safely stop taking it. During a review of Medication Guide for Lorazepam by the National Institute for Health (NIH), dated 2024, guide indicated, Withdrawal symptoms [such as cramping, anxiety, dizziness, depression, panic attacks, vomiting, weight loss, ringing of the ears] if abruptly discontinued after long-term use. During a review of 5 day Follow up dated 10/31/25 indicated, Resident 48 was found on 10/30/25 at a family members home. Document indicated, Upon investigation, it is determined that [Resident 48] took away the keys from the housekeeping staff and used the keys to exit the facility through the door near the dining room. 2. During a review of Resident 98's Facesheet, document indicated Resident 98 had a diagnosis of Schizoaffective Disorder, Bipolar Type. Record review of Resident 98's Baseline Care Plan dated 5/23/24 indicated, the facility assessed Resident 98's elopement risk. Elopement Risk Assessment portion indicated, Medications: .psychotropics [medications used to treat mental health disorders] 0. NONE of these medications was selected. Diseases (dementia, any type of mental illness) 0. NONE Present was selected. Calculated assessment indicate, Elopement Risk Score less than 10 indicating a low risk for elopement. During an interview on 10/30/25, at 12:41 p.m., with the DON, she stated Resident 98 is taking at least one psychotropic medication. The DON stated the elopement risk assessment was not correct. The DON stated, Resident 98 is taking at least one psychotropic medication. The DON stated, Resident 98 also has a mental illness of schizoaffective disorder. The DON stated the score was incorrect. The DON stated should have selected that the Resident 48 takes two psychotropic medications, and that Resident 48 has a mental illness. DON stated, Resident 98 was taking Seroquel (atypical antipsychotic medication used to treat mental health conditions such as schizophrenia) and Abilify (a prescription atypical antipsychotic medication used to treat several mental health conditions). During a review of Resident 98's Change in Condition dated 5/24/24, document indicated, Resident went AWOL out of the facility. 3. During a review of Resident 36's clinical record, record indicated, Resident 36 was admitted on [DATE] and had a diagnoses of Schizoaffective Disorder, Bipolar Type, Anxiety Disorder (a mental illness that causes constant fear), Epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), and Post Traumatic Stress Disorder (it is a mental health condition that can develop after experiencing or witnessing a traumatic event). Review of Resident 36's quarterly BIMS (brief interview for mental status) score dated 8/29/25 (A score of 0-7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact) score was 15. Review of Resident 36's Baseline Care Plan dated 2/20/25 indicated, the facility assessed Resident 36's elopement risk. Elopement Risk Assessment portion indicated, Diseases (dementia, any type of mental illness) 0. NONE Present was selected. Calculated assessment indicate, Elopement Risk Score less than 10 indicating a low risk for elopement. During a review of facility self-reported incident 2652972, dated 10/25/25, incident indicated, At around 8:30am on 10/25/25 during neighborhood walk, resident was observed to suddenly run away from walking group. Staff followed resident and attempted numerous times to convince her to return to facility. Resident was not receptive and continued to run. Another staff member called facility to report incident and AWOL protocol was initiated. Multiple staff followed resident on foot and in cars . During an interview on 10/27/25 at 2:07 p.m., with Registered Nurse (RN) O, RN O stated, Resident 36 has no record of elopement or wandering. During an interview on 10/27/25 at 3:39 p.m., with the PD, the PD stated, Residents who are at high risk for elopement are not allowed to go on community walks outside the facility. During an interview on 10/30/25, at 12:41 p.m., with the DON, the DON stated Resident 36's elopement risk assessment was not correct. The DON stated, Resident 36 also has a mental illness of schizoaffective disorder. The DON stated the elopement risk assessment score was incorrect. All residents are at elopement risk in the facility. During a review of Resident 36's Risk for Elopement dated 10/28/25, Risk for elopement indicated the elopement risk assessment was updated by the DON to accurately reflect Resident 36 having a mental illness. Elopement risk score indicated 27 (high risk for elopement). During an interview on 10/29/25, at 4:24 p.m., with Licensed Vocational Nurse (LVN) P, LVN P stated, Resident 36 is no longer going on community walks, because she is at high risk for elopement. During a review of the facility's policy and procedure (P&P) titled, Policy and Procedure For Elopement and AWOL dated 2024, the P&P indicated, It if the policy of this facility to take appropriate steps to identify the risk of, prevent, detect and respond promptly to resident elopement/AWOL.All residents are assessed for Risk of Elopement upon admission.

Based on interview and record review, the facility failed to provide the needed care and services that are resident centered for one of four residents (Resident 124) when:1.The facility did not accurately assess Resident 124's risk for falls prior to the two fall events Resident 124 had within one month on 2/16/25 and 3/7/25.2. The facility failed to implement an intervention that was included in Resident 124's care plan after her previous fall incident on 2/16/25.3.The facility did not follow their policy and procedure (P&P) when they failed to complete Resident 124's orthostatic blood pressure measurements (blood pressure measurements that are taken in three different positions: Lying down, sitting up, and standing up) as indicated in the SBAR (Situation, Background, Appearance, Recommendation Review and Notification, a way to communicate an event to the provider) completed on 3/7/25, and there was no documented evidence that orthostatic blood pressure measurements were completed in the Fall Risk assessment in Resident 124's chart.These failures contributed to Resident 124's fall with fracture to the left femur (bone in upper leg) after the facility failed to accurately assess the fall risk for Resident 124, resulting in the inability to provide appropriate fall risk interventions that are resident centered. These failures put Resident 124 at risk for further medical complications.Findings:1.Review of Resident 124's MDS Section GG (for measuring resident's assistance levels for activities of daily living such as going to the bathroom, hygiene, walking, with our without assistance) indicated Resident 124 was marked for use of wheelchair, with level of assistance marked as Independent-Resident completes the activity by themself with no assistance from a helper.Review of Resident 124's physician orders indicated Resident 124 had orders for aripiprazole (an antipsychotic medication), divalproex (an anti-seizure medication also used to treat mood disorders), lorazepam (an anti-anxiety medication) and olanzapine (an antipsychotic medication). Review of Resident 124's clinical record document titled Clinical Health Status (Quarterly/Annual), completed on 2/2/25, indicated Resident 124 had a fall risk score of 3. A fall risk score that is below 10 is classified as low fall risk, and a score above 10 is classified as high fall risk. Under Section 1a titled Fall Risk Assessment, question 5, titled GAIT [a person's manner of walking] BALANCE [being able to stay steady on one's feet]: To assess the resident's Gait/Balance, have him/her stand on both feet without holding on to anything; walk straight forward through a doorway, and make a turn is marked for response Balance Problems while walking, when in the MDS assessment, the resident was marked to be using a wheelchair. Question 7, titled MEDICATIONS: Response based on the following types of medications: Anesthetics [a drug or other substance that causes a loss of feeling or awareness], Antihistamines [used to treat allergic reaction symptoms such as hives, sneezing, watery eyes], Antihypertensives [a type of drug used to treat high blood pressure], Antiseizures [used to control or prevent seizures, which is abnormal electrical activity in the brain], Cathartics [used to accelerate having a bowel movement], Diuretics [used to remove excess fluid by causing increased urination], Hypoglycemics [used to lower blood sugar levels], Narcotics [used to relieve pain], Psychotropics [a drug that affects how the brain works], Sedatives [used to induce a calming affect]/Hypnotics [used for trouble sleeping] is marked for response NONE of these medications taken currently or within last 7 days.Review of Resident 124's clinical record document titled SBAR Post Fall, completed on 2/16/25, indicated Resident 124 had a fall risk score of 7. In section S. Situation, for question 5 titled Adaptive equipment [includes walkers, wheelchairs and canes] at time of fall:, the response None was marked. In section B. Background, for question 2 titled Medications received in the last 8 hours, no response was recorded.During a concurrent interview and record review with the DON on 11/4/25 at 11:45 AM, the DON confirmed that the fall risk score documented in the assessment Clinical Health Status (Quarterly/Annual), completed on 2/2/25 and the SBAR Post Fall, completed on 2/16/25, were both not accurate. The DON also stated the assessments were not accurate because the resident was on psychotropic medications, and she used a walker or wheelchair. The score should be higher. The DON also said All residents here in the facility have a high fall risk because they all take psychotropic medications, and for safety.During an interview and demonstration with the infection preventionist (IP) of how the Fall Risk Score is calculated in any assessment that has the Fall Risk Score on 11/5/25 at 9:18 AM, the IP demonstrated how choosing a different response to different questions, such as the medication question and the gait and balance question, would change the fall risk score. The IP further said The medication question is weighted more than other questions, and the score can change a lot depending on the response.Review of facility P&P titled Fall Risk Assessment, revised December 2007, indicated .The staff, with the support of the Attending Physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence and cognition.2.Review of Resident 124's clinical record indicated she was admitted to the facility on [DATE] with diagnoses of Schizophrenia (a mental disorder that causes individuals to hear and see things that are not there), anxiety disorder (a mental disorder that causes individuals to worry too much), and type 2 diabetes mellitus (a disease that causes the body to not process insulin, a hormone that regulates blood sugar, correctly). Resident 124 transferred to acute hospital on 3/8/25 and did not return back to the facility.Review of Resident 124's minimum data set (MDS, a required assessment that needs to be done by skilled nursing facilities) section C (for cognition) indicated Resident 124 had a brief interview for mental status (BIMS, an assessment tool for cognition) score of 13 (a score of 13-15 indicates an individual has intact cognition with no impairment).Review of Resident 124's clinical record indicated that Resident 124 had multiple falls during her stay at the facility, with the most recent falls being on 2/16/25 and 3/7/25. The fall that occurred on 3/7/25 caused Resident 124 to sustain a left femur fracture, and to get transferred to a local general acute care hospital (GACH).For the fall on 2/16/25, an interdisciplinary team (IDT, consists of different departments that work in a skilled nursing facility) review completed on 2/17/25 indicated .resident was trying to get breakfast tray from the food tray cart. CNA [certified nursing assistant] on duty came and was trying to take the tray to assist resident with placement of tray in room. Resident lost her balance and fell on her buttock. The IDT recommended Staff will encourage the resident to wait in her room for her meal tray. That recommendation was added to the fall care plan for Resident 124. However, there was no indication this behavior was being monitored by the staff. For the fall on 3/7/25, the IDT review indicated At time of fall resident stated she was getting up to receive her breakfast tray when she fell. The IDT recommended Staff will offer snacks or nourishment before lunch. During a concurrent interview and record review with the director of nursing (DON) on 11/4/25 at 11:45 AM, the DON confirmed that Resident 124's care plan included the intervention made by the IDT Staff will encourage the resident to wait in her room for her meal tray. The DON also confirmed that there was no documented evidence that this intervention was implemented from the time it was included in the care plan on 2/17/25 until the time of Resident 124's second fall on 3/7/25.Review of facility P&P titled Falls and Fall Risk, Managing, revised December 2007, indicated .The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls.If falling occurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Review of facility P&P further indicated .The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.3.Review of Resident 124's clinical record indicated Resident 124 was transferred out of the facility to a GACH on 3/8/25, because of the fall that occurred on 3/7/25. Review of Resident 124's clinical record document titled SBAR Post Fall, dated 3/7/25, indicated in section R. Response to Xray of left hip and left leg, Neurocheck [a quick examination to evaluate brain function after a potential brain injury] per facility protocol, Orthostatic BP x72 hours. Further review of Resident 124's clinical record indicated there were no orthostatic blood pressure measurements recorded for five eight-hour shifts between 3/7/25 at 8:30 AM and 3/8/25 at 7:46 PM (the day the resident was transferred to a GACH). Further review also indicated in the SBAR Post Fall, completed on 2/17/25, Question 7 SYSTOLIC BLOOD PRESSURE was marked for the response No noted drop between lying and standing.During a concurrent interview and record review with the DON on 11/5/25 at 10:54 AM, the DON confirmed that there were no recorded orthostatic vital signs for Resident 124 between 3/7/25 and 3/8/25, and that the response for Question 7 on the SBAR Post Fall completed on 3/7/25 was not accurate. The DON also said The nurses will sometimes check the orthostatic vitals on the spot but will not record them unless there was a concern.Review of facility P&P titled Blood Pressure, Measuring, revised September 2010, indicated .Documentation. The following information should be recorded in the resident's medical record.The date and time the blood pressure was measured.The name and title of the individual(s) who measured the blood pressure.The blood pressure reading.If the resident refused the treatment, the reason(s) why and the intervention taken.The signature and title of the person recording the data.

