Every finding on record at La Paz Geropsychiatric Center

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one of three sampled residents (Resident 2). This deficient practice resulted in Resident 1 kicking Resident 2 in the face.Findings: During a review of Resident 1's admission Record (Face Sheet, front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included schizophrenia (a chronic brain disorder marked by auditory hallucinations like hearing voices) and major depression disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest affecting how you feel, think and behave). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 7/10/2026, the MDS indicated Resident 1 's cognitive skills for daily decision making was intact (clear with memory, thinking, and reasoning). The MDS indicated Resident 1 was independent with eating, oral hygiene, toileting hygiene, and dressing, and required supervision or touching assistance with showering/bathing and personal hygiene. The MDS indicated Resident 1 was independent in walking. During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), drug induced subacute dyskinesia (a movement disorder marked by involuntary, erratic, and repetitive muscle movements caused by specific types of drugs), and insomnia (difficulty sleeping). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was moderately impaired. Resident 2 was independent with eating, oral hygiene, toileting hygiene, showering/bathing, dressing, but required supervision/touching assistance with personal hygiene. During a review of Resident 1's Nursing Note, dated 8/23/2026, the Nursing Note indicated on 8/22/2026 at 8:30 p.m., Resident 2 was sitting by the living room door. Resident 1 kicked Resident 2 with his leg, hitting him in the right face. Resident 1 and Resident 2 were separated by staff. During a review of Resident 1's Nursing Note, dated 8/23/2026, the Nursing Note indicated Resident 1 was experiencing delusional (false beliefs that do not match reality) thoughts. The Nursing Note indicated Resident 1 stated he kicked Resident 2 because he believed Resident 2 kicked his son. During an interview on 8/25/2026 at 11:15 a.m., with Resident 1, Resident 1 stated he remembered kicking Resident 2 in the face a few days ago (8/22/2026). Resident 1 stated he kicked Resident 2 because his family told him (Resident 1) that Resident 2 hit his child. During an interview on 8/25/2026 at 11:24 a.m., with Resident 2, Resident 2 stated Resident 1 kicked him on the right side of his face for no reason a few days ago (8/22/2026) while sitting on the floor, near the facility's entrance, waiting for his family to visit. Resident 2 denied injuries but reported mild pain on his face which he stated was tolerable. During an interview on 8/26/2026 at 12:35 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 8/22/2026, while exiting the dining room she saw Resident 2 sitting on the floor near the entrance/exit door at the front of the facility. Resident 1 kicked Resident 2 in the face. CNA 1 stated she immediately separated the residents, preventing Resident 2 from retaliating against Resident 1. CNA 1 stated Resident 1 and Resident 2 never exchanged words or communicated with each other prior to the incident. CNA 1 stated both residents were generally quiet and kept to themselves. During an interview on 8/26/2026 at 1:30 p.m., with the Administrator (ADM), the ADM stated Resident 1 kicking Resident 2 was abuse. During a review of the facility's policy and procedure (P/P) titled, Abuse Prevention and Reporting dated 12/22/2025, the P/P indicated any form of mistreatment of residents including but not limited to abuse, neglect, exploitation, involuntary seclusion, or misappropriation of property or any crime are strictly prohibited. The P/P indicated Abuse - means infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The P&P indicated abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well -being. The P&P indicated Willful means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. The P&P indicated instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.

Based on interview and record review the facility failed to notify the physician of an elevated laboratory result for one of five sampled residents (Resident 5's). The facility failed to:1.Ensure Resident 5's physician was notified of elevated prostate-specific antigen level (PSA- a simple blood test to help look for [prostate- a walnut-sized gland in the male reproductive system that makes fluid for semen] problems) laboratory result of 18.2 nanograms (ng-unit of measurement)/milliliters (mL- unit of measurement) greater than 10 ng/mL: Probability of prostate cancer - 50%) dated 1/28/2026.2.Document physician notification or obtain timely follow-up after the abnormal laboratory result was identified.This deficient practice had the potential to delay physician evaluation, diagnostic workup, and implementation of appropriate medical treatment for Resident 5.Findings:During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), and depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).During a review of Resident 5's Minimum Data Set (MDS a resident assessment tool) dated 5/14/2026, the MDS indicated Resident 5 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for toileting hygiene and oral hygiene.During a review of Resident 5's Progress Notes dated 1/30/2026, the Progress Notes indicated, Resident has been scheduled for Gastroenterology (specialist diagnose and treat conditions affecting the digestive system) /Colonoscopy (medical test that uses a tiny camera on a soft, bendable tube to look inside the large intestine (colon)for 5/6/2026 with time to follow. Registered Nurse Supervisor (RNS) was aware.During a review of Resident 5's Progress Notes dated 2/6/2026, the Progress Notes indicated, Assessment Prostate specific antigen outside reference range referral to urology (medical and surgical specialist that deals with diseases if the male and female urinary tract).During a review of Resident 5's Medical Progress Notes dated 2/16/2026, the Medical Progress Notes indicated, elevated Prostate-Specific Antigen level (PSA- a simple blood test to help look for [prostate- a walnut-sized gland in the male reproductive system that makes fluid for semen] problems) PSA at 18.2.Plan: PSA outside reference range, referral to urology.During a review of Resident 5's Physician Progress Notes dated 3/4/2026, the Physician Progress Notes indicated PSA outside reference range, referral to urology.During a review of Resident 5's Care Plan titled Resident PSA level of level of 18.2 ng/mL and considered to be elevated at risk for urinary changes as in incontinence (loss of bladder and/or bowel control), frequency and urgency, painful urination, blood in the urine dated 3/2026 the Care plan intervention interventions including urology consult for evaluation and treatment.During a review of Resident 5's Medical Progress Notes dated 3/16/2026, the Medical Progress Notes indicated, plan: PSA outside reference range, referral to Urology.During a review of Resident 5's Physician Progress Notes dated 4/3/2026, the Physician Progress Notes indicated, PSA outside reference range, referral to Urology.During a review of Resident 5's Annual History & Physical (H&P) dated 4/13/2026, the Annual H&P indicated, PSA outside reference range, referral to Urology.During a review of Resident 5's Order Summary dated 5/15/2026, the Order Summary indicated, urology consult related to elevated PSA and urinary incontinence.During a review of Resident 5's Appointment Progress Notes dated 5/21/2026, the Appointment Progress Notes indicated, resident has a new patient Urology appointment scheduled on 7/1/2026 at 2:00 pm. RN Supervisor was aware.During a review of Resident 5's Appointment Progress Notes dated 6/16/2026, the Appointment Progress Notes indicated, resident had a scheduled colonoscopy appointment on 6/3/2026 but the doctor's office rescheduled it. The appointment was rescheduled for 7/31/2026 7:00 a.m., with all pre-procedure information to follow including the location of the procedure. RN Supervisor was aware.During the review of Resident 5's Appointment Progress Notes dated 6/29/2026, the Appointment Progress Notes indicated the resident had a new patient urology appointment scheduled for 7/1/2026. The doctor's office called to cancel the appointment because the resident was unable to sign the consent forms. The office suggested a higher level of care since the resident was under conservatorship (a legal arrangement where a judge names a helper (a conservator) to take care of an adult who cannot safely make their own choices). The RN Supervisor was aware.During a review of Resident 5's Medical Progress Notes dated 7/3/2026, the Medical Progress Notes indicated, elevated prostate PSA, referral to Urology pending. Patient was unable to get into last urology in June. Discussed with staff importance of getting into a new urology for testing.During a review of Resident 5's Appointment Progress Notes dated 7/13/2026, the Appointment Progress Notes indicated the resident had a new patient urology appointment scheduled for 8/19/2026 at 10:15 a.m. The notes indicated instructed staff to bring the appropriate labs and paperwork to the appointment. The RN Supervisor was aware.During a concurrent interview and record review with License Vocational Nurse (LVN) 1 on 7/23/2026 at 2:11 p.m., Resident 5's laboratory results were reviewed. The PSA laboratory result was dated 01/28/2026, with a reported PSA level of 18.2. LVN 1 stated Resident 5's PSA level was elevated and stated the physician should have been notified of the abnormal laboratory result and notification should have been documented in Resident 5's progress notes. Resident 5's progress notes was conducted with the LVN 1. The record review revealed no documentation Resident 5's physician had been notified of the elevated PSA level of 18.2. LVN 1 was unable to accurately state her understanding of the PSA level. LVN 1 stated failure to report an elevated PSA result to the physician could result in a delay in care. LVN 1 stated potential outcomes could include delayed evaluation and diagnosis of an underlying condition, delayed treatment, worsening of the resident's condition, or progression of an underlying condition due to lack of timely medical evaluation and intervention.During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 7/24/2026 at 10:00 a.m., Resident 5's electronic medical record was reviewed. The ADON stated she first became aware of Resident 5's elevated PSA in February 2026 but was unsure how she was informed. She stated nursing staff were responsible for reviewing lab results, notifying the physician, and documenting the notification in the progress notes. She stated communication among nursing staff occurred during change of shift reports and daily stand up meetings. The ADON stated that she could not identify who notified the physician or when, because there was no documentation in Resident 5's electronic medical record. She stated there was no documentation showing the physician had been notified of the elevated PSA and that the facility assumed the physician had been informed based on entries in the physician's progress notes. The ADON stated the physician ordered a urology consult and a colonoscopy but confirmed that no repeat PSA or follow up laboratory tests were ordered. The ADON stated nursing staff were responsible for ensuring follow up on abnormal laboratory results for the residents assigned to them each day. The ADON stated Resident 5 had been scheduled for a urology appointment in July 2026, but it was canceled because the resident could not sign the consent form and needed the conservator. She stated there was no documentation showing the conservator had been contacted. The ADON stated consent would not have been required for an initial consult, which led to a delay in the resident being evaluated. She stated the facility did not attempt to secure an earlier appointment through another specialist, a cancellation list, or an alternative provider. She stated the resident's condition was not monitored while awaiting the specialist consult. The ADON stated an elevated PSA may indicate prostate cancer (a disease where cells in the prostate gland start to grow out of control) and could contribute to an enlarged prostate, potentially causing urinary incontinence, urinary retention, urinary tract infections, or other complications. She stated Resident 5 exhibited urinary incontinence and prior attempts at bladder training were unsuccessful. She stated that no steps were taken to ensure timely follow up of the resident's abnormal laboratory result and delays in initiating appropriate treatment or follow up could worsen the resident's underlying condition due to the lack of timely medical intervention.During a review of the facility's policy and procedure (P&P) titled Critical Test Results and Critical Values Reporting, [undated], the P&P indicated, Timeframe for Notification: The program will call the ordering provider with the critical values and critical test results within one (1) hour of receipt. If the call to the ordering provider has not been returned within 30 minutes or a timeframe appropriate for the nature of the critical test and critical value result, the staff will implement the chain of command and will call the other facility providers or medical director of the facility.During a review of the facility's policy and procedure (P&P) titled Notification of Diagnostic Test Results, dated 2026, the P&P indicated The facility is responsible for the quality and timeliness of the services, as well as the timely and appropriate notification of the ordering physician/provider of the findings.During a review of the facility's P&P titled Notification of Physician/Prescriber, dated 2026, the P&P indicated, Notify the appropriate provider promptly of:. abnormal laboratory values.

Based on interview, and record review, the facility failed to protect one of four sampled residents (Resident 1) from potential and/or continued sexual abuse when Resident 1 reported to the facility's Social Worker (SW) on 5/19/2026 at 4:35 p.m., that Resident 2 touched her (Resident 1) buttock four times with his hand. Resident 1 and 2 were not placed on every 15 minute monitoring, per their intervention, until 5/20/2026 at 1:30 p.m. (approximately 21 hours after the allegation was made). This deficient practice resulted in Resident 2 being unmonitored for 21 hours after Resident 1 alleged sexual abuse against Resident 2. This deficient practice placed Resident 1 at risk for continued sexual abuse by Resident 2.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had a diagnosis of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 3/9/2026, the MDS indicated Resident 1's cognition was moderately impaired, and she required set up or clean up assistance (helper sets up or cleans up) to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Post Event Assessment form dated 5/22/2026, the Post Event Assessment form indicated on 5/20/2026, Resident 1 reported a male peer (Resident 2) touched her on the buttocks with his hand without her consent. The Post Event Assessment form indicated a recommendation to increase monitoring of Resident 1 and Resident 2 for safety and further observation. During a review of Resident 1's 24 Hour Observation Checklist/Contact Log, the 24 Hour Observation Checklist/Contact Log indicated Resident 1 was monitored every 15 minutes beginning 5/20/2026 at 1:15 p.m. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 had a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was intact and he was able to independently complete his ADLs. During a review of Resident 2's 24 Hour Observation Checklist/Contact Log, the 24 Hour Observation Checklist/Contact Log indicated Resident 2 was monitored every 15 minutes beginning 5/20/2026 at 1:30 p.m. During an interview on 6/12/2026 at 12:06 p.m., a Registered Nurse (RN) stated nursing staff were not made aware of Resident 1's allegation against Resident 2 that occurred on 5/19/2026 until 5/20/2026. The RN stated nursing should have been made aware when the allegation of sexual abuse was made on 5/19/2026 so they could have begun monitoring both Residents immediately that day (5/19/2026). The delay in monitoring Resident 1 and 2 placed Resident 1 at risk for continued sexual abuse by Resident 2. During a review of the facility's Policy and Procedure (P/P) titled Abuse Prevention and Reporting revised on 6/28/2025, the P/P indicated while the investigation is being conducted, the accused individual not employed by the facility will be denied unsupervised access to the resident. The Administrator/Designee will take all measures to protect the resident from further potential abuse.

Based on interview, and record review, the facility failed to report an allegation of sexual abuse for one of four sampled residents (Resident 1) when Resident 1 reported to Social Worker ( SW ) 2 that Resident 2 touched her buttocks. This deficient practice resulted in the California Department of Public Health (CDPH) being unaware of the allegation of sexual abuse and had the potential to affect the CDPH's ability to conduct a timely investigation.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had a diagnosis of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 3/9/2026, the MDS indicated Resident 1's cognition was moderately impaired, and she required set up or clean up assistance (helper sets up or cleans up) to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Social Service Progress note dated 5/20/2026 and timed at 11:41 a.m., the Social Service Progress note indicated Resident 1 reported to the Rehabilitation Therapist (RT ) that Resident 2 grabbed her (Resident 1) four times on the buttocks on 5/19/2026 around 4:29 p.m. During a review of the facility's email communication, the email communication indicated the facility sent the report of suspected dependent adult abuse to the CDPH on 5/21/2026 at 4:16 p.m. (approximately 16 hours after the facility was made aware of the allegation of sexual abuse). During an interview on 6/12/2026 at 2:38 p.m., the Administrator (ADM) stated an allegation of abuse should be reported to the CDPH and as far as he knew, Resident 1's allegation of sexual abuse was reported to the CDPH but stated he did not confirm with their Social Worker (SW) if or when he report was made. During a review of the facility's Policy and Procedure (P/P) titled Abuse Prevention and Reporting revised 6/28/2025, the P/P indicated the facility must report all alleged violations immediately but not later than two hours after forming the suspicion with written report within 24 hours.

Based on interview and record review, the facility failed to ensure an informed consent (a document ensuring the resident was educated of the risks and benefits of the treatment and agreed or disagreed to continue with the treatment) was obtained for one of one resident's (Resident 3) Zyprexa (olanzapine - a medication used to treat mental health conditions such as schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]) prior to administration on 5/18/2026.This deficient practice resulted in Resident 3 receiving Zyprexa without being informed of the medications purpose, risks, benefits, and potential side effects.Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 6/20/2022 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), extrapyramidal and movement disorder (movement disorders that regulate unconscious, reflective, posture-related motor control), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 3's psychiatric (medical specialty in treating mental illness) progress notes dated 4/6/2026, the psychiatric progress notes indicated Resident 3 was alert and oriented to person, place, and situation with mild confusion. The psychiatric progress notes indicated Resident 3's insight and judgement were impaired due to ongoing psychotic (a mental condition where a person has trouble telling what is real from what is not) symptoms.During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 3/26/2026, the MDS indicated Resident 3 had moderate impairment of the ability to think or make decisions. The MDS indicated Resident 3 needed staff supervision with personal hygiene, setup assistance with showering, and was independent with eating, oral and toileting hygiene, upper and lower body dressing, and putting on or taking off footwear.During a review of Resident 3's Post Event Assessment Form Part 1 (COC - change of condition) dated 5/18/2026, the COC indicated Resident 3 was observed banging and punching the entrance double door and displaying physical aggression attempting to hit staff during redirection. The COC indicated olanzapine 10 mg (milligrams - metric unit of measurement, used for medication dosage and/or amount) with Benadryl (diphenhydramine hydrochloride) 50 mg intramuscular was administered.During a review of Resident 3's Order Review Report dated 5/21/2026, the Order Review Report indicated a physician's order for Olanzapine (Zyprexa) Intramuscular Solution Reconstituted 10 mg Inject 10 mg intramuscularly (in the muscle) every 8 hours as needed for banging on doors and severe agitation for 14 days give with Benadryl, give if refuse PO (oral) as needed, not to exceed three doses in 24 hours and diphenhydramine hydrochloride (Benadryl) injection solution 50 mg /ml (milliliters - a metric unit of volume used to measure small amounts of liquid) inject 1 ml intramuscularly every eight hours as needed for banging on doors and severe agitation for 14 days give with Zyprexa, give if refuse oral as needed, not to exceed three doses in 24 hours started on 5/5/2026.During a review of Resident 3's Medication Administration Record (MAR) for 5/2026, the MAR indicated Resident received a dose of Zyprexa and Benadryl on 5/18/2026.During an interview on 5/19/2026 at 10:30 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated during the incident on 5/18/2026, she observed Resident 3 banging on the double doors located near the entrance of the facility. LVN 1 stated Resident 3 had an order for Zyprexa and Benadryl and administered the medications as prescribed for the indication of banging on doors. LVN 1 stated prior to the administration of Zyprexa on 5/18/2026 she did not get a chance to verify if Resident 3 had an informed consent for Zyprexa. LVN 1 stated informed consents for psychotropic medications (medications affecting the central nervous system to treat psychiatric disorders or illnesses) should be obtained upon receiving the physicians order or prior to administration of the first dose.During a concurrent interview and record review on 5/19/2026 at 4:53 p.m., with the Assistant Director of Nursing (ADON), Resident 3's informed consents were reviewed. The ADON stated there was no evidence facility staff obtained an informed consent document for the Zyprexa that was ordered on 5/5/2026. The ADON stated informed consents should be obtained upon receiving the physician's order or prior to administration of the first dose. The ADON stated prior to administration of psychotropic medications, staff should verify if informed consent was obtained. The ADON stated the importance of an informed consent was to ensure the resident or the conservator (a court-appointed individual or organization legally authorized to manage the financial or personal affairs of a person deemed incapacitated) was informed about the medication's purpose, risks, benefits, and potential side effects. The ADON stated if an informed consent was not presented to the resident or the conservator, there would be a potential for Resident 3 to receive medications without knowledge of the purpose, effect, potential side effects, risks or benefits.During a review of the facility's policy and procedures (P&P) titled Informed Consent for Psychoactive Medication dated 4/21/2026, the P&P indicated .Every person served received information from the prescriber regarding psychoactive medications prescribed for them. The prescriber completes, signs and documents in their notes that informed consent was obtained by the adult voluntary person served and/or legal guardian. Adult involuntary and all persons served.must provide a signature on the form.

Based on interview and record review, the facility failed to ensure one of one resident's (Resident 3) administration of Zyprexa (olanzapine - a medication used to treat mental health conditions such as schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]) and Benadryl (diphenhydramine - a medicine given to treat or prevent side effects caused by antipsychotics medications) was documented upon administration on 5/5/2026.This failure had the potential to result in inaccurate medication records, uncertainty regarding whether Resident 3 received Zyprexa and Benadryl as ordered by the physician, unmonitored medication effectiveness and adverse effects, and medication errors.Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 6/20/2022 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) , extrapyramidal and movement disorder (movement disorders that regulate unconscious, reflective, posture-related motor control), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 3's psychiatric (medical specialty in treating mental illness) progress notes dated 4/6/2026, the psychiatric progress notes indicated Resident 3 was alert and oriented to person, place, and situation with mild confusion. The psychiatric progress notes indicated Resident 3's insight and judgement were impaired due to ongoing psychotic (a mental condition where a person has trouble telling what is real from what is not) symptoms.During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 3/26/2026, the MDS indicated Resident 3 had moderate impairment of ability to think or make decisions. The MDS indicated Resident 3 needed staff supervision with personal hygiene, setup assistance with showering, and was independent with eating, oral and toileting hygiene, upper and lower body dressing, and putting on or taking off footwear.During a review of Resident 3's progress notes dated 5/5/2026, the progress note indicated Resident 3 was observed banging and kicking on the door near room [ROOM NUMBER]. The progress notes indicated staff attempted verbal redirection, but Resident 3 became physically aggressive and attempted to strike and push staff members. The progress notes indicated the physician was notified of Resident 3's physical aggression and lack of response to redirection. The progress notes indicated as needed orders for Zyprexa and Benadryl were received, noted, and administered. During a review of Resident 3's Order Review Report dated 5/21/2026, the Order Review Report indicated a physician's order for Olanzapine (Zyprexa) Intramuscular Solution Reconstituted 10 mg Inject 10 mg intramuscularly (in the muscle) every 8 hours as needed for banging on doors and severe agitation for 14 days give with Benadryl, give if refuse PO (oral) as needed, not to exceed three doses in 24 hours and diphenhydramine hydrochloride (Benadryl) injection solution 50 mg /ml (milliliters - a metric unit of volume used to measure small amounts of liquid) inject 1 ml intramuscularly every eight hours as needed for banging on doors and severe agitation for 14 days give with Zyprexa, give if refuse oral as needed, not to exceed three doses in 24 hours started on 5/5/2026.During a review of Resident 3's Medication Administration Record (MAR) for 5/2026, the MAR did not indicate Resident 3 received a dose of Zyprexa and Benadryl on 5/5/2026.During an interview on 5/20/2026 at 7:32 a.m., with Registered Nurse Supervisor (RNS) 3, RNS 3 stated, on 5/5/2026 between 1:00 a.m. and 2:00 a.m. Resident 3 displayed episodes of banging on a door near room [ROOM NUMBER] and Resident 3 was not redirectable. RNS 3 stated she informed the physician and received orders for Zyprexa and Benadryl and administered intramuscular dose to Resident 3. RNS 3 stated she did not obtain the medications from the emergency kit because Resident 3 had previous medications in the medication cart. RNS 3 stated she documented Resident 3's received the Zyprexa and Benadryl in her progress notes on 5/5/2026.During a concurrent interview and record review on 5/20/2026 at 4:18 p.m., with the Assistant Director of Nursing (ADON), Resident 3's progress notes and MAR dated 5/5/2026 and station 1 facility emergency box log (e-kit logbook) were reviewed. The ADON stated Resident 3's progress notes dated 5/5/2026 indicated Resident 3 was prescribed and received Zyprexa and Benadryl on 5/5/2026 at 1:28 a.m. The ADON stated staff did not document on Resident 3's MAR dated 5/5/2026 Resident 3 received Zyprexa and Benadryl on 5/5/2026. The ADON stated the staff did not document on the e-kit logbook a dose of Zyprexa and Benadryl was taken from the emergency kit on 5/5/2026. The ADON stated the importance of documenting a medication administration was to ensure there was a record of medication given to Resident 3 to avoid medication errors. The ADON stated there would be potential for Resident 3 to receive another dose shortly after the undocumented dose was given and potentially would be over medicated.During a review of the facility's policy and procedure (P&P) titled As Needed Medication PRN - Administration dated 8/8/2025, indicated Procedure: .3. PRN medications are initialed electronically or in the appropriate place on the paper MAR immediately following administration.

Based on interview and record review, the facility failed to protect the residents right to be free from physical abuse for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN)1 redirected Resident 1 and Resident 2 away from each other after she observed Resident 1 placing her hand on Resident 2's back. 2. Ensure facility staff provided immediate 1:1 supervision for Resident 1 after an altercation with Resident 2. These failures resulted in Resident 2 being assaulted by Resident 1 on 4/22/2026 and a second allegation of physical abuse on 4/22/2026, when Resident 3 alleged Resident 1 punched her in the face and nose. These failures had the potential to place other residents who resided in the facility at risk for abuse. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1 had diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (extreme worry) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 1's the Minimum Data Set ([MDS] a resident assessment tool), dated 1/23/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired and was dependent (helper does all the effort, resident does none of the effort to complete the activity) on staff for toilet hygiene, showering, lower body dressing, and putting on and taking off footwear. The MDS indicated Resident 1 had delusions (unshakable beliefs in something that is untrue). During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE]. Resident 2 had diagnoses including schizophrenia, anxiety and major depressive disorder. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was moderately impaired). During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was initially admitted to the facility on [DATE]. Resident 2 had diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood and behavior), cataracts (cloudy area in the lens of the eye that blocks light, causing blurry or dim vision) and blepharochalasis (a disorder characterized by recurrent, painless, swelling of the upper eyelids, leading to thin, wrinkled, paper-like skin and stretched, saggy tissues). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognition was intact. During a review of the facility's Summary Investigative Report, dated 4/28/2026, the Summary Investigative Report indicated on 4/22/2026 LVN 1 witnessed Resident 1 push Resident 2 out of her wheelchair, unprovoked. The Summary Investigative Report indicated LVN 1 witnessed the incident in the safety mirror (specialized, reflective surfaces designed to increase visibility, enhance surveillance, and prevent accidents or theft by eliminating blind spots).During a review of the facility's Summary Investigative Report, dated 4/28/2026, the Summary Investigative Report indicated on 4/22/2026 the Clinical Director (CD) and Social Worker (SW) were made aware by Resident 3 that she (Resident 3) was hit in the face by her roommate, Resident 1. The Summary Investigative Report indicated the incident occurred moments after Resident 1 was interviewed for the previous interaction with Resident 2 as CD and SW were standing outside Resident 1 and Resident 3's shared room. During an interview on 4/24/2026 at 2:30 p.m., Resident 3 stated that Resident 1 hit her in the face and in the nose. Resident 3 stated Resident 1 pulled open the curtain between their beds and reached out to punch her. During a telephone interview on 4/28/2026 at 10:40 a.m., LVN 1 stated she was sitting at the nurses' station when she heard a loud verbal exchange between Resident 1 and Resident 2. LVN 1 stated she looked in the security mirror and saw Resident 1 standing near Resident 2, who was sitting in a wheelchair. LVN 1 saw Resident 1 place her hand on Resident 2's back and then push Resident 2 out of the wheelchair and onto the floor. LVN 1 stated she could not reach the residents in time to redirect them because the incident happened too quickly and she was not within arm's reach of the residents and was not in their line of sight to get their attention. LVN 1 stated she did not recall seeing other staff nearby who could have redirected the residents or deescalated the situation. LVN 1 stated Resident 1 had unpredictable, impulsive behaviors and had been newly readmitted on [DATE]. She stated the most effective way to prevent resident to resident altercations was close monitoring and redirecting residents when they were too close to each other or when their behaviors escalated.During an interview on 4/28/2026 at 2:39 p.m., the CD stated on 4/22/2026 at approximately 3:30 p.m., the SW notified her that Resident 1 pushed Resident 2 out of her wheelchair and onto the floor. The CD stated she, LVN 1, and the SW interviewed Resident 1 in her room. Resident 1 stated, through a phone translator, that she pushed Resident 2 because she was angry. The CD stated she observed Resident 1 responding to internal stimuli and appearing agitated during the interview. Resident 1 admitted she was hearing voices at that time. The CD stated that after the interview, she, LVN 1, and the SW stepped out of the room to discuss next steps, leaving Resident 1 unsupervised with her roommate, Resident 3. The CD stated she was standing outside the room when she heard Resident 3 yell that Resident 1 hit her. She stated she saw Resident 1 backing into the hallway with her fists clenched, followed by Resident 3, who reported that Resident 1 hit her. The CD stated staff placed Resident 1 on 1:1 supervision after this alleged incident. She acknowledged they had not implemented immediate supervision earlier because, although they separated Resident 1 from Resident 2, they did not consider the risk of an altercation with Resident 3. During an interview on 4/28/2026 at 4 p.m., the Administrator (ADM) stated the facility was responsible for ensuring all residents were free from abuse and for implementing safeguards to prevent it. The ADM stated he could not confirm that a zone monitor was present in the area where Resident 1 and Resident 2 had their altercation and explained that the facility assigned one staff member to serve as the zone monitor, responsible for patrolling the building, redirecting residents, and tracking their whereabouts. The ADM stated it was impossible for the zone monitor to be present to redirect all residents with escalating behaviors because the facility allotted only one staff member for that role and the facility had always used one zone monitor and had not previously experienced issues. The ADM stated one staff member in that role was sufficient to maintain resident safety and the facility installed security mirrors to enhance resident monitoring for all staff. The ADM acknowledged that in order to redirect residents to safety, a staff member should be physically close enough to the residents or residents to effectively prevent an altercation.During a review of the facility's undated Policy and Procedure (P&P) titled, Zone Management Policy, the P/P indicated zone management system places priority on visual supervision and antecedent management in order to minimize the likelihood for intrusive, aggressive or risky behaviors in the facility. Zone monitoring responsibilities for enhancing safety in the environment may include but are not limited to the following: observe behaviors of clients in the milieu, monitor and reduce noise and crowding, redirect high risk residents from one another, intervene when clients start to have a verbal altercation and alert charge nurse to assess the need for as needed medication. During a review of the facility's P&P titled, Residents' Rights, dated 4/30/2025, the P&P indicated residents rights include the resident's right to be free from abuse, neglect, misappropriation of property and exploitation.During a review of the facility's P&P titled, Abuse Prevention and Reporting, dated 12/22/2025, the P&P indicated the facility is committed to protecting the physical and emotional well-being and personal possessions of every resident, the facility has systems, procedures and a program of employee training and supervision in place to foster dignified treatment, respect and compassion for residents.