Based on observation, interview, and record review, the facility failed to ensure the provision for safe and effective medication administration when:1. The facility allowed the preparation of medications 1 to 2 hours ahead of administration (or pre-pouring) for all residents at the same time without establishing safeguards and policy and procedures for staff to consistently carry out and to avoid mix-ups or medication errors during the preparation and administration.Consequently, four out of six nursing staff observed during medication administration did not label the medication cup for each resident during the preparation; and did not verify the pre-poured medications against the Medication Administration Record (MAR) for correctness, as a final check, at the time of administration. Also, during the medication administration observation, a nursing staff prepared and administered medications for two administration times (5 PM and 9 PM) for two of 12 sampled residents (Residents 75 and 87).2. There has been no feedback or oversight from the consultant pharmacist (CP) to identify and evaluate the medication administration process for safe and effective medication use. These failures had the potential for mix-ups of residents' medications during the preparation and administration, which would result in residents receiving the wrong medications. Medication errors could lead to serious consequences for the residents. A review of the Medication Safety Go beyond the basics, dated 5/9/2016, by Lippincott NursingCenter (a nationally recognized organization with evidence-based nursing resources, principles, and practices) indicated: For any nurse working in a direct care setting, preparing medications and administering them to patients is part of the daily routine. Mistakes can happen at any point in the process. Administration errors are one of the most serious and most common mistakes made by nurses. Under Start with the basics, it indicated: Prepare medications for one patient at a time. A review of the facility's P&P titled Medication Administration - General Guidelines, reviewed on 6/1/25, indicated: Prior to administration, the medication and dosage schedule on the resident's medication record (MAR) is compared with the medication label and Medications are administered at the time they are prepared. Medications are not pre-poured.1. On 10/27/25 at 7:49 AM, at Nursing Station 1 with Registered Nurse (RN) C, the medication cart for Station 1 was observed inside the medication room. RN C stated medications for each resident were pre-poured at around 7 AM this morning, to prepare for the 9 AM medication pass. RN C opened the medication cart for the surveyor to observe. The cart had 4 drawers, and each drawer had multiple compartments (bins) adjacent to one another; each bin was for one resident. Each bin was about the size of half a regular-sized sheet of paper (lengthwise). It had a hand-written or printed name of a resident on the bottom and a small 30-milliliter cup containing the medications for that resident. The medication cups were not labeled with the resident's name or any identifiers. RN C stated most residents will come to the nursing station to take their medications; a few will stay in bed, but staff would get them up to come or bring the medications to them. RN C stated this preparation is necessary because certain residents may get agitated and refuse to take their medications if they wait too long in line. On 10/27/25 at 8:15 AM, many residents were observed lining up in front of Nursing Station 1, waiting to receive their medications. Most were quiet and observing the staff, but a few residents looked impatient and verbalized their frustrations.On 10/27/25 at 8:23 AM, RN C pulled the medication cart from the medication room out to the nursing station. The IP nurse and another staff were observed asking the residents for their names and preparing cups of juice or water for them while RN C pulled the pre-poured medication cups from the medication cart, one by one. To explain another way, after a resident identified him/herself, RN C removed a cup of pre-poured medications from the medication cart and handed it to the resident. She and the other staff observed as the resident took the medications. Then they repeated the same process for the next resident in line. During this process, RN C was observed opening the electronic MAR (eMAR) for that resident, but she did not check the medication cup's contents against the MAR before handing it to the resident.On 10/27/25 at 9:00 AM, the same communal medication administration process was observed at Station 2, where RN D handed the pre-poured cups of medications to the residents, one by one. Certified Nursing Assistant (CNA) E was observed assisting with the resident identification and providing juice/water to the residents. During the observation, after a resident was identified, RN D opened the resident's eMAR and then immediately opened the medication cart drawer and removed an unlabeled cup of medications to hand to the resident without checking the medication contents against the MAR. The medication cups did not have any identifiers on them.During an interview with RN D on 10/27/25 at 9:40 AM, in Station 2 Medication Room, she said she started preparing the medications for all residents in Station 2 around 6:30 AM. Her medication cart set-up was the same as that in Station 1: the medication cart had 4 medication drawers, each drawer had multiple bins being placed side by side; each bin had a resident's name on the bottom and each resident's medication cup would go in each bin. RN D was asked to explain the medication preparation. She stated she would pull all the medications from the shelf for a resident, check them against the eMAR; and whichever is due at that time, she would punch the pill(s) into the medication cup. When all medications were in the cup, she would place the cup into the bin with the resident's name in the medication cart. When asked how she would ensure the pre-prepared cups were placed in the right bins in the medication cart, RN D stated she would check the name of the resident before putting the cup in.During an interview with RN C on 10/27/2025 at 1:41 PM in Station 1 Medication Room, when asked her how to ensure prepared medication cup for a resident is not accidentally placed into the wrong bin for another resident with similar name or same last name, RN C stated she pays very close attention to where the cup should go. She stated some residents know their medications by color and would say something if they are not the right colors. On 10/27/25 at 3:15 PM, in the Station 2 Medication Room, Licensed Vocational Nurse (LVN) A was observed preparing afternoon medications for the residents in Station 2. She stated she is preparing medications for residents who have medications scheduled at 5 PM and will prepare medications that are scheduled at 7PM at a later time. During this observation, the surveyor observed the preparation for 5 residents (Residents 8, 13,15,17, and 23). LVN A started by pulling a resident's medications from the shelf, checked the eMAR, punched the pills into the medication cup, and placed the cup inside the medication cart that had that resident's name. LVN A did not label the medication cups with any identifiers. When asked how she would identify if there was a mix-up or a resident's cup was accidently put in the wrong bin, LVN A stated, Some residents know what meds they are taking and how many, and if there's something different, they would know. She acknowledged some residents would not review the medication contents before taking them, and it should not be dependent on the residents to identify the medication errors.On 10/27/25, from 4:37 PM to 5:18 PM, LVN A was observed administering medications for Station 2 residents who were waiting in line in front of the nursing station. After a resident was identified by name, LVN A removed an unlabeled medication cup from the medication cart and immediately handed it to the resident. She and another staff ensured the resident swallowed the medications, then she repeated the same process with the next resident in line. LVN A did not verify the cup's contents against the MAR before handing it to each resident. Most of the residents did not review or question what medications they were taking.During the administration observation with LVN A above, on 10/27/25 at 4:39 PM, LVN A was observed administering 7 medications to Resident 87. Two of the medications, 1 tablet of atorvastatin (medication for high cholesterol) 20 milligrams (mg) and 1 tablet of olanzapine (an antipsychotic medication) 20 mg, were scheduled to be administered at 9PM. On 10/27/25 at 5:25 PM, LVN A confirmed they were due at 9PM but she administered them during the 5 PM medication pass because the resident wanted them all at the same time. LVN A acknowledged the physician's orders indicated to give them at 9 PM, not at 5 PM.Similarly, on 10/27/25 at 4:40 PM, LVN A was observed administering 5 medications to Resident 75. Four of the medications: 2 capsules of lithium (medication to treat mental illness) 300 mg, 1 tablet of haloperidol (an antipsychotic) 10 mg, 1 tablet of Risperdal (an antipsychotic) 3 mg, and 1 tablet of benztropine (medication to prevent abnormal movement disorder) 1 mg, were due at 9 PM. During a record review and interview on 10/27/25 at 5:20 PM, LVN A stated, When he [Resident 75] goes to bed, he will go to sleep so he doesn't take any more. LVN A acknowledged these 4 medications were ordered to be administered at 9 PM.On 10/28/25 at 9:47 AM, RN D was observed documenting the medication administration after she had just finished with the morning medication pass. She stated documenting the medication administration in the middle of medication pass could cause a delay as some residents get impatient or agitated if they wait too long.During an interview with the Director of Nursing (DON) on 10/28/25 at 10:48 AM, she stated this is not a typical facility where the nurses prepare medications for one resident at a time then administer them right after preparation. She explained that due to the nature of the facility and staff safety, the facility allows for pre-pouring of medications 1-2 hours before administration, and the residents receive their medications at the nursing station. She stated the nursing staff are to prepare medications for one medication pass at a time, such as preparing at 7 AM for 9 AM administration. She stated the facility currently had 62 residents in Station 1, and 54 residents in Station 2. When asked how the staff avoid mix-ups or a medication cup being accidentally placed in someone else's bin, the DON stated the nurses are expected to verify at least the number of pre-poured medications in the resident's cup against the MAR before giving them; and it should not be dependent on the residents to identify the medication errors. She additionally stated that the facility used to require the nursing staff to label the medication cup with the resident's identifier (such as name or initials) but she did not know why it is not done anymore. When asked if the facility policy required the labeling of the cups, she stated, Not in policy. She was requested to provide the policies allowing these practices. On 10/28/25 at 1:15 PM, the DON provided the facility's policy and procedures (P&P) related to pre-pouring of medications. She stated, besides the pre-pouring part, the facility staff followed the provider pharmacy's P&P on general guidelines for medication administration. A review of the provided P&P titled SPECIFIC FACILITY MEDICATION ADMINISTRATION PROCEDURE FOR INSPIRE BEHAVIORAL HEALTH SAN [NAME], undated, indicated: Given facility population with psychiatric and behavioral needs and risks, facility performs pre pouring and administration by licensed nurses only. Purpose:To safely administer medications while maintaining safe environment by preventing escalation in resident's behavior which may result in resident to resident altercation or other accidents. Procedures:1. Licensed Nurse prepare medications via pre pouring following accurate order (Physician order) and infection control.2. Licensed Nurse will only prepare medications for the next administration (i.e. start pre pour for 9 am medication at 7 am and pre pour medication for 5 pm at 3 pm).The above P&P did not address the how process of pre-pouring, such as labeling of medication cup with resident's identifier(s), or any other safeguards to ensure the residents receive correct medications during administration.During a concurrent interview and record review with the DON on 10/29/2025 at 12:11 PM, she verified the facility's policy allowed for pre-pouring but it did not address how the staff should pre-pour and processes to safeguard against mix-ups such as medication cups being placed in the wrong bin during preparation, or the wrong cup being taken out of the medication cart (such as for residents with look-alike or sound-alike names) during a high-stress and busy environment during medication administration. The DON stated the nurses should know to check the medications against the MAR at the point of administration. She continued, Since they prepared the meds ahead of time, they won't be able to check the labels against the MAR prior to administration but at least verify the count. When asked if there were additional policies, she stated she will look into any other policies regarding pre-pouring and medication administration.A review of the facility's resident roster indicated there were 4 residents with the same last name; two of these 4 residents (Residents 75 and 78) had look-alike and sound-alike first name, they only differ by the last letter in the name.During another interview with the DON on 10/30/25 at 3:40 PM, the DON stated she found the STP (special treatment program) policy, but it's very generic. There's nothing different from what I already provided to you.On 10/31/25 at 12:09 PM, the DON provided the 7/2025 Medication administration Nursing Guideline STP Program/Facility policy. She stated, It did not say anything about labeling [of prepared medications] but this is what we have. A review of this policy indicated, Medications will be pre-poured prior to administration for each scheduled medication pass. The nurse shall verify the Five Rights of Medication Administration before pre-pouring: 1. Right Resident, 2. Right Medication, 3. Right Dose 4. Right Route 5. Right Time. This policy did not have any specific procedures to prevent or minimize medication errors.On 10/31/25 starting at 8:36 AM, the surveyor observed medication administration for 6 residents (Residents 15, 17, 40, 50, 67, and 74) at Nursing Station 2, administered by LVN F who was assisted by two other staff. The medication cups for these residents were not labeled, and LVN F did not verify the medication cup contents against the MAR before handling them out to the residents.During an interview with LVN F on 10/31/25 at 10:36 AM, she stated during the medication administration, she would check the resident's identification against the photo in the eMAR, take the pre-prepared medication cup from the cart and give it to the resident, watch them take the medications, and click on the MAR after they took the medications. LVN F verified she did not label the medication cups during the preparation but was supposed to, and did not check the medication contents against the MAR prior to giving it to the residents.On 11/03/25 at 8:28 AM, the surveyor observed the medication administration for multiple residents in Station 2, administered by RN D. At this observation, the medication cups were observed labeled with the resident's initials. On 11/3/25 at 8:41 AM, the DON joined the observation. RN D was observed removing Resident 17's medication cup from the medication cart and immediately handed it to the resident after the resident identified herself. RN D did not verify the medication cup contents against the MAR. The DON stated the nurses have been in-serviced on labeling the medication cups and checking the medications against the MAR before administration. She stated they did a lot of practice on the weekend and I don't know what happened.A review of a publication titled Implement Strategies to Prevent Persistent Medication Errors and Hazards, dated 3/23/23, by the Institute for Safe Medication Practices (ISMP, a nonprofit patient safety organization with recognized national expertise in medication error prevention), indicated, A medication-use system that is inadequate or poorly designed to support practitioners will lead to errors. It further indicated, The responsibility for accurate medication administration does not lie with a single individual. Rather, it lies with multiple individuals, including organizational leaders, who are responsible for the design, implementation, and maintenance of reliable systems to support safe medication use for all practitioners.2. On 10/31/25, the DON provided a binder containing the Consultant Pharmacist's medication regimen reviews (MRRs) and quarterly reports to the facility from January 2025 to October 2025. A review of the reports and MRRs indicated they were conducted by 4 different CPs since January 2025.On 10/31/25 at 2:40 PM, a review of the MRR binder with the DON reflected no documented evidence that the CPs observed the medication pass nor any feedback or recommendations regarding medication preparation or administration. The DON stated the pharmacy's nurse consultant and CP have not raised any concerns about the medication pass that she was aware of.During a telephone interview with the Consultant Pharmacist Manager (CPM) on 11/03/25 at 8:50 AM, he stated the pharmacy has been short-staffed so they had to use CPs from a contracting company. He stated there had been different CPs visiting the facility, but he himself had not been there. He was asked if there had been any documented evidence the CPs identified, evaluated, and addressed medication administration-related issues specifically that the nursing staff had been pre-pouring medications without labeling the medication cups and not verifying the prepared medications against the MAR before administration. He stated he will need to research and get back to the surveyor.During a follow-up telephone interview with the CPM on 11/03/2025 5:08 PM, he stated his conversations with the CPs reflected they did not see it as a risky procedure.A review of the facility's P&P titled CONSULTANT PHARMACIST SERVICES PROVIDER REQUIREMENTS, reviewed June 1, 2025, indicated The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility. In collaboration with facility staff and pharmacy personnel, consultant pharmacist helps identify, communicate, address, and resolve concerns and issues related to the provision of pharmaceutical services. This includes, but not limited to. Assisting the facility in the identification and evaluation of medication-related issues, including the prevention and reporting of medication errors.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards, and facility policy for food service safety in the kitchen and dining room, potentially affecting all the 116 residents when:1. The facility failed to label opened eggs in the walk in fridge with open and use by date. Failed to label 9 trays of prepared desserts with the date, or type of dessert in the walk in fridge.2. The facility failed to ensure kitchen staff performed hand hygiene after touching trash on the floor and after operating dirty equipment prior to returning to food preparation.3. The facility failed to ensure staff performed hand hygiene when assisting during meal times for seven residents (Resident 17, Resident 25, Resident 27, Resident 61, Resident 72, Resident 82, and Resident 92)These failures had the potential for residents to receive expired foods, wrong dessert items, and for cross contamination during meal time dining and kitchen food preparation from staff members not sanitizing their hands. 1. During an observation on 10/27/25, at 7:47 a.m., in the kitchen walk in fridge, an opened tray of eggs was observed on the shelf. The eggs were sitting on a carboard sleeve, no open date or use by date was observed on the eggs. During an interview on 10/27/25, at 7:49 a.m., with the Certified Dietary Manager (CDM), the CDM stated, the eggs were not labeled and they should be. During an observation on 10/27/25, at 7:51 a.m., in the kitchen walk in fridge, a cart was observed to contain 9 trays of prepared various gelatin desserts of yellow and green color. The trays were observed with no labels with the type of dessert or the date prepared. The cart was observed with no labels or dates. During an interview on 10/27/25, at 7:52 a.m., with the CDM, the CDM stated, there is no label on the desserts, those are for lunch today. CDM stated, the yellow dessert is CCHO (diabetic diet) and the green is for regular diet. During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods dated 2023, the P&P indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated.All prepared foods need to be covered, labeled, and dated. During a review of the facility's P&P titled, Procedure for Refrigerated Storage dated 2023, the P&P indicated, Eggs need to be dated to assure proper rotation. 2. During an observation on 10/27/25 in the kitchen, at 8:01 a.m., [NAME] N was observed picking up trash on the floor and touching the lid of the trash can to throw the trash away. [NAME] N then returned to operating the dishwasher without performing hand hygiene and removed a clean tray from the dishwasher with a clean sheet pan. During an interview on 10/27/25, at 8:02 a.m., with the CDM, the CDM stated she saw [NAME] N pick up trash and did not wash her hands after. The CDM asked [NAME] N to stop and wash her hands. During an observation on 10/29/25, at 11:15 a.m., in the kitchen, [NAME] M was observed wearing gloves while operating the dishwasher. [NAME] M opened and closed the lid of the dishwasher while wearing the gloves, to wash a dirty whisk, he then removed the clean whisk from the dishwasher, and returned to preparing the salad dressing while wearing the same gloves and did not perform hand hygiene prior to starting food preparation. During an interview on 10/29/25, at 11:16 a.m., with [NAME] M, [NAME] M stated he did not was his hands prior to starting food prep after washing dishes. During a review of the facility P&P titled, Hand Washing Procedure dated 2023, the P&P indicated, Hand washing is important to prevent the spread of infection.When Hands Need To Be Washed: 1. Before starting work in the kitchen 2. After handling soiled utensils. 8. Touching a trash can or lid. 3. During an observation on 10/27/25 at 12:30 p.m. in the dining room, certified nursing assistant (CNA) H was observed distributing meal trays to residents; CNA H removed food items from the trays, held plates and utensils, and placed the food in front of each resident, and subsequently stacked the trays on the cart. Multiple observations indicated that CNA H did not perform hand hygiene between tasks involving different residents, including Resident 17, Resident 25, Resident 27, Resident 61, Resident 72, Resident 82, and Resident 92. During an interview with CNA H on 10/29/25 at 1:16 p.m., CNA H confirmed that she did not perform hand hygiene between serving food to each resident during lunch on 10/27/25, in the dining room. CNA H indicated that she should sanitized her hands between tasks for each resident to ensure proper sanitation. During an interview with the infection control preventionist (IP) on 10/31/25 at 2 p.m., the IP stated that staff are required to perform hand sanitization prior to handling food plates and utensils between tasks for each resident in order to prevent the transmission of any diseases from one resident to another. A review of the facility's policy and procedure (P&P) titled, Hand Washing Procedure, dated 2023, the P&P indicated when hands need to wash, Before and after handling foods with hands . FDA Food Code 2022 Chapter 2. Management and Personnel, 2-301.14 indicated, When to Wash. (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing task.