Based on interview, and record review, the Facility failed to:develop and update a person-centered care plan for two of six sampled residents (Resident 1 and 6) by failing to:a. Develop or update the care plan upon readmission on [DATE] when Resident 1 exhibited aggressive behaviors.b. Develop a specific care plan addressing Resident 6's aggressive behaviors, including defined interventions for monitoring the aggressive behavior.This deficient practice had the potential to result in inadequate behavioral monitoring, interventions and compromise resident's safety.Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/25/2024 and readmitted on [DATE] with diagnoses including schizophrenia (a chronic, sever brain disorder that causes people to lose touch with reality disrupting how they think, feel, and behave), and bipolar disorder (a chronic mental health condition that causes extreme, intense shifts in mood, energy, and behavior, far beyond normal ups and downs). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 1/30/2026, the MDS indicated Resident 1's cognition (functions your brain uses to think, pay attention, process information, and remember things) was intact. The MDS indicated Resident 1 had no impairment on both upper and lower extremities During a review of Resident 1's progress notes, dated 2/6/2026 through 2/8/2026, the progress notes indicated following:On 2/6/2026 at 4:05 p.m., Resident 1 remained hyperverbal (talking more than usual, jumping from topic to topic) and exhibited aggressive behavior, including yelling and pulling down the privacy curtain.On 2/7/2026 at 10:40 a.m., Resident 1 refused to take oral medication this am when the medication was offered, Resident 1 threw the medication on the floor, refused Electro Cardio Gram (EKG a quick, safe, and painless test that records the heart's electrical activity).On 2/7/2026 at 1:20 p.m., Resident 1 was verbally abusive, irritable and loud to staff & peer, spitting at female peer (unidentified) on the patio.On 2/7/2026 7:15 p.m., Resident 1 has episodes of pacing around the hallway cursing at staff and other residents.On 2/8/2026 01:05 a.m., Resident 1 exhibited intermittent demanding behavior. During a review of Resident 1's Order Summary Report, dated 2/6/2026, the Order Summary Report indicated an order for safety precautions every 15 minutes (every 15-minutes patient safety check) for 48 hours related to re-admission. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 3/25/2025 with diagnoses including schizophrenia (a chronic, sever brain disorder that causes people to lose touch with reality disrupting how they think, feel, and behave), and convulsions (sudden, uncontrollable shaking or jerking of the muscles caused by abnormal electrical activity in the brain). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 required setup or clean-up assistance (helper assists only prior to or following the activity) with oral hygiene, showering, was independent with eating, toileting hygiene. During a review of Resident 2's Post Event Assessment Form, dated 2/8/2026, the form indicated certified nursing assistant (CNA) 2 witnessed an altercation between Resident 1 and 2 when Resident 1 grabbed Resident 2's wrists. During a concurrent interview and record review on 2/17/2026 at 3 p.m., with Registered Nurse (RN) 1, Resident 1's medical record was reviewed. RN 1 stated the facility readmitted Resident 1 on 2/6/2026 from the General Acute Care Hospital (GACH), and aggressive behavior was identified as one of the primary concerns upon readmission. RN 1 stated Resident 1's physician placed Resident 1 on monitoring every 15-minutes safety precautions to assess behavior. RN 1 stated no care plan was developed or updated to address Resident 1's increased aggressive behaviors upon readmission prior to the incident on 2/8/2026 involving Resident 2. RN 1 stated these behaviors included loud and verbally abusive conduct, demanding behavior, medication non-compliance, and making false accusations toward staff. RN 1 stated these behaviors of Resident 1 were more severe compared to previous admissions. RN 1 stated upon readmission, staff are required to develop or update the person-centered care plan for Resident 1. RN 1 stated the care plan serves as the foundation for the resident care and provides guidance to staff regarding the resident's needs, behaviors, and interventions. During a telephone interview on 2/18/2026 at 8:06 a.m., with CNA 2, CNA 2 stated Resident 1 had been exhibiting worsening behaviors, including verbal aggression and demanding behaviors toward staff. CNA 2 stated Resident 1's behaviors had escalated, particularly in the days prior to the altercation with Resident 2 on 2/8/2026. During an interview on 2/19/2026 at 12:30 p.m., with RN 3, RN 3 stated person-centered care plans must be developed upon readmission, the care plan should be individualized to address the resident's specific needs and goals. RN 3 stated the care plan provides guidance to staff in implementing appropriate interventions for the residents. b. During a review of Resident 6's admission Record, the admission Record indicated the Facility admitted Resident 6 on 8/23/2023 and readmitted on [DATE] with diagnoses including paranoid schizophrenia . During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognition was intact. The MDS indicated Resident 6 was independent with eating, oral hygiene, toileting hygiene, showering, dressing, and personal hygiene. During a review of Resident 6's psychiatric (medical specialty in mental illness and mental health) progress notes, dated 1/21/2026, the notes indicated Resident 6 remained oppositional (someone who often disagrees with or resists rules, instructions, or authority) , verbally confrontational in interactions with staff and at a moderate risk for aggressive behavior. During an interview on 2/18/2026 at 12:40 p.m., with the Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 4 is known to be combative, need to approach carefully due to safety concerns. During a concurrent interview and record review on 2/18/2026 at 2:45 p.m. with RN 4, Resident 4's medical record was reviewed. RN 4 stated Resident 4 has a history of aggressive and assaultive behaviors, which could result in physical harm to other residents, including neighboring residents. RN 4 stated there was no specific care plan developed or updated to address, monitor, or prevent the potential for future assaultive behaviors. During a concurrent interview and record review on 2/19/2026 at 8:41 a.m., with the MDS Coordinator (MDSC), the MDSC stated a specific care plan should have been developed to address Resident 6's aggressive behaviors, including measurable goals and clearly defined interventions. The MDCS stated the care plan should include specific monitoring parameters and direction for staff to notify the physician as needed. During an interview on 2/19/2026 at 12:30 a.m., with Registered Nursing (RN) 3, RN 3 stated licensed staff are responsible for updating and implementing the individualized person-centered care plan as needed to ensure the resident's needs are met. During a review of the facility's policy and procedure (P&P), titled Resident Treatment Care Plan/Baseline Care Plan Resident, Treatment/Baseline Care Plan - Long Term Problems (SNF), undated, the P&P indicated following:The comprehensive care plan is an individualized written care plan based upon an initial and continuing assessment of resident needs with input, as appropriate, from the health professionals involved in the care of the resident.1. The care plan indicates the care to be given, the goals to be accomplished, the interventionsto be used, and the professional discipline responsible for each element of care.2. The goal(s) will be measurable/achievable and resident-centered or resident specific.The initial assessment by a licensed nurse will commence at the time of admission, and a careplan will be initiated.All required assessments from all disciplines will be initiated within 24 hours.All care plan problems will be identified as Priority (P), Active (A) or I Information only (not care planned). Priority problems are defined as: Problems or conditions which are most intrusive or debilitating in the resident's life at that time and may include but are not limited to: Behavioral Problems.Interventions: Plans should be written as concretely and specifically as possible with a minimal chance for ambiguity and uncertainty in the implementation of the plan.

Based on observation and record review the facility failed to accurately and completely maintain the 24-hour observation checklist (every 15 minutes safety monitoring observation checklist) for four of five sampled residents as evidenced by the following: a. CNA 1 documented Resident 3, 5, and 7's 10:00 and 10:15 a.m. observations in advance of the scheduled times on 2/18/2026.b. CNA 1 documented Resident 4's 9:45 a.m. 10:00 a.m. observation without having observed the patient on 2/18/2026. This deficient practice resulted in inaccurate documentation and had the potential to compromise resident safety and the reliability of required monitoring and observation. Findings:During a concurrent interview and record review on 2/18/2026 at 9:55 a.m. with Certified Nurse Assistant (CNA) 1, Resident 3, 5 and 7's 24-hour observation checklists, dated 2/18/2026 were reviewed. The observation checklists indicated 10:00 a.m. and 10:15 a.m. observations for the residents had already been completed. CNA 1 stated she conducted rounds at approximately 9:45 a.m. and documented the 10:00 a.m. and 10:15 a.m. observations in advance of the scheduled times. CNA 1 acknowledged this was an error and documentation should only occur after directly observing residents at the scheduled times. During an interview and record review on 2/18/2026 at 10:05 a.m. with CNA 1, Resident 4's observation check list, dated 2/18/26 was reviewed. The observation check list indicated the 9:45 a.m. and 10:00 a.m. entries were left blank. CNA 1 stated she did not observe the resident at 9:45 a.m. and 10:00 a.m., therefore did not complete the documentation. During an interview and record review on 2/19/2026 at 10:21 a.m. with CNA 1, Resident 4's 24-hour observations checklist, dated 2/18/2026 was reviewed. CNA 1 stated she documented 9:45 a.m. and 10:00 a.m. observation for the previous day after seeing the resident at approximately 10:14 a.m. in the hallway. CNA 1 stated she attempted to locate the resident earlier but was unable to find him and did not notify other staff. CNA 1 stated she completed the 9:45 a.m. and 10:00 a.m. entries because she believed the form could not be left blank, despite not having conducted the required observations. During an interview on 2/19/2026 at 10:46 a.m. with the Director of Staff Development (DSD), The DSD stated staff must directly observe the resident before completing the 24-hour observation checklist. The DSD stated pre-charting, including documenting 15 minutes in advance, is not acceptable practice, staff may not predict or assume a resident's status without direct observation. The DSD stated if a patient cannot be located at the scheduled observation time, staff must actively search for the resident and communicate with the assigned nurse to determine the resident's whereabouts and attempt to lactate the resident. The DSD stated documenting an observation after missing the scheduled time without having observed the patient may be considered false charting. The DSD stated the 24-hour observation checklist is typically implemented for residents requiring special monitoring due to safety concerns, fall risk, behavioral issues, assaultive behaviors, or sexually inappropriate behaviors, close monitoring is necessary to prevent escalation and ensure the safety of the residents and others. During an interview on 2/19/2026 at 12:30 a.m. with Registered Nursing (RN) 3, RN 3 stated there is no such practice as pre-charting, documentation must be accurate and completed after direct observation. Pre-charting or charting in advance is considered inaccurate documentation and required correction. RN 3 stated real-time charting is necessary to ensure effective monitoring and timely intervention. Accurate documentation supports appropriate clinical response and patient safety. RN 3 stated staff must be physically present on the unit to directly observe the residents prior to documenting, lack of time is not an acceptable justification, and required observations and documentation must be prioritized. During a review of the facility's Policy and Procedure (P&P) titled, Levels of Observation, undated, the P&P indicatedObservation rounding documentation represents a snapshot in time of the activity and location of theclient at the time the rounding was performed.Every 15 minute (Q15):Risk assessment indicated that the person served level of risk can be observed and assessed every 15 minutes (Q15).Documentation is completed at 15 minutes to reflect rounding on a rounds sheet or electronic device During a review of the facility's P&P titled, General Documentation Guidelines, undated, the P&P indicated entries must be accurate, complete, descriptive, timely recorded within the required time period, promptly as events or observations occur, objectives ins to record facts and what is, do not assume., consistently following facility policy and standards of practice using eh same criteria when assessing or documenting. The P&P indicated legibility: do not document before an event occurs. Do not post-date.

Based on observation, interview and record review, the facility failed to protect the residents' right to be free from physical abuse for two of four sampled residents (Resident 3 and Resident 1). The facility failed to:1.Ensure Resident 4 did not push down Resident 3 who was trying to get up from the couch, held Resident 3's arm down and Resident 3 did not hold onto Resident 4's arm and kicked in an attempt to get up on 12/29/2025 at 5:30 p.m. during group activity in the living room.2. Ensure staff followed Resident 4's Care Plan titled, Resident 4 had been demonstrating psychotic behavior (actions or behaviors that reflect a disconnection from reality), verbally aggressive, intrusiveness (disruptive or interfering in someone's personal space), fixation on selective staff ( attachment or preference toward certain staff) and inappropriate behavior toward others date created 8/11/2025, by intervening before agitation escalates, guide Resident 4 away from the source of distress, and engage in a calm conversation. 3. The Rehabilitation Activity Leader (RAL) did not leave Resident 4 and Resident 3 alone in the living room while they were having an altercation.These failures resulted in Resident 4 pushing down Resident 3 who was trying to get up from the couch, held Resident 3's arm down and Resident 3 did not hold onto Resident 4's arm and kicked in an attempt to get up on 12/29/2025 at 5:30 p.m. during group activity in the living room. 4.Ensure Resident 2 did not grab Resident 1's breast and hit her in in the face on 12/14/2025 approximately 1:30 p.m.This failure resulted in Resident 1 sustaining a four-centimeter (cm-unit of measurement) scratch to her left side of the face. Findings:1.During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] with diagnoses of but not limited to schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), cerebral ischemia (insufficient blood flow to the brain), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 3's Minimum Data set (MDS-a resident assessment tool), dated 11/25/2025, the MDS indicated Resident 3 had the ability to express ideas and wants. The MDS indicated Resident 3 had the ability to understand others and verbal content. The MDS indicated Resident 3 required supervision or touching assistance when transferring to the shower. The MDS indicated Resident 3 required setup or clean-up assistance from nursing staff with showering, eating and personal hygiene. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses of but not limited to schizophrenia ( a mental disorder that is characterized by disturbances in thought) , major depressive disorder, insomnia (difficulty sleeping), and anxiety (emotion characterized by feelings of tension, worried thoughts). During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had the ability to express ideas and wants . The MDS indicated Resident 4 had the ability to understand others and verbal content. The MDS indicated Resident 4 required setup or clean-up assistance from nursing staff with eating, showering and personal hygiene. During a review of Resident 4's Care Plan titled Resident 4 had been demonstrating psychotic behavior, verbally aggressive, intrusiveness, fixation on selective staff and inappropriate behavior toward others date created 8/11/2025, the Care Plan goals indicated Resident 4 will successfully be redirected as evidence by agreeing to engage in deescalation techniques to minimized episodes of aggression and inappropriate behaviors. The Care Plan interventions indicated when Resident 4 becomes agitated staff will intervene before agitation escalates, guide Resident 4 away from the source of distress, and engage in a calm conversation. During a review of Resident 4's Post-Event Assessment Form dated 12/29/2025, it was noted at approximately 5:30 p.m., Residents 3 and 4 were seated next to each other in the living room. Resident 3 blew his nose, prompting Resident 4 to express discomfort, stating, Why did you blow your nose here in front of me? Resident 3, who primarily communicates in a language other than English, responded in his native language. The Post-Event Assessment Form indicated Resident 4 stood up to leave, and Resident 3 also began to rise from his seat. Resident 4 then made physical contact with Resident 3, guiding him back onto the couch while verbally instructing him to stop. Resident 4 continued to hold Resident 3 down briefly, stating, Stop, stop. I can't let you go if you keep trying to kick or hit me. Staff immediately initiated Code [NAME] and intervened to separate both residents. During a review of Resident 4's Medication Administration Record (MAR), dated 12/2025, the MAR indicated on 12/29/2025 3 p.m. to 11 p.m. shift, Resident 4 had anxiety (feeling of fear, worry, or unease) manifested by (m/b) irritability, depressed mood (feeling of sadness, emptiness, or hopelessness) m/b verbal aggression (use of words or language to threaten, insult, humiliate), labile mood (state in which a person's emotional expression changes rapidly and unpredictably), and paranoid delusions (type of false, fixed belief characterized by irrational suspicion or mistrust of others). During an interview on 12/30/2025 at 2:32 p.m., with Resident 4, Resident 4 stated Resident 3 attacked him. Resident 4 stated he believed Resident 3 had a weapon in his bag, so when Resident 3 attempted to get up, he pushed Resident 3 back down onto the couch until staff arrived and separated them. During an interview on 12/31/2025 at 12:31 p.m. with the Rehabilitation Activity leader (RAL), the RAL stated on 12/29/2025 at 5:30 p.m., Resident 4 was seated on the couch in the living room when Resident 3 sat down next to him and blew his nose. The RAL reported that Resident 4 said, Why did you blow your nose in my face? Resident 3 then responded in his own language. The RAL stated she approached the residents and explained to Resident 4 that Resident 3 was simply blowing his nose. Resident 4 then stood up, and when Resident 3 attempted to stand, Resident 4 pushed him back down onto the couch. Resident 3 became upset, and both residents began pushing and shoving each other. The RAL stated she left to get help and called a Code [NAME] (response to a combative/violent resident) The RAL stated she observed Resident 4 holding onto Resident 3's arm while the Director of Nursing (DON) and Rehabilitation Therapist (RHT) 1 repeatedly instructed Resident 4 to let go. She stated Resident 3 eventually stood up, and Resident 4 walked out of the room to the dining area while Resident 3 remained in the group room. The RAL stated she asked Resident 3 how he was feeling, and he replied that he was okay. The RAL stated the group meeting was then closed, and both residents were placed on 15-minute monitoring. During an interview on 12/31/2025 at 1:00 p.m. with the RHT 1, the RHT 1 stated he heard yelling and commotion coming from the living room. RHT 1 stated when he arrived, he observed the RAL attempting to separate Resident 4 and Resident 3. RHT 1 stated Resident 4 was standing over Resident 3, who was seated on the couch. RHT 1 stated Resident 4 stood up, and when Resident 3 attempted to stand, Resident 4 struck Resident 3 on the head. Both residents then began hitting each other. Resident 4 held Resident 3's arms down while Resident 3 held onto Resident 4's arms and kicked in an attempt to get up. Resident 4 stated he did not want to release Resident 3's arms because he believed Resident 3 would kick or hit him if he did. Staff instructed both residents to let go of each other. Resident 4 released Resident 3's arms first, followed by Resident 3 releasing Resident 4's arms. RHT 1 stated he then escorted Resident 4 to his room, and a Code [NAME] was called. RHT 1 added that Resident 4 has a history of becoming aggressive toward other residents by yelling and threatening to hit them. During an interview on 12/31/2025 at 1:19 p.m. with the DON, the DON stated this incident between Resident 4 and Resident 3 was abuse as Resident 4 pushed down Resident 3 and Resident 3 was hitting Resident 4. 4. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of but not limited to schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), insomnia (trouble falling asleep or staying asleep) and cervicalgia (pain in the neck). During a review of Resident 1 Minimum Data Set (MDS-a resident assessment tool), dated 11/5/2025, the MDS indicated Resident 1 was able to make herself understood, had the ability to express ideas, wants and understands verbal content. The MDS indicated Resident 1 required partial to moderate assistance with showering. The MDS indicated Resident 1 required setup or clean up assistance with eating, oral hygiene and upper body dressing. The MDS indicated Resident 1 required supervision or touching assistance personal hygiene and lower body dressing. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] with diagnoses of but not limited to schizoaffective disorder, and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was able to make herself understood and had the ability to express ideas, wants and understand verbal content. The MDS indicated Resident 2 required staff supervision or touching assistance with transferring to the shower. The MDS indicated Resident 2 required setup or clean up assistance with eating, oral hygiene, showering and personal hygiene. During a review of Resident 1's Care Plan, dated 12/14/2025, the Care Plan indicated Resident 1 was scratched on the face by a female peer. Interventions indicated nursing staff will make sure that there is no encounter with female peer who scratched Resident 1's face. During a review of Resident 1's Post-Event Assessment Form dated 12/14/2025, the Post-Event Assessment Form indicated at approximately 1:40 p.m., in Resident 1's room, CNA 1 observed a scratch mark on the left side of Resident 1's face. Upon further assessment and investigation, Resident 1 stated that her roommate (Resident 2) caused the injury. Resident 2 admitted to the action, stating, She stole my breast; she does not want to give it back to me. The Nurse Practitioner was notified, along with the conservator, and Resident 2 was placed on safety observation every 15 minutes. During an interview on 12/30/2025 at 2:28 p.m. with Resident 1, Resident 1 stated Resident 2 hit her with her hand and fist multiple times in the face on 12/14/2025 (unknown time). Resident 1 stated she did not know why Resident 2 hit her and this was the first time this had ever happened. During an interview on 12/30/2025 at 2:43 pm with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 12/14/2025 at approximately 1:30 p.m. in the shared room of Resident 1 and Resident 2, she observed Resident 1 with a scratch on the left side of her face and blood on her gown. CNA 1 stated Resident 1 stated Resident 2 had grabbed her breast and hit her in the face. CNA 1 stated Resident 2 claimed Resident 1 stole her breast. CNA 1 immediately reported the incident to Registered Nurse Supervisor (RNS) 1.During an interview on 12/30/2025 at 2:48 with Registered Nurse Supervisor (RNS 1), RNS 1 stated CNA 1 reported Resident 1 had a scratch on her face. RNS 1 stated Resident 1 said Resident 2 scratched her, and Resident 2 admitted hitting Resident 1 because she believed Resident 1 stole her breast. RNS 1 reported that she immediately notified the Director of Nursing (DON), the physician, and the conservator, and transferred Resident 2 to another room. RNS 1 stated the residents were roommates and this was the first time they had an altercation. RNS 1 stated Resident 1 sustained a four cm scratch on her left cheek.During a review of the facility's policy and procedure (P&P), titled Abuse Prevention and Reporting, undated, the P&P indicated, The facility is committed to protecting the physical and emotional well-being and personal possessions of every resident.Any form of mistreatment of residents including but not limited to abuse, neglect, exploitation, involuntary seclusion, misappropriation of property or any crime are strictly prohibited.All allegations as mentioned shall be investigated. Reports will be made in a timely manner based on State statutes.

Based on observation, interview and record review, the facility failed to ensure the resident did not sustain unplanned severe weight loss (a weight loss greater than 5 % in one month, greater that 7.5% in three months and greater than 10 % in 6 months) of 37 pounds ([lbs. unit of measurement] 24 percent [%] in five months for one of three sampled residents (Resident 8). The facility failed to: 1. Ensure Resident 8 weigh was taken from 5/2025 through 8/2025 as ordered by the physician to identify the resident's significant weight loss in accordance with the facility's policy and procedure (P&P) titled, Notification of Physician/Prescriber, dated 10/20/2025 which indicated It is the policy of the facility to obtain height and weight upon admission and to continue to monitor the weight of persons served as required based on prescriber order or nursing clinical judgment in order to help identify metabolic complications (health problems that arise from the body's inability to properly process and regulates substances) or disorders. 2. Monitor, and report Resident 8's repeated meal refusals to the physician and Registered Dietitian (RD). 3. Notify the physician of Resident 8's refusal to eat 50 times from 6/23/2025 through 8/31/2025 and 29 times from 9/1/2025 through 9/11/2025 in accordance with the facility's P&P titled, Notification of Physician/Prescriber, dated 7/16/2025, which indicated . the licensed nurse is responsible to inform the physician or other prescriber responsible for the medical or psychiatric care of the person served of any changes in the person served emotional, behavioral, physical condition, and/or involvement in adverse events. 4. Ensure licensed nurses informed the RD of Resident 8's poor meal intake to ensure monthly monitoring and timely nutritional recommendations. These deficient practices resulted in Resident 8's 37-pounds weight loss over a five-month period (5/2025 through 9/2025) contributing to Resident 8's transfer to a General Acute Care Hospital (GACH) on 9/11/2025, and placing Resident 8 at risk for malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things), dehydration (dangerous loss of body fluid caused by illness, sweating, or inadequate intake), and skin break down. Findings:During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, (a mental illness that can affect thoughts, mood, and behavior) major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), constipation (difficulty in emptying the bowels) and gastro-esophageal reflux disease (GERD- a chronic condition where stomach acid and other contents frequently flows back into the esophagus). During a review of Resident 8's Physician's Order Summary, dated 10/15/2024, the Physician's Order Summary indicated to weight resident's monthly. During a review of Resident 8's Weights and Vitals Summary dated 4/26/2025, the Weight and Vital Summary indicated on 4/26/2025 Resident 8 weighed 154.6 lbs. Resident 8's Weights and Vitals Summary indicated there was no weight recorded from 5/2025 through 8/2025, a total of four months During a review of Resident 8's Registered Dietician Nutrition Screening, dated 6/27/2025, the Registered Dietician Nutrition Screening indicated that Resident 8 mostly ate snacks throughout the day as well as consumed Ensure (nutritional supplement) twice a day. Registered Dietician Nutrition Screening indicated the RD documented Unclear if weight has been stable as Resident 8 has continually refused to get weighed. The Registered Dietician Nutritional Screening indicated the goal for Resident 8 was to maintain stable weight of 155 lbs. with no significant changes through next assessment 9/2025. Registered Dietician Nutrition Screening form indicated the nutrition interventions included to Monitor/evaluate oral intake, monitor/evaluate monthly weight trends, and continue to provide Ensure twice a day to supplement food intake. The Registered Dietician Nutrition Screening form indicated Resident 8's daily caloric needs were 1620 kilo calorie (kcal-a unit of energy used in nutrition) per day. Registered Dietician Nutrition Screening indicated Resident 8's usual body weight ( the weight that an individual typically maintains over time) was 147 to 157 lbs. During a review of Resident 8's Meal intake record from 6/23/2025 through 8/31/2025, the Meal Intake record indicated Resident 8 refused meals including breakfast, lunch and dinner 50 times. During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool) dated 7/1/2025, the MDS indicated Resident 8's height was 64 inches (unit of measurement) and weighs 155 lbs. The MDS indicated that Resident 8 did not experience a weight loss of 5% or more in the past month, nor a weight loss of 10% or more in the past six months. During a review of Resident 8's Documentation Survey Report (Meal Intake) from 9/1/2025 to 9/11/2025, the Documentation Survey Report indicated Resident 8 refused all daily meals except on 9/2/2025. On September 2, 2025, Resident 8 consumed 100% of the dinner meal only. During a review of Resident 8's Meal Intake record for the period of 9/4/2025 through 9/11/2025, the Meal Intake record indicated Resident 8 refused all meals each day. During a review of Resident 8's Progress Notes, dated 9/7/2025, the Progress Notes indicated Resident 8 refused to go to the dining room for dinner, and did not eat when tray was brought to Resident 8's room on 9/7/2025. During a review of Resident 8's Progress Notes, dated 9/10/2025, the Progress Notes indicated Resident 8 was refusing breakfast, lunch, and dinner. During a review of Resident 8's Progress Notes, dated 9/11/2025 timed at 10:00 a.m., the Progress Notes indicated Resident 8 refused his meals for five days from 9/5/2025 to 9/10/2025. Resident 8 was noted to be disorganized (disrupted thinking, speech and behavior) , disheveled (untidy), isolated, argumentative and combative (ready or eager to fight). The Progress Notes indicated Resident 8 was sent to GACH on 9/11/2025 for further evaluation due to change in condition. Resident 8 returned to the facility on 9/17/2025. During a review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8 needed partial to moderate assistance from nursing staff with showering and dressing. The MDS indicated Resident 8 needed supervision or touching assistance from nursing staff with eating, oral hygiene, toileting and walking. The MDS indicated Resident 8 height was 64 inches and weighed 117 lbs. The MDS indicated Resident 8 loss 5 % or more in the last month or loss 10 % or more in last 6 months. During a review of Resident 8's Care Plan titled Risk for imbalanced nutrition less than body requirements related to diagnoses depression (mental health condition characterized by persistent feeling of sadness, loss of interest, and low energy), decreased appetite, skipping breakfast most of the time as evidenced by poor intake and weight loss dated 5/6/2025, the Care Plan goal indicated Resident 8 will be able to consume at least 75 % of meal intake and will have no significant weight loss. The Care Plan interventions included encouraging and assisting Resident 8 in going to the dining room during mealtimes, providing food substitutes when refusing to eat a full meal, weigh Resident 8 as ordered and notify Resident 8's medical doctor (MD) for any significant weight loss of 5% in a month and 10% in the last six months. During a review of Resident 8's Care Plan titled Decreased oral intake as evidenced by refusal of meals initiated on 9/10/2025, the Care Plan goals indicated Resident 8 will maintain stable weight and will consume at least 75 % of meals within one week. The Care Plan interventions indicated monitor weight weekly, consult dietician for high calorie, high protein diet or supplements, notify MD if poor intake persists for 72 hours or significant weight loss was noted. During a review of Resident 8's Weights and Vitals Summary, the Weight and Vital Summary dated 9/19/2025 indicated on 9/19/2025 Resident 8 weighed 117 pounds. During an interview on 10/21/2025 at 12:15 p.m., with the Registered Dietitian (RD), the RD stated that Resident 8 was in her room with nursing staff preparing for lunch. The RD reported that Resident 8's scheduled mealtime was 12:30 p.m. in the dining area and that Resident 8 required encouragement to attend meals in the dining room. During an observation on 10/21/2025 at 12:43 p.m., in Resident 8's room, Resident 8 was observed seated at the edge of her bed with her head down. No meal tray was present at the bedside. During an interview on 10/21/2025 at 12:49 p.m., Certified Nursing Assistant (CNA) 1 stated she was assigned to Resident 8's room and that all of Resident 8's roommates had already received and eaten their lunch. During an interview on 10/21/2025 at 12:54 p.m., in the dining room Registered Nurse Supervisor (RNS) 2 stated that Resident 8 had not yet eaten. During an interview on 10/21/2025 at 1:01 p.m., CNA 3 stated that around 12:00 p.m., while covering CNA 1, CNA 3 encouraged Resident 8 to eat in the dining room. CNA 3 stated Resident 8 refused but she did not report the refusal to the charge nurse or Registered Nurse Supervisor (RNS). CNA 3 stated that refusals should be reported shortly after meal rounds and that Resident 8 could experience weight loss if meals were not provided in a timely manner. During an interview on 10/21/2025 at 1:24 p.m., RNS 2 stated she delivered a meal tray to Resident 8 at 1:15 p.m. RNS 2 stated that if a resident refuses to eat in the dining room, the tray should be brought to the resident room, and the resident should be supervised during the meal. RNS 2 stated that delayed meals could lead to hunger, refusal to eat, and weight loss. During an interview on 10/23/2025 at 9:20 a.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated that Resident 8 required encouragement to attend meals, had poor intake, and a history of weight loss. LVN 5 stated that Resident 8's weight decreased from 154 lbs. on 4/26/2025 to 117 lbs. on 9/19/2025, a loss of 37 lbs. in five months. LVN 5 stated Resident 8 was sent to GACH on 9/11/2025 after refusing meals for six days from 9/5/2025 through 9/11/2025. LVN 5 stated Resident 8's weight loss was first identified when Resident 8 agreed to be weighed on 9/19/2025 after her return to the facility from the GACH on 9/17/2025. LVN 5 stated that Resident 8 weight was not monitored prior to 9/11/2025. During a concurrent interview and record review on 10/23/2025 at 10:29 a.m., with RNS 1, Resident 8's Point of Care (POC) Response History Meal Intake Percentage dated 9/2025 was reviewed, , the POC Response History Meal Intake Percentage indicated Resident 8 refused breakfast, lunch and dinner from 9/4/2025 to 9/11/ 2025. RNS 1 confirmed that Resident 8's weight loss was not identified until 9/19/2025, on the day the resident's weight was taken. RNS 1 stated Resident 8 was hospitalized from [DATE] to 9/17/2025 for not eating for five days. RNS 1 stated the RD assessed Resident 8 on 9/26/2025 upon Resident 8's return from GACH. RNS 1 stated it was unclear whether Resident 8 was refusing food or just refusing to go to the dining room prior to hospitalization on 9/11/2025. RNS 1 reported that Resident 8 had refused 29 meals from 9/1/2025 through 9/11/2025 prior to hospitalization on 9/11/2025. RNS 1 stated it was the facility's policy to notify Resident 8's MD or RD after two to three days of meal refusal. RNS 1 stated Resident 8's MD and RD were not notified of Resident 8's meals refusal because Resident 8 was consuming snacks consisting of half cheese sandwich and sherbet per physician order dated 3/13/2025. RNS 1 stated that inadequate caloric intake (the amount of energy [calories] consumed through food and beverages) could lead to the resident's malnutrition. During an interview on 10/23/2025 at 11:24 a.m. with the RD, the RD stated she was responsible for monitoring weights and provide recommendations for interventions to prevent weight loss, and to conduct quarterly and annual residents' nutritional assessments. RD stated she does not know when Resident 8 started to lose weight. RD stated she was not aware of Resident 8's weight loss until 9/22/2025. RD stated she was not aware Resident 8 refused meals 29 times from 9/1/2025 to 9/11/2025 before being hospitalized on [DATE]. RD stated Resident 8's weight loss could have been prevented with prompt nutritional interventions to prevent a decline in condition and nutrition. RD stated Resident 8 would have benefited from being monitored monthly and stated that the facility has no system to monitor weight loss. RD stated she should have monitored Resident 8's meal intake. During an interview on 10/24/2025 at 4:04 p.m., with the Director of Nursing (DON) stated that CNAs should report residents who refuse two meals to the charge nurse and offer alternatives. The DON stated it was important to identify weight loss early. The DON stated that snacks alone were insufficient to meet Resident 8 daily caloric needs of 1620 kcal per day (based on RD assessment on 6/26/2025). The DON stated that Resident 8 was not meeting nutritional requirements and was at risk for complications such as skin breakdown, weakness, and medication side effects. During a review of Resident 8's Physician's Orders Summary, dated 9/11/2025, the Physician's Order Summary indicated Resident 8 was transferred to the GACH for an evaluation of altered mental status. During a review of Resident 8's GACH records, dated 9/16/2025, the GACH records indicated, Resident 8 was assessed with failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), altered mental status, hypernatremia (the sodium concentration in the blood is abnormally high due to inadequate fluid intake), hypokalemia (the potassium level in the blood is lower than normal) and elevated creatinine kinase level (CK- an enzyme found in the muscles elevated levels indicate muscle damage). The GACH records indicated Resident 8 received potassium chloride (KCI) 20 milliequivalent (mEq- unit of measurement) one time plus a normal saline (NS- sodium chloride dissolved in one liter of water used to treat dehydration) 0.9% bolus (large dose of fluid administered over a short period to rapidly achieve a desired therapeutic concentration in the body) one liter one time. During a review of the facility's policy and procedures (P&P) titled, Resident Food Services,, revised on 1/2025, the P&P indicated The community will provide three meals daily at regular times comparable to standard mealtimes in the community or in accordance with resident needs, preferences, requests, and individualized plan of care. Meals are available so that no more than 14 hours elapses between the dinner/evening meal and the start time of the breakfast meal the following day except when a nourishing snack is served. During a review of the facility's P&P titled, Weight Variance Reporting and Committee dated 12/9/2024, the P&P indicated, It is the policy of the facility to review and monitor persons served with significant weight variance.When a Licensed Nurse identifies a significant weight change (5% or 5 lbs. or more in 30 days, 7.5% in 90 days, or 10% in 180 days) with a person's served monthly weight, he/she will notify the dietary supervisor and the interdisciplinary team (IDT). Licensed Nurse will include the individual on the list for weekly weight measurement. Licensed Nurse will check the individual to possibly determine contributory or causative factors. Physicians will be notified and consulted. Licensed Nurse will notify the responsible party of the weight change and new plan(s), if any. Licensed Nurse will initiate a or revise an existing care plan. The dietary supervisor will obtain Registered Dietitian consultation and initiate a weekly meeting with Interdisciplinary Team or Weight Variance Committee Team to follow through on the person's served weight and nutritional status. Within 7 (seven) working days after significant weight change is identified, IDT will conduct team analysis to identify causative/contributory factors (physical or psychosocial causes) and develop, update or revise the care plan. Interdisciplinary team or Weight Variance Committee Team may discontinue weekly weight monitoring until the weight is stable, or the desired outcome is achieved. During a review of the facility's P&P titled, Notification of Physician/Prescriber, dated 10/20/2025, the P&P indicated, It is the policy of the facility to obtain height and weight upon admission and to continue to monitor the weight of persons served as required based on prescriber order or nursing clinical judgment in order to help identify metabolic complications or disorders. During a review of the facility's P&P titled, Notification of Physician/Prescriber, dated 7/16/2025, the P&P indicated, .It is the policy of the facility to provide evidence-based best practices including that the licensed nurse is responsible to inform the physician or other prescriber responsible for the medical or psychiatric care of the person served of any changes in the person emotional, behavioral, physical condition, and/or involvement in adverse events. During a review of the facility's Clinical Dietician Job Description, dated 1/2029, the P&P indicated, Essential Functions and Responsibilities: Assesses the nutritional status of adult and/or geriatric patient/resident through documentation in the medical record. Uses parameters such as anthropometric (scientific study of measurements of the human body) measurements, nutrition-focused physical assessment and interpretation of laboratory values. Develops, revises and individualizes nutrition care plan based on information from the resident, medical record, family and health care team members.