Based on observation, interview, and record review, the facility failed to ensure its medication error rate was below 5%. The facility had the medication error rate of 13.11% when 8 medication errors occurred out of 61 opportunities observed during the medication administration observation for 4 out of 12 sampled residents (Residents 39, 65, 75, and 87). Residents 75 and 87 received their medications 4 hours before scheduled time, which had the potential for adverse effects such as medications being given too close together from the previous dose or medications not given as intended (such as before bedtime to help sleep). Resident 39 received the incorrect priming (a required safety check to ensure the pen and needle work properly) of the insulin pen (a pre-filled pen containing insulin - medication to lower blood sugar). For Resident 65, the nursing staff did not prime her insulin pen before administering an insulin dose. The failure had the potential for adverse effects such as too low or high blood sugar.1. On 10/27/25 at 3:15 PM, in the Station 2 Medication Room, Licensed Vocational Nurse (LVN) A was observed preparing medications for the residents in Station 2. She stated she is preparing medications for all residents who have medications scheduled at 5 PM at this time, and will prepare medications that are scheduled at 7PM at a later time. On 10/27/25 at 4:39 PM, Resident 87 was observed in front of the Station 2 Nursing Station waiting to take his medications. There were 7 pills of medications inside a small plastic cup which LVN A handed to the resident to take.During the reconciliation of Resident 87's medications against the physician's orders, on 10/27/25 at 5:25 PM with LVN A, it indicated only 5 medications were due (scheduled) at 5 PM. LVN A stated two additional medications, 1 tablet of atorvastatin (medication to treat hyperlipidemia - high lipids in the blood) 20 milligrams (mg, unit of measurement) and 1 tablet of olanzapine (antipsychotic medication to treat mental health conditions) 20 mg, were due at 9PM but she administered them during the 5 PM medication pass because the resident wanted them all at the same time. LVN A acknowledged the physician's orders indicated to give them at 2100 (9 PM), not at 5 PM. A review of Resident 87's physician's orders included the following:a. Atorvastatin 20 mg, give 1 tablet by mouth at bedtime for hyperlipidemia, dated 9/3/23. It was scheduled to be administered daily at 2100 (9 PM). b. Zyprexa (olanzapine) 20 mg, give 1 tablet by mouth at bedtime for episodes of non-factual statements related to schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior), dated 4/6/23. It was scheduled to be administered daily at 9 PM. 2. On 10/27/25 at 4:40 PM, Resident 75 was observed standing in front of Nursing Station 2 waiting to take his medications. LVN A was observed removing a medication cup containing 5 different medications from the medication cart and handed it to Resident 75.During the reconciliation of the observed medications against the physician's orders with LVN A on 10/27/25 at 5:20 PM, Resident 75's clinical record indicated only 1 medication was due at 5 PM; the other 4 medications were due at 9 PM. They included 2 capsules of lithium (medication to treat mental illness) 300 mg, 1 tablet of haloperidol (an antipsychotic) 10 mg, 1 tablet of Risperdal (an antipsychotic) 3 mg, and 1 tablet of benztropine (medication to prevent abnormal movement disorder) 1 mg. LVN A stated, When he [Resident 75] goes to bed, he will go to sleep so he doesn't take any more. LVN A acknowledged these 4 medications were ordered to be administered at 9 PM.A review of Resident 75's physician orders included the following:a. Lithium 600 mg, give 1 capsule by mouth at bedtime for episodes of abrupt changes in behaviors, dated 4/30/24; it was scheduled daily at 9 PM.b. Benztropine 1 mg, give 1 tablet two times daily for extrapyramidal symptoms (involuntary abnormal movements), dated 11/21/22; it was scheduled daily at 9 AM and 9 PM.c. Haloperidol 10 mg, give 1 tablet two times a day for paranoid schizophrenia, dated 6/12/25; it is scheduled daily at 9 AM and 9 PM.d. Risperdal 3 mg, give 1 tablet two times a day for paranoid schizophrenia, dated 4/30/24; it was scheduled daily at 9 AM and 9 PM.During an interview with the Director of Nursing (DON) on 10/28/25 at 10:48 AM, she stated routine medications are to be administered 1 hour before and 1 hour after scheduled time, and nurses are to prepare medications for one administration at a time, such as nurses can prepare medications at 7 AM for 9 AM administration only.A review of the facility's policy and procedures (P&P) titled, Preparation and General Guidelines, reviewed on 6/1/2025, indicated: Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after), except before and after meal orders, which are administered based on mealtimes. Medications are administered in accordance with written orders of the attending physician.A review of the facility's undated P&P titled SPECIFIC FACILITY MEDICATION ADMINISTRATION PROCEDURE FOR INSPIRE BEHAVIORAL HEALTH SAN [NAME], indicated: 1. Licensed Nurse prepare medications via pre pouring following accurate order (Physician order) and infection control. 2. Licensed Nurse will only prepare medications for the next administration (i.e. start pre pour for 9 am medication at 7 am and pre pour medication for 5 pm at 3 pm)3. During a medication administration observation on 10/28/25 at 11:53 AM, in the Treatment Room with Registered Nurse (RN) B and Resident 39, RN B was observed pricking Resident 39's left middle finger to obtain a blood sample for blood sugar (BS) measurement. The BS reading was 120. RN B stated the resident had an order to receive 6 units of Novolog (a rapid-acting insulin).On 10/28/25 at 11:59 AM, RN B was observed removing Resident 39's Novolog Flexpen from the medication tray, removed the pen cap, wiped the rubber stopper with an alcohol swab, attached a new needle on the pen, and dialed the dose selector to 2 units. Then she pressed on the push-button at the end of the pen to release the insulin into a cup. Then she removed the needle that she had just primed and replaced it with a new needle. Then she dialed the dose selector to 6 units and proceeded to inject the insulin into the resident's abdomen. RN B was observed removing the needle as soon as she clicked the push-button to give the injection. In other words, she did not hold the pen in the skin for any amount of time.During an interview post medication administration, on 10/28/25 at 12:15 PM, when asked to explain how she primed the Novolog pen, she stated she primed the pen with 2 units of insulin and replaced the needle after it was primed. As for how long to hold the needle in place during the injection, she stated Less than 15 seconds?On 10/28/2025 12:20 PM, a review of the manufacturer's instruction video on how to administer Novolog Flexpen (https://www.novomedlink.com/diabetes/products/treatments/novolog/dosing-and-administration.html) with RN B indicated to prime the pen and needle with 2 units, press the push-button till it turns to zero, then dial the dose selector to the units you need to inject. As for giving the injection, the instruction video indicated to inject the dose by pressing the push-button all the way in until the 0 lines up with the pointer. Keep the needle in the skin for a least 6 seconds and keep the push-button pressed all the way in until the needle has been pulled out from the skin. This will make sure that the full dose has been given. After the video viewing, RN B stated, Oh so you don't change the needle after priming. She also acknowledged she did not hold the pen in place for at least 6 seconds as required. A review of Resident 39's clinical record indicated an order, dated 8/27/25, for NovoLOG FlexPen.100 UNIT/ML [unit of insulin per milliliter]. inject 6 unit subcutaneously before meals for diabetes mellitus. 4. During another medication administration observation with RN B in the Treatment Room with Resident 65, on 10/28/25 at 12:05 PM, RN B was observed pricking Resident 65's left ring finger to obtain a blood sample for BS measurement. The BS reading was 157 (high). RN B stated the resident will need 1 unit of insulin based on the physician's order.On 10/28/25 at 12:09 PM, RN B was observed removing Resident 65's Admelog SoloStar pen (a pre-filled pen containing a rapid-acting insulin) from the medication tray, removed its cap, wiped the rubber stopper, attached a new needle, dialed the dose-selector to 1 unit, and injected into Resident 65's right upper arm. RN B did not prime the needle before administering the dose. She held the pen in the skin for about 1-2 seconds before removing it. During an interview post medication administration, on 10/28/25 at 10/28/2025 12:18 PM, RN B acknowledged she did not prime the Admelog Solostar before administering the dose to Resident 65, and did not hold the pen in long enough during the injection.A review of Resident 65's clinical record indicated a physician's order, dated 3/21/25, for Admelog Injection Solution 100 UNIT/ML, inject subcutaneously before meals and at bedtime for insulin sliding scale (set of instructions for administering insulin dosages based on specific BS readings) related to diabetes mellitus.During an interview with the DON on 10/28/25 at 2:19 PM, she stated insulin pens need to be primed before each injection. A review of the Admelog Solostar's Instructions for Use, revised 2019, indicated: Step 3: Do a safety testAlways do a safety test before each injection to:Check your pen and the needle to make sure they are working properlyMake sure that you get the correct insulin dose. 3A. Select 2 units by turning the dose selector until the dose pointer is at the 2 mark.3B. Press the injection button all the way in. When insulin comes out of the needle tip, your pen is working correctly.If no insulin appears:You may need to repeat this step up to 3 times before seeing insulin. Step 4: Select the dose. 5D. Keep the injection button held in and when you see '0' in the dose window, slowly count to 10 This will make sure you get the full dose.A review of the facility's 9/2014 P&P on Insulin Administration, provided by the DON on 11/3/25, indicated it did not address the process for insulin pen administration.

Based on observation and interview, the facility failed equip the corridors with firmly secured handrails when the handrail in the hallway across from a resident room (Hallway B). This failure had the potential to adversely affect the health and safety of the residents in the area that use the handrail.During an observation on 10/27/25 at 12:19 PM, the handrail in Hallway B was observed to be loose. An indent in the dry wall was seen where the handrail is supposed to be attached to the wall. During a second observation on 10/29/25 at 12:19 PM, the handrail in Hallway B was observed still to be loose.During an interview with the maintenance person (MAIN) on 10/29/25 at 1:13 PM, the MAIN confirmed the handrail in Hallway B was not supposed to be loose. The MAIN also said he would repair the handrail right away.

Based on observation and interview, the facility failed to maintain equipment and environment in safe operating and sanitary condition when a toilet paper holder was left open in one resident bathroom (Resident Bathroom A). This failure had the potential to adversely affect the health and safety of the residents in Resident Bathroom A.During an observation on 10/27/25 at 8:59 AM, the toilet paper holder in Resident Bathroom A was seen open, with the toilet paper exposed. During a second observation on 10/29/25 at 10:58 AM, the toilet paper holder in Resident Bathroom A was still seen open as during the first observation.During an interview with the maintenance person (MAIN) on 10/29/25 at 1:13 PM, the MAIN confirmed the toilet paper holder in Resident Bathroom A was open and supposed to be closed.

Based on observation, interview, and record review, the facility failed to ensure three residents (Resident 52, Resident 83, & Resident 95) received their therapeutic diet (specialized meal plan designed to treat or manage specific medical conditions) as ordered by the Registered Dietician and Physician when Resident 52, Resident 83, & Resident 95 did not receive their fortified item during lunch tray line.This failure had the potential for Resident 52, Resident 83, & Resident 95 to not receive their total calories as ordered in their diet, which could contribute to weight loss overtime.During a review of the facility Fortified Lunch Menu dated 10/29/25 indicated, fortified item (foods prepared or modified to meet the increased nutritional needs of residents in a skilled nursing facility, ensuring they get more calories and protein than they might from standard foods) was 1.2 ounce melted margarine.During a record review of Resident 52's meal tray ticket 10/29/25, at 12:03p.m ticket indicated, Fortified.During an observation of lunch tray line in the kitchen on 10/29/25, at 12:03p.m., staff were observed to plate Resident 52's lunch tray and place it on the cart without adding the fortified item.During an interview with the Certified Dietary Manager (CDM) on 10/29/25, at 12:03p.m, the CDM stated Resident 52's tray did not have the fortified item. The CDM stated, she would add the item to the tray.During a record review of Resident 83's meal tray ticket 10/29/25, at 12:03p.m ticket indicated, Fortified.During an observation of a lunch tray line in the kitchen on 10/29/25, at 12:03p.m., staff were observed to plate Resident 83's lunch tray and place it on the cart without adding the fortified item.During an interview with the CDM on 10/29/25, at 12:03p.m, the CDM stated Resident 83's tray did not have the fortified item. The CDM stated, she would add the item to the tray.During a record review of Resident 95's meal tray ticket 10/29/25, at 12:03p.m ticket indicated, Fortified.During an observation of a lunch tray line in the kitchen on 10/29/25, at 12:21p.m., staff were observed to plate Resident 95's lunch tray and began to serve him in the dining room without adding the fortified item.During an interview with the CDM on 10/29/25, at 12:03p.m, the CDM stated Resident 95's tray did not have the fortified item. The CDM stated, she would add the item to the tray.During an interview on 10/29/25, with the Registered Dietician (RD), the RD stated, it is his expectation that all residents receive the diet ordered to them for each meal.

Based on observation, interview and record review, the facility failed assess for the need of a transfer pole for two out of two residents (Residents 9 & 81). These failures had the potential to put the residents at risk for entrapment and serious injury.Review of Resident 9's clinical record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder (a mental disorder that causes individuals to hear and see things that are not there), conversion disorder with seizures or convulsions (a mental disorder that causes medical symptoms in individuals with no explanation), neuroleptic induced Parkinsonism (a disorder of the musculoskeletal system caused by certain medications), and history of falling.Review of Resident 9's minimum data set (MDS, a required assessment done by skilled nursing facilities) Section GG (for functional abilities) indicated Resident 9 was marked for using a wheelchair as an assistive device, with level of function marked as 3- Partial/moderate assistance-Helper does LESS THAN HALF the effort. Helper lifts or holds trunk or limbs, but provides less than half the effort.Review of Resident 9's clinical record indicated there was no documentation on the use of a transfer pole for her.Review of Resident 81's clinical record indicated Resident 81 was admitted to the facility on [DATE] with diagnoses of Schizoaffective Disorder, prediabetes (the stage before a person develops full diabetes, which is a disorder that affects the regulation of blood sugar levels), and other hyperlipidemia (a disease that increase the levels of fats in the blood).Review of Resident 81's MDS Section GG indicated Resident 81 was marked for using a wheelchair as an assistive device, with level of function marked as 6-Independent-Resident completes the activity by themself with no assistance from a helper.Review of Resident 81's clinical record indicated there was no documentation on the use of a transfer pole for her.During an observation on 10/27/25 at 12:31 PM, Resident 81 was seen in her room sitting in a wheelchair near her bed. A transfer pole was observed on the left hand side of resident's bed. During an observation on 10/27/25 at 12:43 PM, Resident 9 was seen in her room sitting up in her bed. A transfer pole was observed on the left hand side of the resident's bed.During an interview with certified nursing assistant (CNA) G on 10/27/25 at 12:52 PM, CNA G said both Resident 9 and Resident 81 had the transfer poles in their rooms for as long as he can remember. During a concurrent interview and record review with the director of nursing (DON) on 10/30/25 at 3:29 PM, the DON confirmed that there was no documentation on the use of the transfer poles for both Resident 9 and Resident 81. The DON also said Currently, we do not have a document to document on the use of a transfer pole, and that this is something that needs to be included in PCC [point click care, an electronic health record software].Review of facility policy titled Proper Use of Side Rails, revised October 2010, indicated .An assessment will be made to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: Bed mobility; and Ability to change positions, transfer to and from bed or chair, and to stand and toilet.The use of side rails as an assistive device will be addressed in the resident care plan.