Based on observation, interview, and record review, the facility failed to ensure proper food handling practices were followed. The facility failed to ensure that a dietary aide washed her hands and wore a hairnet before entering the food preparation area after coming from outside. This deficient practice had the potential to result in food contamination and increase the risk of foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) among residents.Findings: During a tray line (system of food preparation, used facility, in which trays move along an assembly line) observation on 10/22/2025 at 11:32 a.m., a Dietary Aide (DA) was observed standing in the kitchen food preparation area holding a cup with a straw in her hand. The DA was not wearing a hairnet at the time. When approached by the surveyor, the DA stated, I just walked in, and immediately proceeded to put on a hairnet and wash her hands.During an interview on 10/22/2025 at 3:41 p.m., DA stated that she was aware of the requirement to wear a hairnet and wash her hands before entering the kitchen. DA stated that she made a mistake by not following the protocol. DA stated that going forward, she will ensure she puts on her hairnet and washes her hands before beginning any tasks in the kitchen. During an interview on 10/22/2025 at 3:29 p.m., with the Director of Food Services (DFS), the DFS stated that all staff entering the kitchen were required to wear hairnets or hair coverings and must wash their hands before entering the food preparation area. The DFS stated that failure to follow proper hand hygiene can lead to food contamination. The DFS stated that staff have received both verbal and written in-service training on these procedures and will continue to receive ongoing education to reinforce compliance.During review of the facility's policy and procedures (P&P) titled, Uniform Dress Code revised on 01/25, the P&P indicated Wear the approved hair restraint when on duty regardless of length or presence of hair. Food service staff must wear hairnets when assembling a meal or snack.

Based on observation, interview and record review the facility failed to ensure three of seven sampled residents (Resident 41, Resident 55 and Resident 134) were treated with respect and dignity. The facility failed to 1.Provide a privacy curtain in Resident 55's room. 2. Close Resident 40 and 134 privacy curtains to protect residents' privacy during medication administration. These failures had the potential to result in feelings of decreased self-esteem and self-worth for Resident 41, Resident 55 and Resident 134.Findings:1.During a review of Resident 55's admission Record, the admission Record indicated the Resident 55 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder(a mental illness that can affect thoughts, mood, and behavior),bipolar type(sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), antisocial personality disorder(mental health condition characterized by a persistent pattern of disregard for social norms, laws and the rights of others), and diabetes mellitus,(DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 55's Minimum Data Set (MDS- a resident assessment tool) dated 7/17/2025, the MDS indicated Resident 55 had an intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 55 was independent (resident completes the activity by themselves without assistance from a helper) with oral hygiene, toileting hygiene, dressing, bed mobility and transfer from a bed to a chair.During a concurrent observation and interview on 10/21/2025 at 10:15 a.m. with Resident 55 in Resident 55 room, observed Resident 55 lying in bed, and no privacy curtain hanging in resident's room. Resident 55 stated he would like to have a curtain in his room so he can have privacy.During an interview on 10/23/2025, at 4:59 p.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated when she made rounds in the morning of 10/22/2025 Resident 55's privacy curtains were still present and did not know what happened to the curtains. CNA 6 stated it was important to have privacy curtains in a resident's room to ensure privacy. CNA 6 stated Resident 55 would feel bad if there was no privacy curtain because it was a resident right to have privacy.During an interview on 10/23/2025, at 10:26 a.m. with Housekeeping (HSK 1), HSK 1 stated she had to report to the Maintenance Department if a resident's room had no privacy curtains. HSK 1 stated any issues with privacy curtains and bathrooms should be reported to the Maintenance Department because the residents need to be safe and comfortable.During an interview on 10/23/2025 at 9:52 a.m. with the Housekeeping Supervisor (HS), the HS stated housekeeping staff should have informed the Maintenance Department to fix the privacy curtains. HS stated the staff could have informed HS of the missing privacy curtains in residents' rooms so they will be addressed.During an interview on 10/24/2025, at 12:21 p.m. with the Director of Nursing (DON), the DON stated privacy curtain should be present in each resident room to promote dignity and privacy. The DON stated the residents can get embarrassed and upset if privacy curtains were not provided.During a review of facility's policy and procedure (P&P) titled, Residents' Rights dated 4/30/2025, the P&P indicated The facility will treat each resident with respect and dignity and provide an environment that will maintain and enhance their quality of life.2a. During a review of Resident 41's admission Record, dated 10/23/2025, the admission Record indicated Resident 41 was admitted to the facility on [DATE] with diagnoses including insomnia (unable to sleep), major depressive disorder (a condition with persistently low or depressed mood, feelings of guilt or worthlessness) and anxiety disorder (a condition characterized by excessive and persistent fear and worry).During an observation on 10/22/2025 at 1:25 p.m., Licensed Vocational Nurse (LVN) 3 prepared one capsule of gabapentin (a medication used to treat nerve pain) 400 milligrams ([mg] a unit of measure for mass) to be administered to Resident 41. During medication administration, LVN 3 did not close Resident 41's privacy curtain while Resident 134 was also in the same room.During a review of Resident 41's Order Summary Report, dated 10/23/2025, the Order Summary Report indicated the following physician order: Neurontin oral capsule 400 mg (generic name - gabapentin), give 1 capsule by mouth three times a day for mood stability manifested by (m/b) racing thoughts (rapid thought patterns) , order date 6/29/2025, start date 6/29/2025 2b. During a review of Resident 134's admission Record, dated 10/23/2025, the admission Record indicated Resident 134 was admitted to the facility on [DATE] with diagnoses that included but not limited to schizoaffective disorder, bipolar type, type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and major depressive disorder.During an observation on 10/22/2025 at 1:19 p.m., LVN 3 prepared the following medications to be administered to Resident 134.1. One tablet of gabapentin 600 mg2. One tablet of metformin (a medication used to treat high blood glucose) 850 mg3. One capsule of ziprasidone (a medication used to treat mood disorders) 80 mgDuring medication administration, LVN 3 did not close Resident 134's privacy curtain while Resident 41 was also in the same room.During a review of Resident 134's order summary report, dated 10/23/2025, the document indicated but not limited to the following physician orders: Gabapentin oral tablet 600 mg, give 1 tablet by mouth three times a day for nerve pain, order date 6/5/2025, start date 6/6/2024. Metformin hydrochloride (HCl) oral tablet 850 mg, give 850 mg by mouth with meals for DM give with food, order date 10/22/2025, start date 10/22/2025 Ziprasidone HCl oral capsule 80 mg, give 1 capsule by mouth two times a day for grandiose delusions, auditory and visual hallucinations, order date 1/13/2025, start date 1/13/2025During an interview on 10/23/2025 at 9:23 a.m. with LVN 3, LVN 3 stated it was important to close the privacy curtains while administering medications to provide privacy for the residents. During an interview on 10/22/2025 at 4:08 p.m. with the DON, the DON stated the facility's nursing staff should pull the privacy curtain during medication pass, to provide privacy and protect residents' rights, so that they were not uncomfortable taking the medications in front of other residents.During a review of the facility's policy and procedure (P&P) titled Residents' Rights (SNF), dated 4/30/2025, the P&P indicated, This facility shall treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality.

Based on observation, interview and record review the facility failed to ensure four of six sampled residents' psychotropic medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), prior to starting medication. The facility failed to:1.Provide Resident 2, Resident 8, and Resident138 were provided with psychotropic medication informed consent, prior to starting medication. 2. Provide current documentation of an informed consent for Resident 90's Lexapro's ([generic name - escitalopram] a medication used to treat major depressive disorder [a mood disorder that causes a persistent feeling of sadness and loss of interest] and generalized anxiety disorder [a mental health condition characterized by excessive and uncontrollable worry about everyday things]) current dose of 10 milligrams ([mg] a unit of measurement for mass), olanzapine (a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]) 10 mg, and Depakote ([generic name - divalproex] a medication used to treat mood disorder and seizure [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) extended release 750 mg, for unnecessary medications review for psychotropic medications. This failure violated the residents' right to make an informed decision regarding the use of psychotropic medications.Findings: 1.During a review of Resident 2's admission Record, (Face Sheet front page of the chart that contains a summary of basic information about the resident) dated 10/24/2025, the admission record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), anxiety (emotion characterized by feelings of tension, worried thoughts) and insomnia (trouble falling asleep or staying asleep). During a review of Resident 2's History & Physical (H&P) dated 9/15/2025, the H&P indicated Resident 2 was awake, alert and oriented. During a review of Resident 2's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 9/22/2025 the MDS indicated Resident 2's cognition was severely impaired (limitations in a person's physical or mental abilities). The MDS also indicted Resident 2 needed partial/moderate assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated Resident 2 was taking an antipsychotic (a type of medication prescribed to treat mental health problem ) medication, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) medication and an anticonvulsant (mood stabilizer) medication. During a review of Resident 2's Order Summary Report dated 10/24/2025, the order summary report indicated Resident 2 was prescribed: 1. Abilify (antipsychotic) oral tablet 10 milligrams (mg – unit of measure) at night for attention seeking behaviors/striking out, medication start date 9/15/2025. 2. Depakote (mood stabilizer) oral tablet delayed release 750 mg by mouth in the morning for mood stabilizer, medication start date 9/15/25. 3. Depakote oral tablet delayed release 1000 mg by mouth in the evening for labile mood (sudden and intense changes in mood), medication start date 9/15/2025. 4. Fluoxetine (antidepressant) one capsule by mouth one time a day for depression and anxiety, medication start date 9/15/2025. 5. Haldol (antipsychotic) intermuscular, inject 200mgs at bedtime every 28 days for hyperverbal and aggressiveness, medication start date 9/15/2025. 6. Mirtazapine (antidepressant) oral tablet 7.5 mgs at bedtime for depression manifested by (m/b) decreased appetite, medication start date 9/15/2025. During a review of Resident 8's admission Record, dated 10/24/2025, the admission record indicated Resident 8 was admitted to the facility on [DATE] with the diagnosis including schizoaffective disorder, depression and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) During a review of Resident 8's H&P dated 1/31/2025, the H&P indicated Resident 8 was alert and oriented. During a review of Resident 8's MDS, dated [DATE] the MDS indicated Resident 8 had memory problems. The MDS also indicated Resident 8 was independent with ADL'S. The MDS also indicated Resident 8 was taking an antipsychotic medication, antidepressant medication and anticonvulsant medication. During a review of Resident 8's Active order Summary Report dated 10/24/2025, the active order summary report indicated Resident 8 was prescribed: 1. Depakote oral tablet delayed release 250 mgs by mouth at bedtime for mood stabilizer, medication start date 9/26/2025. 2. Lithium (mood stabilizer) carbonate oral capsule 300 mgs 1 capsule by mouth in the morning for labile mood, medication start date 6/18/2025. 3. Lithium carbonate oral capsule 300 mgs, 2 capsules by mouth at bedtime for labile mood, medication start date 6/18/2025. 4. Mirtazapine oral tablet 15 mgs one tablet by mouth at bedtime for depression m/b poor food intake, medication start date 9/29/2025. 5. Risperdal (antipsychotic) 1.5 mgs by mouth at bedtime for paranoid delusions (having false or unrealistic beliefs) and labile mood, medication start date 9/17/2025. 6. Zyprexa (antipsychotic) 10 mg one tablet by mouth one time a day for psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) m/b paranoid delusions and labile mood, medication start date 10/19/2025. 7. Zyprexa 20 mg one tablet by mouth at bedtime for psychosis m/b paranoid delusions and labile mood, medication start date 10/19/2025. During a review of Resident 138's admission Record, dated 10/24/2025, the admission record indicated Resident 138 was admitted to the facility on [DATE] with the diagnosis including schizophrenia, anxiety and insomnia. During a review of Resident 138's H&P dated 1/31/2025, the H&P indicated Resident 138 was alert and oriented. During a review of Resident 138's MDS, dated [DATE], the MDS indicated Resident 138's cognition was intact. The MDS also indicated Resident 138 was independent with ADL'S. The MDS also indicated Resident 138 was prescribed an antipsychotic medication, anxiety medication, hypnotic (helps with sleeping) medication and anticonvulsant medication. During a review of Resident 138's Active Order Summary Report dated 10/24/2025, the active order summary report indicated Resident 138 was prescribed: 1. Abilify inject 400 mgs intermuscular in the morning every 28 days for psychosis m/b paranoid delusions, medication start date 10/3/2025, 2. Ativan (antianxiety medication) 1 mg one tablet by mouth three times a day for anxiety m/b inability to relax, medication start date 6/17/2025. 3. Depakote delayed release 500 mgs by mouth in the morning for a mood stabilizer, medication start date 6/25/2024.4. Depakote delayed release 500 mgs two tablets by mouth at bedtime for labile mood, medication start date 11/24/2023. 5. Latuda (antipsychotic) 40 mgs 120 mgs by mouth one time a day for paranoid delusions give with food or right after a meal, medication start date 4/09/2025. 6. Zolpidem (hypnotic) 10 mgs by mouth at bedtime for difficulty sleeping, medication start date 7/7/2025. During a concurrent interview and record review on 10/24/2025 at 8:11 a.m. with the Registered Nurse Supervisor 1(RNS) 1, Resident 2, Resident 8 and Resident 138's Informed Consents for the use of psychotropic medications were reviewed. RNS1 stated whenever a resident is started on a psychotropic medication, before the medication can be administered the resident or conservator needs to be informed of the risks and benefits of taking those medications. RNS1 stated that Resident 2, Resident 8 and Resident 138 were not notified about the risks and benefits of taking psychotropic medications or were there conservators notified prior to starting the medications. RNS1 stated Resident 2, Resident 8 and Resident 138's rights were violated. During an interview on 10/24/2025 at 1:02 p.m. with the Director of Nursing (DON), the DON stated she was made aware that Resident 2, Resident 8 and Resident 138's psychotropic medication informed consents were not done. The DON stated informed consent on medication use and side effects needs to be discussed prior to the medications be started and then every six months with either the resident or their conservators. The DON stated that the quality of the resident's life could be affected if they are taking medications that they don't want to take. During a review of the Policies and Procedure (P&P) titled Informed Consent for Psychoactive Medications, dated 5/6/2025, the P&P indicated, it is the policy of Telecare to ensure that persons served are provided with information on psychoactive medications by the prescriber, and that the informed consent form is completed by the prescriber indicating consent was obtained from the person served and/or legal guardian for adult voluntary clients. The P&P indicated every person served receives information from the prescriber regarding psychoactive medications prescribed for them. The P&P indicated the prescriber completes signs and documents in their notes that informed consent was obtained by the adult voluntary person served and/or legal guardian. The P&P indicated the facility ensures that persons served are advised of their rights to refuse psychoactive medication except in the case of persons served found to be incompetent through a judicial hearing. This right to refuse medication does not apply to medication that is ordered in an emergency. 2.During a review of Resident 90's admission Record dated 10/23/2025, the admission Record indicated Resident 90 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, depressive type, major depressive disorder, recurrent, unspecified and unspecified dementia, unspecified severity with anxiety. During a review of Resident 90's Minimum Data Set (MDS – a resident assessment tool) dated 7/25/2025, the MDS indicated, Resident 90's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated, Resident 90 needed supervision level of assistance from the facility staff for performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as personal hygiene, setup or clean-up assistance for eating and showering, and independent in performing oral hygiene, toileting hygiene, upper and lower body dressing and putting on or taking off footwear. During a review of Resident 90's Order Summary Report dated 10/23/2025, the Order Summary Report indicated but not limited to the following physician orders: Depakote extended release 24-hour oral tablet 250 mg (divalproex sodium), give 750 mg by mouth at bedtime for labile mood, order date 7/16/2025, start date 7/16/2025. Lexapro oral tablet 10 mg (escitalopram oxalate), give 10 mg by mouth in the evening for depression, order date 5/28/2025, start date 5/28/2025. Olanzapine tablet 10 mg, give 1 tablet by mouth at bedtime for disorganized thought process, paranoia, auditory hallucinations (AH- sounds a person believes to be real but are not real), and responding to internal stimuli (RTIS), order date 6/1/2024, start date 6/1/2024. During a review of Resident 90's Medication Administration Record (MAR) dated 10/1/2025 to 10/23/2025, 9/1/2025 to 9/30/2025 and 8/1/2025 to 8/31/2025, the MAR indicated the following medications were administered daily: a. Lexapro oral tablet 10 mg, give 10 mg by mouth in the evening for depression b. Olanzapine tablet 10 mg, give 1 tablet by mouth at bedtime for disorganized thought process, paranoia, AH and RTIS c. Depakote ER oral tablet 250 mg (divalproex sodium), give 750 mg by mouth at bedtime for labile mood During an interview on 10/20/2025 and 10/23/2025 at 2:54 p.m. with Licensed Vocational Nurse (LVN) 6, LVN 6 could not locate the informed consent and requested another LVN to help find the informed consents. During a review of Resident 90's Informed Consent for Psychotropic Medications, dated 5/21/2024, the Informed Consent for Psychotropic Medications indicated an informed consent for Lexapro 5 mg by mouth at bedtime and Olanzapine 10 mg by mouth at bedtime. During a review of Resident 90's Informed Consent for Psychotropic Medications, dated 12/2/2024, the Informed Consent for Psychotropic Medications indicated an informed consent for Namenda 5 mg by mouth two times a day. During a concurrent interview and record review on 10/23/2025 at 4:15 p.m. with Medical Records Supervisor (MRS), Resident 90's Informed Consent for Psychotropic Medications, was reviewed. The informed consent was a printout of a scanned copy and was difficult to read. The document seemed to indicate a date of 10/1/2025 and medications listed were Lexapro 5 mg by mouth at bedtime, olanzapine 10 mg by mouth at bedtime and Depakote 750 mg with dose range of 250 mg to 1000 mg. MRS stated he would try to locate the original document. During an interview on 10/23/2025 at 5:37 p.m. with the Director of Nursing (DON), the DON stated the informed consent for psychotropic medications should have been received every six months. The DON stated if there was a change in the dose of medications, then the facility needed to get a new informed consent. The DON stated if the last informed consent for Resident 90's psychotropic medications was in 10/1/2025 and the ones prior to this were in May 2024 and December 2024, then informed consent would be considered as lapsed. The DON stated the conservators (a person who is chosen by a law court to look after the personal affairs) and residents needed to be informed about the prescribed psychotropic medications and related side effects. The DON stated it was important to ensure patient safety by making sure that residents were on the smallest dose possible to treat their conditions and were not over-medicated to prevent oversedation and falls. During a review of the facility's policy and procedure (P&P) titled, Informed Consent for Psychoactive Medication, dated 5/6/2025, the P&P indicated, It is the policy of the facility to ensure that persons served are provided with information on psychoactive medications by the prescriber, and that the informed consent form is completed by the prescriber indicating consent was obtained from the person served and/or legal guardian for adult voluntary clients. During a review of the facility's P&P titled, Use of Antipsychotic Medication in Skilled Nursing Facility, dated 3/5/2025, the P&P indicated, When prescribing antipsychotic medications, the psychiatrist or provider will: 2. Obtain an informed consent for psychotropic medication. During a review of the facility's P&P titled, Medication Administration, dated 6/2/2025, the P&P indicated, Before administration of psychotropic medication, check that the Informed Consent for the Use of Psychotropic Medication for the drug ordered is completed and signed by the Prescriber, person served, and the person served conservator (if applicable).