Based on interview and record review the facility failed to timely notify a representative of the Office of the State Long-Term Care Ombudsman (an entity that serves as an impartial advocate for individuals or groups who have concerns or complaints about a particular organization) regarding discharges for one of one sampled resident (Resident 121). The facility faxed discharge notices on the day of discharge. This failure resulted in missed opportunities for an ombudsman to advocate if residents had concerns about their discharge.Findings:A Review of Resident 121's facesheet (A facesheet is a summary document containing a Resident's personal and demographic information, including contact details and medical history) indicated the resident was admitted on [DATE] with diagnoses including Schizoaffective disorders ( a mental health condition that's is marked by a mix of schizophrenia [a serious mental health condition that affects how people think , feel and behave] symptoms such as hallucination [an experience involving the apparent perception of something not present] and delusions [ a fixed, false beliefs that's persist despite evidence to the contrary and are disconnected from cultural or religious norm] , and mood disorder symptoms), other Stimulant Dependence (continued use of stimulant that leads to significant impairment or distress), Depression ( a mood disorder that cause a persistent feeling of sadness and loss of interest), Anxiety disorder ( involve more than occasional worry or fear.). Further review of Resident 121's progress notes indicated he was discharged to board and care /assisted living/group home on 8/6/25. A review of resident 121's NOTICE OF PROPOSED TRANSFER /DISCHARGE the resident was provided the discharge notice on 7/30/25, with the discharge effective date on 8/6/25. A review of the fax transmission document sent to the office of the State LTC Ombudsman dated 8/7/25 indicated ,THE FOLLOWING Data Could not be sent. PLEASE GIVE THIS TRANSACTION REPORT TO SENDER. During a concurrent interview and record review with Social Services Director (SSD) on 11/3/25 at 10:39 a.m., the SSD verified that the discharge notice for Resident 121 was dated 8/6/25, and a copy of the notice to the Ombudsman faxed on 8/7/25 did not go through. The SSD further stated she forgot to verify the notification showing it was not sent. The facility faxed the Notice of Proposed Transfer and Discharge to the Ombudsman's office during the facility's annual recertification survey on 11/3/25. During an interview with the Director of Nursing (DON) on 11/4/25 at 11:28 a.m., the DON stated they need to follow the Federal /State regulation of notifying the Ombudsman's office regarding discharge. During an interview with the Administrator (ADM) on 11/4/25 at 9:44 a.m., the ADM stated for planned discharge the social services will notify everybody, including MD (doctor), RP (responsible party) and Ombudsman. The ADM also stated, she usually follow up the next the morning if the notice was sent.

Based on observation, interview, and policy review, the facility failed to ensure infection control practices were implemented when the maintenance director (MD) did not wash his hands when entering the kitchen. This failure had the potential to spread infection to residents and staff.Findings:During an observation on 9/9/25, at 1:05 p.m., the MD put on the hair net and entered the kitchen, but he did not wash his hands.The MD opened the three lids of the grease trap that was outside and in the back of the kitchen and closed them with his bare hands. Then the MD went back inside the kitchen, stood in front of the two-compartment sink, and grabbed on the front-and-top edge of the sink with his hands before going to the hand washing sink to wash his hands.During an interview with the MD on 9/9/25, at 1:30 p.m., he confirmed that he did not wash his hands when he entered the kitchen. The MD acknowledged that he should wash his hands when entering the kitchen.During an interview with the certified dietary manager (CDM) on 9/10/25, at 12:15 p.m., she stated the staff should put on the hair net and wash their hands when they enter the kitchen.Review of the facility's 2023 policy, Handwashing, indicated . Hand washing is important to prevent the spread of infection . When hands need to be washed: 1. Before starting work in the kitchen.

Based on observation, interview and record review, the facility failed to implement effective safety measures in place to prevent elopement (the act of leaving without supervision and authorization) or absence without leave (AWOL, leaving the facility without permission) for one of four sampled residents ( Resident 1) who was at high-risk for elopement due to the fact that: 1. Staff had prior knowledge and awareness of Resident 1's desire and motivation to elope when Resident 1 had expressed a desire to go home prior to the visitation by a friend on 1/15/25, 2. Facility's staff did not follow the instructions of Resident 1's conservator restricting visitation by Resident 1's friends after the reported incident on 12/17/24 when Resident 1 was found to have a contraband (goods that have been imported -[goods or services brought into a country from abroad for sale] or exported illegally [goods and services that are produced in one country and sold to [NAME] in another without proper documents] and cigarette lighter in her drawer. 3. Certified Nursing Assistant (CNA) B did not ensure Resident 1 was not near or in close proximity to the visitor's lounge exit door when her visitor was leaving the facility after visitation; hence, Resident 1 was able to exit and ran outside of the facility when CNA B opened the door to let the visitor out. 4. The care plan for elopement was not updated to include interventions to help prevent elopement such as restricting visitation from friends and checking of Resident 1's visitors ID (identification) as indicated by the program director (PD) plan when Resident 1's conservator instructed facility not to allow friends to visit Resident 1. 5. Staff did not check Resident 1's visitor's ID when they visited Resident 1 on five occasions. These failures resulted in Resident 1's elopement from the facility where staff could not bring her back safely to the building, and her whereabouts could not be determined after the elopement incident, which collectively could jeopardize her health and safety. Findings: Review of Resident 1's admission record indicated she was admitted to the facility on [DATE] with diagnoses including psychosis ( is a condition of the mind or psyche that results in difficulties determining what is real and what is not real), stimulant induced psychotic disorder ( a mental disorder that occurs when a person experiences delusions (is an unshakable belief in something that's untrue)or hallucinations (is a false perception of something not present) soon after ingesting or withdrawing from a substance) and depression ( a common mental health condition that causes a persistent feeling of sadness and changes in how persons think, sleep, eat and act). Review of Resident 1's physician progress notes, dated 9/19/24, indicated, This is a [AGE] year-old . female with a long history of mental illness (a problem on a person's state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well) and stimulant disorder (a type of substance use disorder where the use of stimulants caused clinically significant impairment or distress), was admitted recently on a 5150 (is a legal term that refers to the California law code for an involuntary hold of someone who's a danger to themselves or others) after she was observed on stranger doors and that babies are getting murdered. She eventually stabilized . She denies auditory hallucinations (hearing voices or noises that aren't there and has no gross delusions. She wants to go home. Review of Resident 1's admission Risk for Elopement assessment, dated 9/19/24, indicated a score of greater than 10, (a score of 10 and above indicates at risk for elopement. Review of Resident 1's Risk for Elopement assessment, dated 10/15/24, indicated a score of 13, she was at risk for elopement. Review of Resident 1's care plan, At risk for elopement related to: mental illness and history of drug abuse dated 9/19/24, it included interventions as, the resident is determined to be an AWOL risk, resident will be placed on close supervision and Resident will be redirected away from the exit doors when observed standing by the exit doors. There is no documented evidence that the care plan was updated to include interventions such as: checking the identification (IDs) of Resident 1's visitors and restricting visitation from friends. During an interview on 3/3/25, at 3:00 p.m., with the Director of Nursing (DON), the DON verified that the Client 1's care plan for elopement was not updated. Review of Resident 1's minimum data set (MDS, a federally mandated resident assessment tool), dated12/26/24, it indicated her brief interview for mental status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 (a core of 14-15 indicates intact cognitive response). Review of Resident 1's change in condition evaluation, dated 1/15/25, it indicated Resident eloped from facility. Review of Resident 1's Progress notes by her primary care physician (PCP, primary care provider, is a health care professional who practices general medicine) dated 1/15/25,indicated, Patient went AWOL, seemingly assisted by visitors to the facility; incident is still currently investigated. During a further review of Resident 1's interdisciplinary team (IDT, is a group of different experts who work together with a common goal for the resident) notes, dated 1/16/25, it indicated, Around 7:15 pm, staff reported resident suddenly ran out of the visitors lounge during a visit. Facility AWOL protocol was utilized. Staff responded immediately, followed resident on foot and in cars at a safe distance. Resident was observed walking and running unsafely on a . street. Staff attempted to redirect resident back to the facility, but resident was not receptive, selectively mute. Resident remained in sight of staff. Suddenly a white van with her visitor and another man drove by resident and resident went inside the van. The van drove quickly away from the facility. Staff attempted to follow the van but lost sight. Law enforcement notified and notified of van's license plate. During a telephone interview on 1/24/25, at 10:30 a.m.,and 2/7/25, at 4:17 p.m., with Registered Nurse (RN) A, RN A stated after the elopement incident on 1/15/25, he notified Resident 1's conservator (person responsible for making decisions for a mentally ill adult) and was told by Resident 1's conservator that only Resident 1's parent was approved to see her. RN A further stated, during visitation on 1/15/25, Resident 1 was heard telling her visitor that she wants to go home. RN A also stated; that the elopement occurred on 1/15/25, at 7:15 p.m., after which he called the police at 7:30 p.m. when staff were unable to redirect Resident 1 back to the facility. RN A confirmed she should have called the police right away as usually done in the past. During a telephone interview on 1/24/25, at 2:48 p.m., Resident 1's conservator, the conservator stated, on 1/3/25 and 1/10/25 she had spoken with the facility's staff (a nurse) and the Assistant Program Director (APD) giving instructions not to allow Resident 1's friends to visit her except her parent (mother). The conservator also stated that, Resident 1's location could not be determined until this time. During a review with the APD on 3/3/25, at 1:37 p.m., the APD provided copies of the email messages from Resident 1's conservator to the Program Director (PD, who no longer works atthe facility) dated 12/18/24, and Cc: (copy furnished) to the DON, Program Director, Social Services and the mental health worker (MHW) that indicated, Effectively immediately, please do NOT allow (Resident 1) to have visitation from friends (words highlighted by the sender). Staff found packet of lighter in her drawer, upon interviewing her, she said it was given by friend who visited her, she did not mention name of friend. IF she wants friends to visit, please let me now (know) name and number of friends, I will then contact her parents to see if that particular friend safe to visit. And please let ALL the staff know, especially the weekend staff. (Resident 1) was introduced to Meth (Methamphetamine- a potent central nervous system stimulant that is mainly used as a recreational or performance-enhancing drug and less commonly as a second-line treatment for attention deficit hyperactivity disorder)/drugs from these supposed friends . Further review with the APD on the email message response by the PD to Resident 1's conservator dated 12/19/24, indicated, Thank you for the information. I will let staff know to closely monitor any visitations from friends with (Resident 1). I will also ask staff to check IDs (identification) of visitors and make copies. We will keep you posted A review of Resident 1's visitation log from 12/19/24 to 1/15/25, it indicated she had a total of five visits from her friends on 12/19/24,12/21/24,12/29/24,12/25/24 and 1/15/25. During an interview on 1/24/25, at 3:40 p.m., with the administrator (ADM), the ADM confirmed that staff did not follow Resident 1's conservator's instructions to prevent Resident 1's friends from visiting her. The ADM admitted the facility staff (PD, APD, DON and DSS, director of social services) who received the email message from Resident 1's conservator did not notify the IDT and /or call the attending physician to obtain a visitation restriction order for no visitations from friends for Resident 1 after receipt of the email instruction on 12/18/24. During a telephone interview on 1/27/25, at 4 p.m., the Program Director (PD)stated, Resident 1 acknowledged her substance abuse, she has poor insight with episode of anxiety and had mentioned she wants to leave the facility. During a telephone interview on 1/28/25, at 9:38 a.m., and 2/7/25, at 3:25 p.m., with CNA B), CNA B stated during the shift change on 1/15/25, CNA D endorsed to her and to other staff in the unit that CNA D overheard Resident 1 crying to someone over the phone before 3 p.m. on 1/15/25, asking to let her out of the facility and that she wanted to go home. CNA B also stated she supervised Resident 1 at the visitation lounge room on 1/15/25, from 7:05 p.m. when Resident 1's visitor arrived at the facility. CNA B stated when the visitor was leaving, she opened the door for the visitor but did not check the whereabouts of Resident 1. Suddenly, Resident 1 pushed her from behind and ran out of the door towards the street. CNA B further stated Resident 1 was last seen sitting on a black chair about seven steps from the visitor's lounge door. CNA B claimed Resident 1 had planned this elopement. During an interview with the ADM on 2/6/25, at 10:10 a.m., and 10:50 a.m., the ADM stated CNA B should have provided preventive safety measures to prevent Resident 1's elopement, and staff (CNA B) should have asked for help in supervising Resident 1 during this visitation. The ADM also stated the staff who spoke with Resident 1's conservator should have communicated to the IDT regarding the conservator's instructions to restrict Resident 1's visitation by friends. The ADM stated after the incident of Resident 1's elopement from the facility, she revised their facility's policies and procedures that requires two persons to supervise residents during visitation, and to ensure residents are back to the unit before letting visitors out, and to keep residents away from the door during any visit. During an inspection of the visitation lounge (location where Resident 1 and her visitor was during the visit) and concurrent interview on 3/3/25, at 12:50 p.m., with the DON, the DON checked the distance of the side seats (where Resident 1 was sitting during that time of visit) from the exit door. The DON stated if Resident 1 was sitting on that chair which was about seven steps away from the exit door, then Resident1's location would be too close to the exit door. The DON also stated CNA B probably did not pay attention cautiously. During a review of the facility's sign in log for December 2024 and January 2025 with the DON on 3/4/25, at 2:30 p.m., the DON confirmed there was no documented evidence indicating the IDs (identification) of Resident 1's two different visitors (friends) were checked by the facility staff when they visited Resident 1 from 12/19/24 to and 1/15/25. During an interview with the Director of Social Services (DSS) on 3/3/25, at 4:30 p.m., and on 3/21/25 at 4:00 p.m , the DSS stated Resident 1's whereabouts were still unknown up to this time. Review of the facility's policy and procedure (P&P) titled, Policy and Procedure for Elopement And AWOL. dated 10/15/24, indicated, The facility shall take the following steps to identify, prevent, detect and respond to situations of resident elopement/ AWOL. Staff shall not open the exit doors if a resident is in the close proximity of the door. Review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person- Centered, indicated, Reflects currently recognized standard of practice for problem areas and conditions. Care plan interventions are . , and relevant clinical decision making. Assessment of residents are ongoing, and care plans are revised as information about the residents and the resident's condition change.