Based on interview and record review, the facility failed to ensure the Notice of Proposed Transfer and Discharge was provided to the Ombudsman (resident advocate) at the time of discharge for three of three sampled residents (Resident 2, Resident 6 and Resident 154).This deficient practice had the potential to deny Resident 2, Resident 6 and Resident 154 protection from being inappropriately discharged and violated the residents' rights. Findings: A. During a review of Resident 2's admission Record (facesheet), dated 10/24/2025, the admission record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis including schizoaffective disorder (schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), anxiety ( (emotion characterized by feelings of tension, worried thoughts) and insomnia (trouble falling asleep or staying asleep). During a review of Resident 2's History & Physical (H&P) dated 9/15/2025, the H&P indicated Resident 2 was awake, alert and oriented. During a review of Resident 2's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 9/22/2025 the MDS indicated Resident 2's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS also indicted Resident 2 needed partial/moderate assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 2's Post Event assessment dated [DATE], the post event assessment indicated Resident 2 was sent to GACH on 9/8/2025 at 6:05 p.m. During a review of Resident 2's Progress Note dated 9/9/2025 at 5:30 a.m. the progress note indicated Resident 2 had been admitted to GACH for ventricular tachycardia (abnormal fast heart rate). During a review of Resident 2's progress note dated 9/15/2025 at 5:00 p.m. the progress note indicated Resident 2 was readmitted back to the facility. B. During a review of Resident 6's admission Record dated 10/24/2025, the admission record indicated Resident 6 was admitted on [DATE] with diagnosis including schizophrenia ((a mental illness that is characterized by disturbances in thought), insomnia, and constipation. During a review of Resident 6's H&P dated 6/24/2025, the H&P indicated Resident 6 was alert and oriented. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognition was intact. The MDS also indicated Resident 6 needed set up or clean up assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 6's Post Event assessment dated [DATE], the post event assessment indicated Resident 6 was sent to GACH on 4/24/2025 at 7:05 a.m. During a review of Resident 6's progress noted dated 4/24/2025 at 10:37 a.m. the progress note indicated Resident 6 was admitted to GACH for pneumonia (infection in the lungs). During a review of Resident 6's progress note dated 4/26/2025, the progress note indicated Resident 6 was readmitted back to the facility on 4/26/2025 at 4:20 p.m. During an interview on 10/24/2025 at 12:43 p.m. with the Assistant Director of Nurses (ADON), the ADON stated that when residents are admitted to the GACH, the LTC Ombudsman needs to be notified. The ADON stated the LTC Ombudsman was not notified of Resident 2's admission to GACH on 9/18/2025 or Residents 6 admission to GACH on 4/24/2025. The ADON stated that even though we do are best for the residents the ombudsman is a third party who advocates for the residents and needed to be notified. During an interview on 10/24/2025 at 1:02 p.m. with the Director of Nurses (DON), the DON stated she was made aware that the LTC Ombudsman was not notified when Resident 2 and Resident 6 were admitted to the GACH. The DON stated the LTC Ombudsman needs to be notified because they are the advocate for the residents. The DON stated this could possibly be a violation of the residents' rights. During a review of the facility's Policy & Procedure (P&P), Admission, Transfer, and Discharge Rights and Requirements dated 10/15/2024, the P&P indicated in all cases of facility -initiated transfers and discharges, the facility personal shall notify the resident, there designated representative (if applicable), as well as the long-term care ombudsman. C. During a review of Resident 154's admission Record, the admission Record indicated Resident 154 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and hypertension (HTN- high blood pressure). During a review of Resident 154's MDS dated [DATE], the MDS indicated Resident 154's cognition was intact. During a review of Resident 154's Order Summary dated 9/27/2025, timed at 1:26 p.m., the Order Summary indicated an order to discharge Resident 154. During a review of Resident 154's Progress Note dated 9/30/2025, timed at 12:30 p.m., the Progress Note indicated Resident 154 was discharged , with no indication the Ombudsman was notified. During a concurrent interview and record review on 10/23/2025 at 12:13 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when a resident is discharged , part of their process is to notify the Ombudsman and document that they were notified in a progress note. LVN 1 stated after reviewing Resident 154's progress notes, there is no indication the Ombudsman was notified. LVN 1 stated the Ombudsman should have been notified to ensure the discharge was appropriate. During a concurrent interview and record review on 10/23/2025 at 1:39 p.m., with the Registered Nurse Supervisor (RNS) 1, the RNS 1 stated he was unsure if the Ombudsman is to be notified when a resident is discharged because he does not worry about that. RNS 1 stated the Ombudsman should be notified when a resident is discharged in case something happens to the resident, they can advocate for the resident. During an interview on 10/24/2025 at 10:35 a.m., with the Director of Nursing (DON), the DON stated when a resident is discharged , the Ombudsman should be notified because they are the ones that advocate for the residents' well-being and ensure the discharge is appropriate. The DON stated the nurses are supposed to notify the Ombudsman but are not consistent with doing so. During a review of the facility's policy and procedure (P&P) titled, Admission, Transfer, and Discharge Rights and Requirements, undated, the P&P indicated, To the extent practicable/feasible, before the transfer or discharge occurs, the facility shall notify the resident and, if known, the family member, surrogate, or representative, as well as the Long-Term Care Ombudsman of the transfer/discharge and the reasons for the transfer/discharge and record the reasons in the clinical record.

Based on interview and record review, the facility failed to:1. Include signatures of two Licensed Vocational Nurses (LVNs) on the medication donation records titled Medication Destruction Record for 35 records on three out of three sampled pages in the donation log, as per facility's policy and procedure (P&P) titled, Donated Medications, dated 10/10/2024.2. Ensure the disposition or destruction records for controlled medications (medications that the use and possession of are controlled by the federal government) included signatures of a pharmacist in addition to a Registered Nurse (RN) or Director of Nursing (DON) on six of six sampled records, as per facility's P&P titled Accounting for Administered and Wasted Medications including Expired Medications, dated 6/11/2025. These deficient practices increased the risk for controlled medications diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use), misuse, and the potential for accidental exposure to harmful medications to the facility staff and residents, possibly leading to physical and psychosocial harm.Findings:1. During a concurrent interview and record review on 10/22/2025 at 9:25 a.m. with Licensed Vocational Nurse (LVN) 4, the medication donation records titled as Medication Destruction Record, dated 10/8/2025 were reviewed. LVN 4 stated she could show the medication destruction records and happened to open the donation records instead. The sampled 35 donation records indicated names of residents, medication names, medication strength, medication quantities and one licensed nurse's signature. LVN 4 stated the records were donation records for medications that were donated from facility to another location, but they were noncontrolled medications and only psychotropic medications (any drug that affects brain activities associated with mental processes and behavior). LVN 4 stated the donation record did not have a signature of Witness #2 Licensed Signature. The Medication Destruction Record for August 2025, September 2025 and October 2025 indicated one signature only. LVN 4 stated the registered nurse (RN) took care of the donation, so LVN 4 was not sure of the process. During an interview on 10/22/2025 at 4:08 p.m. with the DON, the DON stated one of the facility's charge nurses took care of the donation process. The DON stated discontinued noncontrolled psychiatric medications would be sent for donation. The DON stated the donation form needed to be corrected indicating it was a 'donation record' not destruction record. The DON stated according to the facility's donated medications policy, there should have been two licensed nurses' signatures documented. The DON stated, without a witness signature, the facility was at risk of being uncertain whether the meds were truly donated or not. During a review of the facility's P&P titled, Donated Medications, dated 10/10/2024, the P&P indicated, Medications donated will be recorded on the Donated Medications Disposition Log, complete the Donation Log with the following information: name of the drug. signature of 2 licensed staff. The P&P indicated, To provide documented accountability of medication disposal, destruction including donated medications that is consistent with State and Federal laws. Medications are disposed of as required . the donation to a voluntary drug repository and distribution program in accordance with State and Federal laws. 2. During a concurrent interview and record review on 10/22/2025 at 4:08 p.m. with the DON, there were six narcotic sheets or (controlled drug record [CDR] a document indicating perpetual inventory and administration of controlled substances) with no signatures that would indicate their disposition and no medication cards or container attached to them. The DON stated she was saving the narcotic sheets because she wanted to investigate further about the waste entries on the record. The DON stated the facility conducted controlled medication disposition on 9/23/2025 with the facility pharmacist so there were no controlled medications waiting to be destroyed. The DON stated the disposition records should have the resident's name, medication name, medication strength, quantity and one signature from the pharmacist and one signature from the DON documented on the disposition records during destruction process.During a concurrent interview and record review on 10/23/2025 at 5:06 p.m. with the DON, the six CDR or narcotic sheets for six different residents with controlled medications such as lorazepam (a medication used to treat anxiety), zolpidem (a medication used to treat insomnia [inability to sleep] and temazepam (a medication used to treat insomnia), were reviewed. The DON stated the narcotic sheets indicated on them the quantity remaining and copies of the medication bubble pack (a card that packages doses of medication within small, clear, or light-resistant, amber-colored plastic bubbles). The DON stated when she was informed during the survey that a pharmacy consultant would be joining the survey, the DON panicked and destroyed the six controlled medications without waiting for the facility pharmacist's presence as a witness to the process. The DON stated she did not have any witness when she wasted the controlled medications. The DON stated she signed the CDR or narcotic sheets with her signature. The DON stated she wanted to be honest instead of surveyor thinking there was medication diversion or if the nurses had been doing something they were not supposed to. During a review of the facility's P&P titled, Accounting for Administered and Wasted Medications including Expired Medications, dated 6/11/2025, the P&P indicated, The facility provides documented accountability of medications used in the facility including expired medications. The facility has in place measures to maintain. accountability of all medications delivered. administered and wasted or destroyed. The P&P indicated, Controlled Medication Disposal and Destruction Procedure. 1. Disposal of controlled medications must be completed by one RN and one pharmacist. 2c. The disposal will be inputted and recorded into the Controlled Medication Disposal Log. The pharmacist and one RN completing the disposal must both provide: 1. Patient's name.7. Signature of one pharmacist and one RN.

Based on observation, interview, and record review, the facility failed to maintain and observe infection control practices by failing to:1.Ensure the laundry staff performed hand hygiene prior to handling clean linens.2.Ensure the laundry staff were keeping a log and monitoring the washing machine water temperatures and ensure the water heater was functioning prior to using the washing machines. 3. Perform proper hand hygiene procedures after checking Resident 140's blood glucose, and before and after administering insulin (medication that lowers blood sugar level), per facility's policy and procedure (P&P) titled, Hand Hygiene, dated 12/9/2024, affecting one of nine residents observed during medication administration.4.Follow facility's P&P on disinfecting blood glucose monitor after its use according to manufacturer guidelines and facility's P&P titled Cleaning of Non-critical, Reusable Equipment used by Persons Served (SNF), dated 8/11/2025, affecting one of nine residents observed during medication administration. 5.Follow facility's requirements of not using resident's blood glucose monitor for personal use and failed to disinfect blood glucose monitor after its use, per facility's P&P, titled Cleaning of Non-critical, Reusable Equipment used by Persons Served (SNF), dated 8/11/2025.6.Clean and disinfect medication cart counters before and/or after medication pass in between residents, per facility's P&P titled Cleaning of Non-critical, Reusable Equipment used by Persons Served (SNF), dated 8/11/2025, affecting three of nine residents observed during medication administration.7. Ensure that the privacy curtain in Resident 138's room was not touching the floor, maintained in a sanitary and safe condition.These failures had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for spread of infection. Findings: 1.During a concurrent observation and interview on 10/23/2025 at 7:40 a.m., in the laundry room, the Laundry Aide (LA) was observed unloading the washer without performing hand hygiene prior to handling the clean linens. The LA stated she should have washed her hands prior to handling the clean linens because not doing so could spread infection and germs. During an interview on 10/23/2025 at 9:21 a.m., with the Infection Prevention Nurse (IPN), the IPN stated staff should be washing their hands prior to handling clean linens to prevent cross contamination which could lead to the residents developing a skin rash or an infection. During an interview on 10/24/2025 at 10:42 a.m., with the Director of Nursing (DON), the DON staff should be washing their hands before handling clean linens to prevent cross contamination. The DON stated not washing their hands before handling clean linens could contaminate the linens. During a review of the facility's Housekeeping and Laundry Supervisor Job Description, dated 11/30/2017, the Job Description indicated, Essential Functions: Inspects equipment and evaluates the need for new parts, repairs, and overhaul. Coordinates all infection control procedures. Makes daily rounds to monitor the performance of the Housekeeping and Laundry Department. 2.During a concurrent observation and interview, in the laundry room, on 10/23/2025 at 7:21 a.m., with the LA, the LA stated there was not a washer temperature log. The LA stated she does check the washer water temperatures and does not know if the water temperature was hot enough to kill bacteria. The LA stated she checks the water heater prior to washing linens but stated the water heater was not currently working. The water heater gauge reading was 78 degrees Fahrenheit (unit of measurement) and the LA stated she did not inform anyone that the water heater was not working properly but should have told the Laundry Supervisor . The LA stated she should not have been washing linens being the water heater was not functioning properly. During an interview on 10/23/2025 at 7:55 a.m., with the Housekeeper Supervisor (HS), the HS stated the LA should have informed him of the water heater not functioning properly and the LA should not have been using the washers. The HS stated washer temperatures should be monitored prior to washing anything because if the washer temperatures are incorrect, the linens and clothes may not be properly sanitized or disinfected and could lead to cross contamination and spread of infection throughout the facility. During an interview on 10/23/2025 at 9:21 a.m., with the Infection Prevention Nurse (IPN), the IPN nurse stated there should be a washer temperature log, so the laundry staff know they were washing linens at the correct temperature to kill bacteria. During an interview on 10/24/2025 at 10:42 a.m., with the DON, the DON stated there should be a temperature log for the washers to ensure the water was hot enough to kill germs and prevent cross contamination. During a review of the facility's P&P titled, Soiled Linens, Collecting, and Handling, undated, the P&P indicated, It is the policy of the facility to prevent the spread of infection or cross-contamination from used/soiled linens and to provide a safe and clean environment for persons served, staff, and visitors. All soiled linens are considered to be potentially infectious, therefore careful precautionary procedures are followed by the program staff. 3. During a review of Resident 140's admission Record dated 10/23/2025, the admission Record indicated Resident 140 was admitted to the facility on [DATE] with diagnosis including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 140's Minimum Data Set (MDS – a resident assessment tool) dated 1/24/2025, the MDS indicated, Resident 140 had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated, Resident 140 needed setup or clean-up assistance from the facility staff for performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating, oral hygiene, showering and personal hygiene, was independent in performing ADLs such as toileting hygiene, upper and lower body dressing and putting on or taking off footwear. During a concurrent observation and interview on 10/22/2025 at 11:16 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 prepared to check Resident 140's blood glucose level using an blood glucose monitor in the resident's room. LVN 4 stated Resident 140's blood glucose level was 182 milligrams ([mg] a unit of measurement for mass) per deciliter ([dL] a unit of measurement for volume). LVN 4 did not wash hands after checking Resident 140's blood glucose and before administering insulin. LVN 4 stated the facility policy required the nursing staff to have a second check of insulin dose before administering to the resident. After LVN 4 received a verification for insulin dose, LVN 4 prepared and administered four units of insulin lispro (a medication used to treat high blood glucose) 100 units per mL, subcutaneously ([SubQ] - under the skin) to Resident 140. During a review of Resident 140's Order Summary Report dated 10/23/2025, the Order Summary Report indicated but not limited to the following physician orders: Insulin Lispro injection solution 100 units per mL, inject as per sliding scale: if 150-250 = 4 units subcutaneous (SubQ- applied under the skin); 251-350 = 6 units SubQ; 351-450 = 8 units; over 450 call medical doctor (MD), subcutaneously before meals for DM, order date 1/20/2024, start date 1/20/2024 During an interview on 10/23/2025 at 9:23 a.m. with LVN 3, LVN 3 stated it was important to wash hands before and after checking blood glucose, to prevent spread of infection for staff and residents and to prevent cross-contamination. LVN 3 stated it was important to wash hands with soap and water before administering insulin. During an interview on 10/22/2025 at 4:08 p.m. with the DON, the DON stated the facility's licensed nursing staff should have washed hands, gathered supplies, worn gloves, then conducted blood glucose test for the residents and disposed of everything. The DON stated the licensed nurse should have washed hands and cleaned equipment after discarding the test strip, insulin syringe and gloves. The DON stated it was important that the facility nurse washed hands after checking Resident 140's blood glucose and before administering insulin to prevent cross-contamination. The DON stated the nurse would be touching different medications and different surfaces on carts and could potentially increase the risk of spreading infection among facility residents. 4. During a concurrent observation and interview on 10/22/2025 at 11:16 a.m. with LVN 4, LVN 4 prepared to check Resident 140's blood glucose level using a blood glucose monitor in the resident's room. LVN 4 was not observed disinfecting the blood glucose monitor according to facility's P&P and manufacturer's recommendations after its use. During an interview on 10/22/2025 at 4:08 p.m. with the DON, the DON stated the licensed nurse should have washed hands and cleaned equipment per blood glucose monitor manufacturer's recommendations after discarding the test strip. 5. During a concurrent observation and interview on 10/23/2025 at 8:46 a.m. with LVN 1, LVN 1 was observed in the facility hallway with a blood glucose monitor on top of her medication cart with the test strip attached to the monitor. LVN 1 removed the test strip off the monitor, covered it in a paper napkin and discarded it in the trash and proceeded to put the blood glucose monitor away in the medication cart drawer. LVN 1 was not observed cleaning or disinfecting the glucose monitor or medication cart. LVN 1 stated she used the blood glucose monitor in the medication cart to check her own blood glucose because she was not feeling well. During an interview on 10/23/2025 at 9:39 a.m. with LVN 1, LVN 1 stated her blood glucose was 75 mg/dL and that's too low for me and she did not have a chance to eat breakfast in the morning. LVN 1 stated she started to feel tremors, so decided to check her blood glucose and her morning reading at home was 119 mg/dL. LVN 1 insisted that she was feeling better, so she continued to work after eating crackers and drinking coffee with sugar and creamer. LVN 1 stated facility did not know about her condition. LVN 1 stated, I do not want to be a burden to facility, and I need to take care of patients. I did not eat breakfast, so I was feeling this way today. LVN 1 became tearful and stated, It's ok it's ok. LVN 1 stated her personal blood glucose monitor was in her purse and she decided to use the blood glucose monitor stored in the medication cart. LVN 1 stated it was the facility's protocol to clean glucose monitor after each use to prevent contamination for other residents. LVN 1 stated she cleaned the glucose monitor after checking her own blood glucose and before surveyors approached her. During an interview on 10/23/2025 at 5:20 p.m. with the DON, the DON stated if the facility staff nurse was not feeling well, he/she/they should have notified the supervisor and the DON. The DON stated if the nurse was not feeling well because of a chronic condition such as high or low blood pressure, high or low blood glucose, that it could have adverse effects such as blurred vision or even stroke. The DON stated the facility nurse could cause medication errors and place residents' lives at risk if they passed medications to the residents during such circumstances. The DON stated depending on the symptoms, the facility staff might need to be tested for COVID-19 (a virus that could cause viral infection). The DON stated it would be important for the facility staff or nurse to go home if they were not feeling well to prevent residents from getting sick. The DON stated the facility staff should not have used the blood glucose monitor from the medication cart because that would increase the risk of cross-contamination and infection as they were intended for the facility residents. 6. During an observation on 10/22/2025 at 11:16 a.m., LVN 4 prepared to check Resident 140's blood glucose level and administered four units of insulin lispro100 units per mL, SubQ to Resident 140. LVN 4 did not clean or disinfect top of the medication cart counter before and after preparing medications for administration. During an observation on 10/22/2025 at 12:35 p.m., LVN 4 prepared one tablet of divalproex sodium (a medication used to treat seizure (sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) delayed release 250 mg medication to be administered to Resident 65. LVN 4 did not clean or disinfect top of the medication cart counter before and after preparing medications for administration and between residents. During an observation on 10/22/2025 at 1:19 p.m., LVN 3 prepared three medications to be administered to Resident 134. LVN 3 did not clean or disinfect top of the medication cart counter before and after preparing medications for administration and between residents. During an interview on 10/22/2025 at 4:08 p.m. with the DON, the DON stated the medication cart counter tops need to be always cleaned and organized. The DON stated medication carts should be cleaned to ensure there was no risk of spread of infection between residents and rooms after medication administration. During a review of the facility's P&P titled, Hand Hygiene, dated 12/9/2024, the P&P indicated, All employees and vendors rendering care are responsible for maintaining adequate hand hygiene by adhering to specific infection control practices. The P&P indicated, The health care worker uses soap and water only to clean their hands at these times.6. After contact with chemicals. The health care workers follow these glove guidelines: 1. Use gloves whenever contact with blood, body fluid or other potentially infectious matter is present.during cleaning activities.4. Perform hand hygiene immediately after glove removal. During a review of the facility's P&P titled, Cleaning of Non-Critical, Reusable Equipment used by Persons Served (SNF), dated 8/11/2025, the P&P indicated, It is the policy of the facility for all programs to implement and maintain processes to ensure all non-critical, reusable equipment used by residents are routinely cleaned, disinfected, or discarded after use in accordance with existing infection prevention.and any applicable manufacturer's recommendations. The P&P indicated, Reusable Equipment and Medical Devices – are devices that health care providers can reprocess and reuse on multiple individuals served. These devices are designed for multiple uses. cleaning followed by disinfection between individuals served. During a review of the blood glucose monitor's manufacturer recommendations titled, Guidelines for Cleaning and Disinfecting the., undated, the document indicated, The. Blood Glucose Monitoring System may only be used for testing multiple patients when standard precautions and the manufacturer's disinfecting procedures are followed. The meter should be cleaned and disinfected after use on each patient. The cleaning procedure is needed to clean dirt, blood and other bodily fluids. before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of blood-borne pathogens. During a review of the facility's P&P titled, Blood Glucose Monitoring, dated 6/18/2025, the P&P indicated, Procedure: 10. Dispose of lancet in the Sharps disposal container. 11. Remove gloves and wash hands. 7. During a review of Resident 138's admission Record, dated 10/24/2025, the admission record indicated Resident 138 was admitted to the facility on [DATE] with the diagnosis including schizophrenia (a mental illness that can affect thoughts, mood, and behavior), anxiety (emotion characterized by feelings of tension, worried thoughts) and insomnia (trouble falling asleep or staying asleep). During a review of Resident 138's History & Physical (H&P) dated 1/31/2025, the H&P indicated Resident 138 was alert and oriented. During a review of Resident 138's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 9/25/2025 the MDS indicated Resident 138's cognition was intact. The MDS also indicted Resident 138 was independent with activities of daily living (ADL's - Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview on 10/21/2025 at 12:27 p.m. with Resident 138 in Resident 138's room. Resident 138's privacy curtain was not fully attached to the curtain rack. The privacy curtain was missing five hooks and was touching the floor. Resident 138 stated his curtain had been like that for six months. During a concurrent observation and interview on 10/21/2025 at 1:50 p.m. with Certified Nursing Assistant 7 (CNA) 7 in Resident 138's room. CNA 7 stated the privacy curtain should not be touching the floor because the bacteria that is on the floor could get on the privacy curtain and possibly get the resident sick. During a concurrent observation and interview on 10/21/2025 at 1:55 p.m. with Licensed Vocational Nurse 7 (LVN7) in Resident 138's room. LVN 7 stated the privacy curtain should not be on the floor, and it was an infection control issue. LVN 7 stated, germs from the floor could get on the privacy curtain and possibly get Resident 138 sick. During an interview on 10/24/2025 at 1:02 p.m. with the Director of Nurses (DON), the DON stated that the resident's privacy curtain should not be touching the floor because the floor has bacteria and germs on it. During a review of the facilities Policy's and Procedure (P&P) titled (Safe and Comfortable Environment) the P&P indicated The facility will maintaining a safe, clean, comfortable and homelike environment includes, but is not limited to establishing and maintaining practices that ensure that the physical space is routinely cleaned/sanitized in accordance with applicable infection control procedures and is free of accident hazards to the extent possible/practicable.

Based on observation, interview, and record review, the facility failed to notify the physician for a change in condition for one of three sampled residents (Resident 117), when Resident 117 verbalized suicidal ideations.This deficient practice had the potential for delayed physician assessment and intervention, placing Resident 117 at risk for delayed behavioral health intervention, worsening psychiatric symptoms, and possible harm.During a review of Resident 117's admission Record, the admission Record indicated the facility admitted Resident 117 on 5/16/2019, with diagnoses including schizoaffective disorder bipolar type (mental illness that can affect thoughts, mood, and behavior), dementia (a progressive state of decline in mental abilities), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN-high blood pressure).During a review of Resident 117's History and Physical (H&P), dated 5/8/2025, the H&P indicated, Resident 117 had impaired judgement and insight.During a review of Resident 117's Minimum Data Set (MDS-a resident assessment tool), dated 9/12/2025, the MDS indicated, Resident 117 had severely impaired cognition (ability to think and understand). The MDS indicated Resident 117 needed supervision from staff for toileting hygiene, dressing and eating.During observation and interview on 10/22/2025 at 8:44 a.m., Licensed Vocational Nurse (LVN) 2 was inside Resident 117's room, when Resident 117 stated in her primary language that she wanted to die.During a concurrent interview and record review on 10/22/2025 at 4:12 p.m., with Registered Nurse Supervisor (RNS) 3, Resident 117's Nursing Notes, dated 10/22/2025 was reviewed. The Nursing Notes indicated Licensed Vocational Nurse (LVN) 2 had no documentation of notifying physician of Resident 117's verbalization of suicidal ideation. RNS 3 stated the physician was not notified during morning shift of same day. RNS 3 stated notifying physician was important because physicians have the expertise to determine appropriate treatment, including medication review and adjustments. RNS 3 stated failure to notify physician had potential to place the resident at risk for harm.During an interview on 10/24/2025 at 12:01 p.m., with Director of Nursing (DON), the DON stated she was not aware of Resident 117's suicidal ideation. The DON stated suicidal ideations required immediate physician notification so physician can adjust medication and make a decision on resident's needs. The DON stated failure to notify the physician places the resident at risk for serious resident harm or self-injury.During a review of facility's policy and procedure (P&P), titled, Notification of physician/Prescriber, dated 7/16/2025, the P&P indicated, It is the policy of the facility to provide evidence-based best practices including that the licensed nurse is responsible to inform the physician or other prescriber responsible for the medical or psychiatric care of the person served of any changes in the person served's emotional, behavioral, physical condition, and/or involvement in adverse events.Notify the appropriate provider promptly of: Any sudden and or marked adverse change in signs, symptoms of medical condition or behavior exhibited by an individual.

Based on observation, interview, and record review, the facility failed to maintain a comfortable, homelike, and safe environment for one of six sampled residents (Resident 124). The facility failed to:1.Ensure adequate water flow during Resident 124's shower time.2.Maintain the physical environment by allowing the baseboard in a shared resident bathroom to peel off.This deficient practice had the potential to negatively impact Resident 124's well-being and posed a risk of accidents or injury to residents due to an unsafe and poorly maintained environment.Findings:During a review of Resident 124's admission Record, the admission Record indicated Resident 124 was admitted to the facility on [DATE] with diagnoses including schizophrenia(a mental illness that is characterized by disturbances in thought), diabetes mellitus(DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified cataract( clouding of the eyes' lens but the specific cause is undetermined) and mood disorder(mental health condition where a person's emotions become severe and long-lasting and significantly interfering with their daily life).During a review of Resident 124's Minimum Data Set (MDS- resident assessment tool) dated 8/30/2025, the MDS indicated Resident 1124 had an intact cognition (ability to think, understand, learn, and remember) and was independent ( resident completes the activity by themselves with no assistance from a helper) with bathing or showering, dressing, toileting hygiene, and bed mobility.During a concurrent observation and interview on 10/21/2025 at 10:01 a.m. at Resident 124's room, Resident 124 was pointing at the shared bathroom that had peeling baseboard. Resident 124 stated in an angry tone that the shower head in one of the shower rooms was not flowing with water adequately and the pressure of water was not strong enough to have a shower. Resident 124 stated she liked a strong flow of water coming out from the shower to ensure she was clean thoroughly after a shower. Observed a peeling baseboard inside the bathroom shared by Resident 124 with other residents from the other room.During a concurrent observation and interview on 10/23/2025 at 9:18 a.m. with Maintenance Assistant (MA) at the resident shower rooms, the water in Shower room [ROOM NUMBER] was not flowing adequately. MA stated he will replace and fix the shower.2.During a concurrent observation and interview on 10/23/2025 at 9:40 a.m. at Resident 124's bathroom with MA. MA stated the baseboard had peeled off inside the bathroom shared by residents. MA stated housekeeping should notify the maintenance department with any concerns in the bathroom. MA stated the peeled baseboard will be fixed and the shower will be replaced because the residents should feel comfortable and safe in their home.During an interview on 10/23/25 at 10:26 a.m. with Housekeeping (HSK)1, HSK 1 stated they report to the maintenance department any issues in the bathroom like peeling baseboard because it can endanger the residents' safety. HSK 1 stated the residents should be provided a home-like and comfortable environment because they live in the facility.During an interview on 10/23/2025 at 9:52 a.m. with Housekeeping Supervisor (HS), the HS stated peeling baseboard in a shared bathroom can potentially lead to a hazardous situation like accidents. The HS stated the housekeeping should have notified the maintenance department to fix it.During a review of the facility's policy and procedure (P&P) titled, Safe and Comfortable Environment, dated 4/30/2025, the P&P indicated the facility will protect and promote residents right to a safe, clean, comfortable, and homelike environment by ensuring the building, grounds are kept clean, applicable equipment, supplies, and furnishing are maintained in a state of good repair. The P&P indicated efforts shall be made by the facility to provide a homelike setting which includes accommodation of residents' preferences and choices.