Based on interview and record review, the facility failed to accurately code the elopement risk assessment (an assessment tool to evaluate whether an individual that need additional safety measures is at risk of leaving the facility unsupervised) for one of two residents (Resident 1). This failure had the potential to place the resident's health and safety at risk for not receiving appropriate care. Findings: Review of Resident 1's medical record on 1/3/25 indicated that on 12/26/24 at 11:55 a.m., Resident 1 had an incident of elopement /AWOL(absence without leave- the act of leaving a facility unsupervised and without prior authorization) from the facility. He was returned safely to facility with no injuries around 12:14 p.m. on same day. Review of Resident 1's medical record indicated he was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included schizoaffective disorder (a mental disorder that affect your thoughts, mood, and behavior), bipolar type (sometimes called manic-depressive disorder; mood swings that range from the lows of depression of elevated periods of emotional highs). Review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 10/31/24 indicated his cognition (mental process including thinking, attention, language, learning, memory, and perception) was intact, but with periods of difficulty focusing attention and disorganized thinking. He also had episodes of hallucinations (false perception of objects or events) and delusions (false beliefs that conflict with reality). He did not have impairment of both upper and lower extremities and was able to walk independently. Review of Resident 1's Psychiatry Discharge Summary from the Hospital dated 4/24/24 indicated he had a history of often AWOLs from unlocked residential facilities to use drugs. Review of Resident 1's readmission initial elopement risk assessment dated [DATE] indicated, Registered Nurse A (RN A) coded that Resident 1 had no history of elopement attempts. During an interview with the Registered Nurse A (RN A) on 1/6/25 at 11:29 a.m., she confirmed she coded incorrectly the readmission initial elopement risk assessment dated [DATE] that Resident 1 had no history of elopement attempts. RN A further stated she did not read the Psychiatry's Discharge Summary from the Hospital dated 4/24/24 that Resident 1's had a history of often AWOLs from the unlocked residential facilities to use drugs. RN A acknowledged she should have read the Psychiatry Discharge Summary and should have coded that Resident 1 had made one or more attempts of elopements. During an interview with the Director of Nursing (DON) on 1/3/25 at 3:45 p.m., he acknowledged RN A should have read Resident 1's Psychiatry Discharge Summary from the Hospital dated 4/24/24 that Resident 1 had history of AWOLs and should have coded that Resident 1 had one or more elopement attempts on readmission initial elopement risk assessment dated [DATE] for Resident 1's appropriate care. Review of the undated facility's policy and procedure titled, Admission Assessment and Accuracy: Role of the Nurse: Steps in the Procedure indicated, 7. Conduct an admission assessment (history and physical), including: a. A summary of the individual's recent medical history, including hospitalization s, acute illnesses, and overall health prior to admission. B. Relevant medical, social, and family history. Review of the facility's policy and procedure dated 8/17/15 titled Job Description: Charge Nurse (RN) indicated, Assure that effective quality nursing care is delivered which is outcome focused through utilization of the nursing process (a systematic step by step method that nurse use to provide patient-centered care that involves: assessment, diagnosis, planning, implementation, and evaluation).

Based on interview and record review, the facility failed to prevent two of three residents (1 and 2) from elopement when the staff and visitors did not look around to make sure Resident 1 and Resident 2 were not close by in the area when they opened the locked exit door to prevent the residents from exiting the locked door immediately when the door was opened. This failure placed the residents at risk for accident and injury. Findings: Review of Resident 1's Admission Record indicated she was admitted to the facility on [DATE] with schizoaffective disorder (a mental health condition that is marked by a mix of seeing things or hearing voices that others don't observe, believing things that are not real, persistent feeling of sadness and loss of interest, and having great excitement and occasionally violent behavior) diagnosis. Review of Resident 1's Risk for Elopement, dated 12/20/23 and 1/7/24, indicated Resident 1 was high risk of elopement. Review of Resident 1's Change in Condition Evaluations, dated 12/20/23, 1/8/24, and 1/27/24, indicated she eloped from the facility on 12/20/23, 1/7/24, and 1/27/24. Review of Resident 1's Interdisciplinary Team (IDT, a group of professionals from various fields who work together to treat patients) Notes, dated 12/26/23, indicated around 10:12 a.m. on 12/20/23, Resident 1 quickly ran out of the exit door when the staff entered, pushed staff away from the lobby door and ran towards the street. Resident 1 walked unsafely on the street, entered a bank, got on and off the bus, and walked in the plaza. Law enforcement was notified and helped to bring Resident 1 back to the facility. Review of Resident 1's IDT Notes, dated 1/10/24, indicated around 3 p.m. on 1/7/24, Resident 1 bustled and moved through the exit door when she saw it opened, ran down the street and away from the facility. Review of Resident 1's IDT Notes, dated 1/31/24, indicated around 6:25 p.m. on 1/27/24, Resident 1 was standing near the exit door and quickly followed a staff out. Resident 1 walked on the street and attempted to get on the bus. Review of Resident 2's Admission Record indicated she was admitted to the facility on [DATE] with schizoaffective disorder diagnosis. Review of Resident 2's Change in Condition Evaluation, dated 5/24/24, indicated she eloped from the facility on 5/24/24. Review of Resident 2's IDT Notes, dated 5/29/24, indicated around 1 p.m. on 5/24/24, Resident 2 walked out of the exit door when nursing students entered the unit. Resident 2 walked unsafely on the street, walked into a store, and attempted to get matches and cigarettes. Law enforcement was notified and assisted. During an interview with the director of nursing (DON) on 10/11/24, at 2:45 p.m., he stated the nursing instructor opened the exit door for the nursing students to enter the unit, and Resident 2 walked out the door; the nursing instructor and students had already had orientation about the residents' elopement and absence without leave (AWOL) when they came to the facility for clinical rotation. The DON stated the staff and visitors should look around to make sure the residents were not close by in the area when they opened the locked exit door. Review of the facility's undated policy and procedure, Elopement and AWOL, indicated . Prevention: . 6. Staff shall not open the exit doors if a resident is in the close proximity of the door. 7. Staff shall look through the glass window to see that no resident is on the other side of the door before entering the units.

Based on interview and record review, the facility failed to conduct performance review at least once every 12 months for three of three certified nursing assistants (CNA A, CNA B, and CNA C). This failure resulted in unidentified the needed training for the CNAs to improve their skills in resident care every year. Findings: Review of CNA A's personnel file indicated she was hired on 8/14/20, and she did not have the performance review done in the year 2021, 2022, and 2023. During an interview with the director of staff development (DSD) on 9/23/24 at 4:10 p.m., she reviewed CNA A's personnell file and confirmed that CNA A did not have the performance review done in the year 2021, 2022, and 2023. Review of CNA B's and CNA C's personnel files indicated they were hired on 4/15/13 and 8/22/12, and they did not have the performance review done in the year 2021 and 2022. During an interview with the DSD on 9/24/24 at 11:45 a.m., she reviewed CNA B's and CNA C's personnel files and confirmed that CNA B and CNA C did not have the performance review done in the year 2021 and 2022. The DSD stated the performance of the CNAs should be reviewed every year. Review of the facility's Employee Handbook, dated 2/2024, indicated . Performance Evaluations: . The first performance evaluation may be after completion of the Introductory Period. After that review, performance evaluations may be conducted annually, on or around their anniversary date.

Based on interview and record review, the facility failed to provide supervision to prevent one out of three sampled residents (Resident 1) from leaving the facility without staff's knowledge and permission. This failure had a potential risk to compromise Resident 1's health and safety, as she was found walking toward the parking lot outside the facility on 8/11/24. Findings: A review of Resident 1's medical record indicated she was admitted to the facility on [DATE] with diagnoses including unspecified schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 1's minimum data set (MDS, an assessment tool) dated 6/25/24 indicated his brief interview for mental status (BIMS, cognition level) score was 12 (8 to 12 points suggests moderate cognitive impairment). During an interview with the Program Consultant (PC) on 9/6/24 at 9:13 a.m., the PC stated that she looked through her glass window in her office around 10:46 a.m. and found Resident 1 was walking on the sidewalk pavement towards the parking lot outside the facility. She and her co-workers immediately followed Resident 1 and redirected Resident 1 back to the facility. No injury was noted. The PC confirmed Resident 1 did not have permission to leave the facility. The PC further stated that this facility was locked, and all residents coming out from the facility without permission waere not allowed. During an interview with the social service director (SSD) on 9/6/24 at 10:20 a.m., the SSD confirmed that Resident 1 did not have the go-out pass and should not have left the facility without permission. The SSD further stated that when staff opened the door, they should have looked back to ensure the door was locked and no resident was following them. A review of Resident 1's Interdisciplinary Team (IDT) notes dated 8/14/24 indicated around 11:00 a.m., on 8/11/24, A staff observed Resident 1 walking on the sidewalk just outside the facility towards the parking lot. Staff immediately followed Resident 1 on foot and provided redirection back to the facility. Resident 1 was receptive and returned safely to the facility with no issues. A review of the facility's undated Policy and procedure (p&p) titled Preventing Elopement indicated, .staff shall not open the exit doors if a resident is in close proximity to the door. Staff shall look through the glass window to see that no resident is on the other side of the door before entering the units. The door handle shall not be released until the door latches to assure that the door has been locked .

Based on observation, interview, and record review, the facility failed to implement their policies and procedures to report a sexual allegation within the required two hours timeframe to the local law enforcement, the California Department of Public Health (CDPH) and Ombudsman as required for one of three sampled residents (Resident 1); and prevent the recurrence of sexual allegation for of three sampled residents (Resident 2) when: 1. Resident 1 claimed Resident 2 held her breast on 6/18/24. 2. Resident 2 had two sexual assault incidents involving two female residents in a period of one week. The failure to report the sexual allegation within two hours to reporting entities could compromise the welfare, health and safety of Resident 1 and other vulnerable residents; and the failure to prevent recurrence of sexual assaults could potentially put all vulnerable residents at risk. Findings: 1. Review of Resident 1's Situation Background Assessment Recommendation (SBAR, a verbal or written communication tool used by healthcare professional), dated 6/18/24 at 12:16 p.m., indicated, Resident (Resident 1) claimed that Resident 2 held her breast last night (6/17/24). Further review of Resident 1's minimum data set (MDS, an assessment tool) assessment, dated 6/4/24, it indicated her brief interview for mental status (BIMS) summary scored 13 (BIMS score from 13 to 15 means cognitively intact). According to her progress notes on 6/18/24 at 10:39 a.m. that assistant of program director E (APD E) received resident 1's self-reporting at 7 a.m. of 6/18/24 and law enforcement notified at around 7:26 a.m. of 6/18/24. During an observation and interview on 6/18/24, at 1:40 p.m., with Resident 1 in her room, she stated, while she played poker and talked to Resident 3 in the hallway where was nearby the nursing station one, Resident 2 passed by her and suddenly touched and grabbed her right breast. She immediately swung back to Resident 2, so he walked away. She further stated that couple of certified nursing assistants (CNAs) were in the nursing station one at the time of incident, but they did not do anything to help her, so she had approached to staff in nursing station one to allege Resident 2 inappropriately touched her breast before going back to her room. Resident looked upset while described what happens to her. During an interview and record review on 6/18/24, at 1:49 p.m., with Resident 3 in a private room near the activity room, Resident 3 confirmed Resident 1's statements about the sexual assault that happened on 6/17/24. Resident 2 stated Resident 1 reported the incident to couple of staff about the sexual assault just after the incident, then she walked back to her room. Review of Resident 3's MDS dated [DATE] indicated her BIMS score was 14 (cognitively intact). During a telephone interview on 6/19/24, at 11:19 a.m., with the licensed vocational nurse A (LVN A), she stated she was the med (medication) nurse working at the nursing station 2 (NS 2) on the night of 6/17/24. While she was walking by NS 1 looking for NS1's med nurse, Resident 1 approached her and reported that Resident 2 inappropriately touched her breast. During a telephone interview on 6/19/24, at 11:38 a.m., with licensed vocational nurse B (LVN B), LVN B stated, she was the med nurse for NS 1 on the night of 6/17/24 when the incident of sexual assault happened, but she did not receive any reports from the staff when Resident 1's breast was inappropriately touched by Resident 2. During a telephone interview on 6/19/24, at 12:52 p.m., with CNA D, she confirmed Resident 1 approached her in the nursing station 1 (NS 1) while she was with other CNAs on 6/17/24 at around 9:00 p.m., Resident 1 reported that Resident 2 touched her breast while she in the hallway near nursing station playing poker card with Resident 3 on 6/17/24. During a telephone interview on 6/19/24, at 1:11 p.m., with the registered nurse C (RN C) who was the supervisor on the night of 6/17/24, she confirmed the sexual allegation incident was reported late. RN C further stated, she received reports from CNA D that Resident 1 was touched by Resident 2, but CNA D did not elaborate the specific detail information, so she just endorsed to the incoming night shift nurse for that night (6/17/24) to keep an eye on both Residents 1 and 2. During a telephone interview on 6/21/24, at 2:30 p.m., with ADM to verify the date and time of the incident because of the discrepancy between documented date of incident and the interviews conducted, the ADM stated the documentation of incident occurred time was based on Resident 2's statements for the time of incident was between 7 p.m. to 8 p.m. of 6/17/24. However, after the ADM interviewed staff, the interview indicated the incident happened 8:45 to 9 p.m. on 6/17/24 when at that time Resident 1 yelled and screamed for help. The ADM further stated after investigation, she suspended RN C for not following their abuse policy and procedure of reporting sexual abuse allegation right away. 2. Review of Resident 2's progress notes dated 6/11/24, indicated at 8:30 p.m. he inappropriately touched another female resident's buttocks (Resident 4) in front of the nursing station. Further review of his progress notes dated 6/12/24, indicated at around 2 p.m. Resident 2 hit a female resident's buttocks (Resident 4) in front of the nursing station. Resident 2's MDS dated [DATE] indicated his BIMS score was 13 (cognitively intact). Review of Resident 2's plan of care for alleged sexual abuse, dated 6/11/24 , indicated . notification to physician, public guardian (PG, conservator serves as conservator of a person and/or estate of individuals needing protective intervention), Ombudsman, Department of Health (DOH), Sheriff's Department, abuse coordinator and all regulatory agencies. Separated residents and assessed for any injuries or PRN (as needed). Placed on 24 hours monitoring for72 hours alert charting and would continue to monitor for safety. The record review of Resident 2's care plan indicated, there was no added intervention/s in place to prevent future incident/s of sexual assault/abuse as confirmed by the program director (PD). During an interview on 6/18/24, at 1 p.m., with the program director (PD), she stated, Resident 2 was sent to emergency psychiatric service (EPS, is the only 24-hour locked psychiatric emergency room , which provides emergency psychiatric care) because Resident 2 had pattern of recurrent of sexual allegation in one week. The PD admitted that Resident 2's current plan of care was ineffective in preventing any further incidents of sexual abuse. Review of the facility's policy and procedure (P&P) titled , Preventing, Investigating, and Reporting Alleged Sexual Assault and Abuse Violation, dated 2/14/18, the P&P indicated, it is the responsibility of all employees to immediately report any reasonable suspicion of a crime, alleged violation of abuse, neglect injuries of unknown source, misappropriation of resident property and exploitation. All alleged violations will be reported immediately, but not later than: within 2 hours if the alleged violation involves ABUSE OR results in serious bodily injury.

Based on interview, record review, and facility policy, the facility failed to notify the Ombudsman when a resident transferred or discharged from the facility for 3 (Residents #75, #78, and #118) of 3 sampled residents reviewed for hospitalization . Findings included: A facility policy titled, Transfer or Discharge, Emergency, revised in 09/2012, indicated, 1. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident; e. Notify the representative or other family member; f. Assist in obtaining transportation; and g. Others as appropriate or as necessary. 1. An Admission Record revealed the facility admitted Resident #75 on 05/12/2020. According to the Admission Record, the resident had a medical history that included a diagnosis of hypertension. Resident #75's Progress Notes, dated 04/20/2024 at 2:37 PM, revealed Resident #75 discharged to the hospital for further evaluation due to some abnormal laboratory test results. 2. An Admission Record revealed the facility admitted Resident #78 on 04/02/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of insomnia. Resident #78's Progress Notes, dated 04/12/2024 at 10:41 PM, revealed 911 was called to transport the resident to the hospital. Resident #78's Progress Notes, dated 04/13/2024 at 2:47 PM, revealed the resident was still in the hospital. 3. An Admission Record revealed the facility admitted Resident #118 on 12/27/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of insomnia. The Admission Record revealed the resident discharged from the facility on 05/04/2024. During an interview on 07/11/2024 at 11:10 AM, the Administrator stated the previous Social Services Director (SSD) was terminated at the end of 05/2024 and the termination did not go well. He Administrator stated the former SSD did not leave their office in good order and the staff had been unable to locate a lot of information, to include the transfer/discharge binder that contained documentation of the Ombudsman notification of residents' transfers/discharges. The Administrator stated the facility was not able to locate any of the transfer/discharge notifications from 01/2024 to 05/2024. During an interview on 07/11/2024 at 11:19 AM, Director of Nursing (DON) stated he was not involved in the process of notifying the Ombudsman of resident transfers/discharges. The DON stated he would expect the Ombudsman to be notified timely of all resident transfer/discharges. During an interview on 07/11/2024 at 11:41 AM, the Ombudsman stated the ombudsman's office did not have any of the transfer/discharge notifications for Residents #75, #78, and #118.

Based on observation, interview, and facility policy review, the facility failed to staff washed their hands before they applied gloves during the preparation of food. This deficient practice had the potential to affect all residents who received food from the kitchen. Findings included: A facility policy titled, Glove Use Policy, dated 2023, revealed 3. Wash hands when changing to a fresh pair. Gloves must never be used in place of hand washing. On 07/10/2024 at 10:32 AM, Specialist Dining Services Aide (SDSA) #16 answered the locked kitchen door, while he was in the middle of making peanut butter and jelly sandwiches. After SDSA #16 answered the door, he applied a new pair of gloves without washing his hands first, and then continued to make the peanut butter and jelly sandwiches. During an interview on 07/10/2024 at 1:00 PM, SDSA #16 confirmed that he did not wash his hands before he applied a new pair of gloves. SDSA #16 stated he understood handwashing was important to prevent contamination. During an interview on 07/10/2024 at 1:19 PM, the Dining Services Manager stated staff should change gloves and wash hands after touching high-contact surfaces and before touching food items. During an interview on 07/11/2024 at 9:02 AM, the Director of Nursing stated that staff were expected to wash their hands after they touched high-contact surfaces and before touching food. During an interview on 07/11/2024 at 12:01 PM, the Administrator stated kitchen staff should follow infection control procedures and she expected staff to wash their hands after they touched the door or trashcan and before they made sandwiches.

Based on observation, resident interview, staff interview, and facility policy review, the facility ensure 1 (Station 2 dining room) of 2 dining room provided sufficient space to accommodate all the residents who wished to eat their meals in the dining room. Findings included: An undated facility policy titled, Social Dining, specified, Our recovery-oriented program offers a structured environment designed to assist residents in managing daily living tasks. Social Dining, a key component of this program, is specifically tailored to meet residents' needs in developing and practicing a range of skills. These include, but are not limited to, fairness, patience, courtesy, mood regulation, acceptance of reality, and learning the benefits of orderly conduct like queuing. Residents are given the opportunity to request preferred meals, wait patiently for their meal to be served, appreciate the communal aspect of dining, await their turn for seconds, and manage their emotions when their preferences cannot be met. During an observation of dining on 07/09/2024 at 12:32 PM, it was noted that one of the dining rooms was not large enough to accommodate all the residents. There was a queue of eight residents outside of the dining room, with five more residents coming down the hallway toward the dining room. During an interview on 07/09/2024 at 12:37 PM, Mental Health Worker (MHW) #1 stated the dining room was not large enough to accommodate all the residents. MHW #1 stated the room could only accommodate 24 residents and she was not sure how many residents were on the unit, but there were 116 in the facility. During an interview on 07/10/2024 at 2:49 PM, Resident #90 and Resident #109 both stated that they had to wait about five to15 minutes to get to lunch because there was not enough space for everyone in the dining room at once. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/16/2024, revealed Resident #90 had a Brief Interview for Mental status (BIMS) score of 15, which the resident had intact cognition. A quarterly MDS, with an ARD of 06/29/2024, revealed Resident #109 had a BIMS score of 14, which indicated the resident had intact cognition. During an interview on 07/10/2024 at 3:14 PM, Resident #111 stated they had to wait 15 minutes, sometimes longer, for food service. Resident #11 stated there was not enough room in the dining room for everyone who wanted to attend. A quarterly MDS, with an ARD of 05/24/2024, revealed Resident #111 had a BIMS score of 14, which indicate the resident had intact cognition. During an interview on 07/10/2024 at 3:16 PM, Certified Nursing Assistant (CNA) #2 stated the dining room was not big enough to accommodate all the residents. During an interview on 07/10/2024 at 3:30 PM, CNA #3 stated residents usually had to wait only 10 minutes for lunch. CNA #3 stated there was not enough room for everyone in the dining room and only 24 residents could fit in the Station 2 dining room. During an interview on 07/10/2024 at 3:33 PM, CNA #4 stated there was room for only 24 residents in the dining room and residents usually had to wait for only five minutes while in line. During an interview on 07/11/2024 at 9:02 AM, the Director of Nursing said it was his expectation that all residents should be able to eat at mealtimes when they were hungry or ready to eat. During an interview on 07/11/2024 at 10:41 AM, the Dining Services Manager stated the occupancy of the dining room on Station 2 was 24 residents. During an interview on 07/11/2024 at 12:01 PM, the Administrator stated staff had tried two different setting for meals; however, it did not work so now the dining room on Station 2 had a first-come, first-served system to prepare the residents for transition back into the community. During an interview on 07/11/2024 at 12:51 PM, Resident #87 stated the line wait for the ding room was sometimes 10 to 15 minutes and they did not like having to wait in line because they got tired and wanted to sit down. An admission MDS, with an ARD of 05/29/2024, revealed Resident #87 had a BIMS score of 14, which indicated the resident had intact cognition.

Based on interview and record review, the facility failed to provide supervision and assistance to prevent a choking hazard for one of 22 sampled residents (22). Resident 22 was not supervised by staff on [DATE] during the Easter social party as required in her assessment and care plan. Findings: Resident 22 was admitted to the facility with [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set, an assessment tool, indicated Resident 22 was moderately impaired in cognition, and required extensive assistance with one person physical assistance during dining. Resident 22 was conserved by the local public guardian. The social progress note dated [DATE] indicated: "Resident is on consistent carbohydrate puree diet with a usual intake of 100% during meals. Resident has to be fed by the staff to avoid aspiration. Resident is eating fast and not really chewing her food before swallowing. Resident is edentulous (without teeth) and has dentures". The [DATE] dentist's evaluation indicated Resident 22 "does not wear denture; eating well without denture". On [DATE], the attending physician ordered a "pureed CON (consistent) CHO (carbohydrate)" small diet for all three meals based on the recommendation of the facility registered dietitian. Puree is cooked food that has been ground, pressed or blended to the consistency of a soft creamy paste or thick liquid. Physician orders [REDACTED]. A care plan dated [DATE] indicated Resident 22 required staff assistance with feeding to maintain her safety. "Resident tends to rush through meals, eats too fast and swallows without chewing food posing a choking hazard". Care plan interventions included eating assistance as needed. The facility corporate registered dietitian (RD 1) wrote a care plan dated [DATE] which indicated Resident 22 "eats food very quickly, does well with blenderized puree; weight gain since admission". "Blenderized puree" is using a blender to alter the consistency of the cooked food to a creamy paste or thick liquid. Care plan interventions included "provide supervision and redirection meal service and snack times". The facility did not care plan how Resident 22 would be supervised on special occasions when diet restrictions are off. A progress note dated [DATE] written by a program counselor indicated "encouraged her to swallow food slowly to avoid choking hazard". The dietary services manager (DSM) wrote a note dated [DATE] "staff continues to monitor at mealtime as resident tends to get extra food with every opportunity; current weight is 178.6 pounds; weight changes not significant but is not desired for the resident". The facility consultant registered dietitian (RD 2) note dated [DATE] indicated "adjust diet to consistent carbohydrate puree". Resident 22 had the [DATE] noon meal consisting of beef, sauteed onions, au gratin potato, green beans, bread slice and white cake, which were all pureed. A progress note indicated vital signs of Resident 22 taken before 9:00 a.m. on [DATE] were: blood pressure = ,[DATE], respiratory rate = 20, and heart rate = 76. Licensed nurse A (LN A) wrote a note dated [DATE] at 2:20 p.m.: Resident was "having Easter party at the middle room adjacent to TV room with other residents. Per CNA (certified nurse assistant) who noticed resident change of condition, resident was observed to be silent and unresponsive with bluish discoloration of the lips". During an interview on [DATE] at 2:45 p.m. LN A stated he was at the chart room on [DATE] at 2:20 p.m. when certified nurse assistant C (CNA C) called him for an emergency. LN A rushed to Resident 22's room, and saw the resident sitting in the wheelchair, unconscious and unresponsive to verbal and tactile (touch) stimulation with bluish discoloration of the lips and a non-palpable (not felt) pulse. LN A immediately performed cardiopulmonary resuscitation (CPR) and instructed other staff to call 911. LN A stated he noticed salivary secretions drooling from Resident 22's mouth. LN A opened the resident's mouth with one hand and continued chest compression with his other hand. LN A inserted two fingers in the resident's mouth and extracted a "piece of previously taken food". LN A stated it looked like the cupcakes served during the Easter social party. LN A stated that at this point in time ([DATE] at 2:35 p.m.) he was unable to get vital sign readings. LN A stated it was at this time the 911 paramedics arrived and took over the chest compressions. LN A stated Resident 22 was sent to the acute care hospital at about 2:55 p.m. on [DATE]. During an interview on [DATE] at 8:00 a.m. certified nurse assistant B (CNA B) stated she was assigned to Resident 22 for the day shift on [DATE]. CNA B stated Resident 22 requested she take her to the middle classroom so she could attend the Easter social party. CNA B stated cupcakes with different colored icings on top, juice and water were served at the party. CNA B stated she left the middle classroom as soon as she brought Resident 22 to attend to her other residents. CNA B stated she did not see how Resident 22 acquired the cupcakes. No staff was directly supervising the resident. CNA B stated she was providing care to other residents when CNA C took Resident 22 in her wheelchair back to the resident's room. CNA C shouted to CNA B "code blue" signifying an emergency situation. Both CNAs went to Resident 22's room. CNA B stated she, CNA C, LN A, and program counselor staff were in the room. CNA B stated she could not get readings when she felt the resident's carotid (neck) pulse and attached the blood pressure equipment. CNA B stated she saw LN A doing chest compressions. CNA B stated CNA C extracted "lots of pieces" of chocolate brown cupcake similar to the ones served at the Easter social party. During an interview on [DATE] at 8:25 a.m. the program counselor (PC) stated that program counselor staff distributed cupcakes, the only solid food served at the party. The PC stated the cupcakes came in different colors but she remembered the chocolate brown color. The PC stated she saw Resident 22 during the party. The PC stated she did not know how Resident 22 obtained the cupcake. The PC stated she became aware there was a problem when she saw CNA C move Resident 22 out of the middle classroom. During an interview on [DATE] at 8:50 a.m. the dietary services manager (DSM) stated the activity director requested cupcakes be supplied to residents during the Easter social party. The DSM stated she ordered the supply of cupcakes from the facility food vendor. The DSM stated the cupcakes were the only solid food items served at the Easter social party and they were given to the residents present in the party as received from the food vendor. The DSM stated the cupcakes were not appropriate for Resident 22 to eat because the resident was on a puree texture diet. The DSM stated the cupcakes would have to be pureed using the standard procedure the kitchen staff used with the pureed white cake served during the [DATE] noon meal to prevent a choking hazard for Resident 22. During an interview on [DATE] at 7:15 a.m. CNA C stated as a high-risk CNA she was responsible in conducting a resident head count to ensure no residents eloped from the facility. CNA C stated when she arrived in the middle classroom on [DATE] at 2:20 p.m. she found Resident 22 sitting in her wheelchair and looking pale. CNA C tried to rouse Resident 22 but the resident was unresponsive. When asked why she did not intervene to correct a potential choking episode, CNA C stated she did not think Resident 22 choked because the resident was unresponsive and pale and did not have cupcake-looking food in her hands. CNA C stated she helped LN A extract three pieces of dark chocolate colored substance from Resident 22's mouth which looked like cupcake. Review of the emergency department of the acute care hospital physician assessment dated [DATE] at 6:00 p.m. indicated: The facility staff reported to the 911 paramedics Resident 22 "was last seen alive on [DATE] at 2:10 p.m., and she was seen eating a cupcake. Nurses state that the patient was found lying on the bed, pulseless and apneic (without breathing) with vomit on the bed. The patient was initially in asystole (no pulse). Patient was administered 1 milligram of epinephrine and 1 mg of atropine intravenous push with return of pulses. The patient then went from a sinus tachycardia (rapid pulse) to a [DIAGNOSES REDACTED], was pulseless again. The patient was administered 100 milligrams of lidocaine intravenous push with the patient then going into normal sinus rhythm at a rate of 90. The patient was placed onto the gurney and transported to the ambulance. During the transport, just prior to the arrival to the emergency room , the patient went into pulseless electrical activity. CPR was initiated and the patient was administered 1 milligram of epinephrine intravenous push with pulses returned and no other changes during transport." Resident 22 was transferred to the intensive care unit (ICU) on [DATE] at 6:00 p.m. The discharge summary dated [DATE] indicated: "Throughout the patient's intensive care unit stay she persistently would demonstrate neurologic instability manifesting itself as a comatose state void of any significance sedatives to cause such a neurologically distributive shock and neurologic fevers with periodic [DIAGNOSES REDACTED] and seizure activity. The patient was assessed by neurology and critical care services, and early on the prognosis was predicted to be poor. This was conveyed to the conservator's office, and the conservator directed the medical team to seek two medical opinions. After a second medical opinion from neurology was rendered as to the extremely poor prognosis for this patient and both parties recommended comfort care, comfort care was indeed applied and a do not resuscitate was placed on the chart. The patient ultimately continued to progress to pass from the natural progression of her stroke disease and ceased vital signs including respirations and pulse on [DATE] at 1731". The discharge summary dated [DATE] indicated cause of death was global anoxic brain injury (days) secondary to food aspiration/asphyxiation (accidental) in the setting of Alzheimer's dementia, hypertension, [DIAGNOSES REDACTED]. The facility failed to provide supervision to prevent a choking hazard to Resident 22 on [DATE] during the Easter social party. The resident choked on food she obtained without staff supervision. She became pulseless and/or comatose, required CPR, and 911 transport to the hospital.