Based on observation, interview, and record review, the facility failed to ensure that one of three sampled residents (Residents 63) were free from sexual abuse by another resident (Resident 146). The facility failed to: 1. Supervise Resident 146 with history of inappropriate sexual comments towards staff and residents, showing his private part, standing too close to staff and not giving enough boundaries. This failure had the potential to result in Resident 63 experiencing unwanted sexual contact, placing the resident at risk for emotional trauma, psychological harm, and a compromised sense of safety within the facility. Findings:During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipidemia (abnormally high levels of cholesterol and or triglycerides in the blood), and vitamin D deficiency (it occurs when the protective cartilage that cushions the ends of the bones wears down over time).During a review of Resident 63's Minimum Data Set (MDS - a resident assessment tool) dated 10/6/2025, the MDS indicated Resident 63 had the ability to understand others with clear comprehension. The MDS indicated Resident 63 needed setup or clean-up assistance from staff with eating and showering. The MDS indicated Resident 63 was independent with oral hygiene, toileting, dressing, personal hygiene, transferring and walking. During a review of Resident 146's admission Record, the admission Record indicated Resident 146 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, drug induced subacute dyskinesia (a type of involuntary movement disorder that develops gradually over weeks to months after taking certain medications), insomnia (trouble falling asleep or staying asleep), and anxiety(emotion characterized by feelings of tension, worried thoughts).During a review of Resident 146's Psychiatric Progress Notes, dated 12/18/2024, the Psychiatric Progress Notes indicated Resident 146 continued having inappropriate behavior such as showing his private part to staff during a shower, standing too close to staff and not giving enough boundaries. During a review of Resident 146's MDS dated [DATE], the MDS indicated Resident 146 had the ability to understand others with clear comprehension. The MDS indicated Resident 146 needed supervision or touching assistance with showering and transferring. The MDS indicated Resident 146 needed setup or clean-up assistance with eating and personal hygiene. The MDS indicated Resident 146 was independent with oral hygiene, toileting, dressing, transferring and walking. During an interview on 10/21/2025 at 9:45 a.m. with Resident 63, in Resident 63's room. Resident 63 stated two days after being admitted to the facility she was in the hallway using the phone when Resident 146 touched her on the hips and buttocks. Resident 63 stated she was scared and told Certified Nursing Assistant (CNA) 8 and a male Social Worker (SW) 1. Resident 63 stated she sees Resident 63 during meals and Resident 63 approaches her for conversation. Resident 63 stated the incident happened during the night on 10/1/2025 at 8:30 p.m.During an interview on 10/22/2025 at 3:45 p.m. with Certified Nursing Assistant (CNA) 9, CNA 9 stated she was familiar with Resident 146. CNA 9 stated Resident 146 likes to talk to women and had to be watched for inappropriate behaviors last month (September 2025). CNA 9 stated she does not know what the inappropriate behaviors are. During a concurrent observation and interview on 10/23/2025 at 1:57 p.m., in the hallway with Resident 146, Resident 146 was talking to male and female residents. Resident 146 denied touching any residents without permission. During a concurrent interview and record review on 10/24/2025 at 10:03 a.m. with Licensed Vocational Nurse( LVN) 8, Resident 146's Sexual Activity Screening, dated 2/29/2024 was reviewed. The Sexual Activity Screening indicated Resident 146 exposed himself in public, kissed a female resident and touched a female resident's buttock. LVN 8 stated Resident 146 needs a lot of redirections for speaking inappropriate sexual comments towards staff and residents. During an interview on 10/24/2025 at 10:55 a.m. with Registered Nurse Supervisor (RNS) 2, RNS 2 stated she had not heard of Resident 146 sexually abusing residents. RNS 2 stated the facility has made the west hallway all female to redirect male residents from going into female rooms. RNS 2 stated the facility monitors for inappropriate sexual behaviors from the beginning of admission.During an interview on 10/24/2025 at 11:20 a.m. with Social Services (SW) 2, SW 2 stated she was aware Resident 146 was sexually inappropriate to residents and staff. SW 2 stated Resident 146 exposes himself to other residents, does inappropriate touching, and tried to kiss a staff member. SW 2 stated Resident 146 was placed on monitoring on 2/29/2024 for touching a female resident. During a review of Resident 146's Care Plan titled, Living in Control, date created 8/9/2023, date initiated 8/18/2025 and date revised 10/22/2025. The Care Plan indicated Resident 146 had a history of aggression, inappropriate sexual behaviors toward residents and staff exposing his private areas. The Care Plan indicated interventions including Resident 146 will develop appropriate social interactions with peers and refrain from aggressive behavior and sexual acting (exposing, masturbating, touching buttocks and kissing). During a review of Resident 146's Order Summary, dated 10/22/2025, the Order Summary indicated Resident 146 had a physician order for observation and monitoring every 15 minutes related to allegedly touching a female resident. During a review of the facility's policy and procedure (P&P), titled Abuse Prevention and Reporting, dated 11/15/2025, the P&P indicated, Telecare is committed to protecting the physical and emotional well-being and personal possessions of every resident. Telecare Skilled Nursing Facilities have systems, procedures and a program of employee training and supervision in place to foster dignified treatment, respect, and compassion for residents. Any form of mistreatment of residents including but not limited to abuse, neglect, exploitation, involuntary seclusion, misappropriation of property or any crime are strictly prohibited. All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and suspicion of a crime are reported immediately to the administrator of the facility and to other officials in accordance with State law (including to the State licensing and certification agency). All allegations mentioned shall be investigated. Reports will be made in a timely manner based on State statutes. Telecare Corporation encourages all residents, staff, families, visitors, volunteers, and resident representatives to champion resident's rights and report any suspected acts of abuse without fear of reprisal.

Based on observation, interview, and record review, the facility failed to implement its policy to protect one of four sampled residents (Resident 1) from being sexually abused by Resident 2, by not monitoring both residents. On 7/21/18 at 1:10 p.m., Resident 2 sexually assaulted Resident 1 (Cross referenced to F689). This deficient practice resulted in Resident 1 being sexually assaulted and transferred to a general acute care hospital (GACH). The GACH report indicated Resident 1 sustained a bruise to the right shoulder, right thigh, abrasions (area damaged by scraping or wearing away) to bilateral breast nipples, bruise (skin discoloration) to the left side of the back, and a large open laceration (cut) to the posterior fourchette (small fold of membrane connecting the labia minora in the posterior part of the vulva) of the vagina. Findings: A review of the facility's final investigation related to Resident 1 being abused, dated 7/24/18, indicated that the facility's Laundry staff (L1) observed Resident 2 on top of Resident 1. L1 stated that Resident 2 raped (sexual assault involving sexual intercourse and penetration) Resident 1 without her consent. A review of the Resident 1's Admission Record (face sheet) indicated the resident was admitted to the facility on [DATE]. Resident 1 [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 5/9/18, indicated Resident 1 was moderately impaired with poor decision-making and required cues/supervision for daily decision- making. A review of the facility's Post Event Assessment Form (PEAF), dated 7/21/18 and timed at 12:15 p.m., indicated that Resident 2 was seen by L1 in Resident 1's room in bed laying on top of Resident 1. It also indicated that Resident 1 was clothed and getting off Resident 1 and into his wheelchair. The PEAF indicated Resident 2 put his finger to his lips in a shhh manner and told the witness don't say anything. The report indicated L1 observed blood on Resident 1's clothes, the bed and on Resident 2's hand. The report indicated that during the interview with Resident 2, when asked about the incident, Resident 2 stated, I was only kissing her. The report indicated that blood was observed on Resident 2's left hand by the nursing staff. A review of the Sheriff Supplemental Report-Special Victims Bureau, dated 7/23/18, indicated Resident 2 was passing by Resident 1's room and went in to Resident 1's room and was lying on top of her kissing her and was touching her body. The report indicated that Resident 2 put his hand on Resident 1's vagina and was touching her vagina when the facility's staff came in and caught them. It also indicated Resident 2 denied having sex with Resident 1. Resident 2 stated that Resident 1 must have been on her menses (period) because he had blood on his hands and fingers from when he was digitally penetrated Resident 1's vagina. A review of the care plan titled, Living in Control Recovery Plan, dated 2/22/18, indicated that the goal was to educate Resident 1 on ways to protect herself from inappropriate sexual behavior. The staff's interventions indicated that the facility staff would ask Resident 1 about specific current situations in which she may be experiencing inappropriate sexual behavior from peers and the staff would help Resident 1 when feeling confused about a situation. A review of the physician's orders [REDACTED]. A review of Resident 1's physician progress notes [REDACTED]. The note indicated that Resident 1 was observed with vaginal bleeding, blood on the clothes and floor, with vaginal pain of (10/10) on a pain scale, 10 being the worse. A review of the physician's assessment, dated 8/10/18, indicated that Resident 1 did not have the capacity for sexual consent. A review of the Nurses Progress note, dated 7/21/18 and timed at 3:44 p.m., indicated Resident 1 was sent out to the GACH due to the sexual assault. A review of a forensic nurse (nursing process utilized in health care in the investigation of trauma and/or death related to abuse, violence, criminal activity, liability, and accidents) report, dated 7/21/18 and timed at 8:05 p.m., indicated Resident 1 had red bruising to the right shoulder, right thigh measuring one centimeter (cm) by four (4) cm and 4cm x 5cm, red abrasions to the nipples, red bruising to the left side of the back measuring 5cm x 6cm, and a large open laceration (deep cut) freshly bleeding to the bottom vaginal area. A review of the Resident 2's Admission Record (face sheet) indicated the resident was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated [DATE], indicated a BIMS score of 14 (13-15 = cognition (thought process) intact), which indicated that Resident 2 had no problems remembering or impaired cognition. The MDS indicated Resident 1's range of motion (ROM) was impaired on one side of the lower extremities and the resident used a wheelchair for mobility. On 7/24/18 at 2:42 p.m., during a telephone interview, L1 stated that on 7/21/18 at approximately 1:20 p.m., she walked into Resident 1's room after opening the door to deliver the residents' clothes, and saw Resident 1 with her legs spread open and Resident 2 on top of her. L1 stated that she told Resident 2 to get away from Resident 1 and that she would be reporting it to the nurses. L1 stated she saw a pool of blood on Resident 1. L1 stated that Resident 2 got up and got in his wheelchair and wheeled himself out of the room. L1 stated that Resident 1 denied consenting for sexual intercourse with Resident 2 and Resident 1 stated she could not call for help because Resident 2 put his tongue and spat inside her mouth. On 7/26/18 at 12:30 p.m., during an interview, Social Worker 1 (SW 1) stated she did not report Resident 2's multiple request to have sex with Resident 1 and another female resident in the facility to the treatment team. SW1 stated that she did not reported because she had talked to Resident 1 regarding having sex with other residents. On 7/26/18 at 12:38 p.m., during an observation and concurrent interview, Resident 1 appeared nervous and fidgeting (small movements of hands or feet through nervousness or impatience) with her fingers, holding onto the chair. Resident 1 stated she had no memory of what happened with Resident 2, of her being sexually assaulted. On 7/26/18 at 1:03 p.m., during an interview, SW 2 stated that on 7/21/18 she went to see Resident 1 after the incident. SW 2 stated that Resident 1 appeared as if she was not there, leaning forward on the chair looking down at the floor. SW 2 stated that Resident 1 was affected by what happened due to the look in her eyes (staring blank to the wall). SW 2 stated that after Resident 1 returned from the hospital, she showed behaviors of holding on tight to the chairs and looking down to the floor when ambulating compared to walking straight with her head looking straight ahead. SW 2 stated that Resident 1 was placed on a 30 minute monitoring check on 5/21/18 due to a previous incident of a Resident 4 kissing Resident 1. SW 2 stated that during the monitoring, staff should had been checking on Resident 1 to ensure the incident would not happen again. On 7/26/18 at 1:21 p.m., during an interview, the Clinical Director (CD) stated that 30 minutes checks means that staff physically sees the resident that was being monitored and documents it on a form. On 7/26/18 at 1:40 p.m., during a concurrent interview and review of the facility's video footage with the Director of Nursing (DON), Resident 2 was seen entering Resident 1's room at 1:10 p.m., on 7/21/18 and shutting the door. At 1:21 p.m., 11 minutes later, L1 seen entering Resident 1's room. At 1:22 p.m., the same day Resident 2 was observed wheeling himself out of Resident 1's room and positioning himself in front of the room. At 1:23 p.m., the same day, the facility's staff was seen running into Resident 1's room. The DON stated that the staff should have been monitoring Resident 2 to prevent him from going near Resident 1 again after the initial incident on 7/21/18. On 7/27/18 at 3:30 p.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) stated that upon walking into room, Resident 1 was observed with moderate amount of blood on her pants by the vaginal area. On 8/1/18 at 8:32 a.m., during an interview and concurrent record review, Registered Nurse 1 (RN 1) stated that a facility staff was supposed to be watching Resident 1 at all times and should not had allowed Resident 2 to approach Resident 1 after the sexual assault on 7/21/18 at 1:10 p.m., incident occurred. On 8/1/18 at 1:43 p.m., during an interview, the CD stated that the facility's staff conducts sexual assessments on residents that verbalize wanting to be sexually active. The CD stated that there was no sexual assessment conducted for Resident 2 since neither residents had the capacity to give sexual consent. A review of the facility's policy titled, Abuse Prevention and Reporting, revision date 11/20/17 indicated that the resident must not be subject to abuse by anyone, including but not limited to facility staff, other residents, consultants, or volunteers, family, friends or other individuals. The policy indicated that the victim and/or aggressor shall be placed on safety precautions and the physician and responsible party shall be notify.

Based on observation, interview, and record review, the facility failed to follow its policy and residents' plan of care to ensure that one of six sampled residents was free from abuse and mental anguish. Resident 1 was physically assaulted and abused by Resident 2 on 4/15/17, while not supervised, resulting in injury and mental anguish. This deficient practice of residents not being supervised in the hallway, resulted in Resident 1 being physically abused, and transfer to a general acute care hospital (GACH) and diagnosed with [REDACTED]. Findings: A review of Resident 1's Admission Face Sheet Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 4/6/17, indicated Resident 1 had severe cognitive (thought process) and memory impairment. The MDS indicated Resident 1 ambulated without any assistive devices and did not required staff oversight at any time during locomotion on/off unit. On 5/1/17 at 3:03 p.m., during a concurrent observation and interview, in the presence of the Clinical Director (CD), Resident 2 stated while smiling, I don't remember pushing or hitting anyone. During the concurrent interview, the CD stated Resident 2 has aggressive behaviors towards others. A review of Resident 2's Admission Face Sheet Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated [DATE], indicated Resident 2's cognition was intact and had no memory impairments. The MDS further indicated Resident 2 required the use of a walker for ambulation and did not require staff supervision at any time during locomotion on/off unit (how resident moves between locations). On 5/1/17 at 3:30 p.m., during an interview, the Director of Nursing (DON) stated Resident 2 have a history of being verbally aggressive towards other residents. The DON stated there was no staff present on 4/15/17 during the altercations between Resident 1 & 2, but two residents witnessed (Residents 3 and 4) the altercation. The DON stated, The hall should have been monitored to prevent residents from getting hurt. A review of Resident 2's care plan, dated 7/20/16, and titled, Mental Health Recovery- altercations in Mood and Behavior, potential for aggressive behaviors, indicated the staff should monitor episodes of mood swings every shift, record, and do monthly summaries. On 5/1/17 at 4:11 p.m., during an interview in the presence of the DON, Resident 3 stated that while waiting in the hallway to go on a smoking break, Resident 2 punched Resident 1 in the face six (6) times and then dragged Resident 1 down to the floor using her clothing for no reason. Resident 3 stated that Resident 1 was bleeding from her nose and there was no staff around supervising them. Resident 3 stated she too felt afraid of Resident 2 because of Resident 2's aggressive behavior. A review of Resident 3's Admission Face Sheet Record indicated the resident was admitted to the facility on [DATE]. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's MDS, dated [DATE], indicated Resident 3's cognition was intact and had no memory problems. At 4:35 p.m., on 5/1/17, during a concurrent interview and record review, the DON stated she was not aware of the resident's (Resident 1) nasal fracture. The DON stated Resident 2 should had been monitored for her aggressive behavior. On 9/15/17 at 10 a.m., during an interview, Resident 1 did not remember being hit in the face by Resident 2. On 9/15/17 at 12:33 p.m., during a concurrent interview and record review of the incident report, Registered Nurse 1 supervisor (RN 1) stated that the incident between Residents 1 and 2 occurred in the hallway near Station 2. RN 1 stated Resident 1 was bleeding from her nose and she immediately notified the primary physician (MD) with orders for an x-ray. RN 1 stated that Resident 2 was very aggressive. On 9/15/17 at 12:48 p.m., during an interview, Certified Nurse Assistant 1 (CNA 1) stated Resident 2 was strong and aggressive, while Resident 1 was calm and would just walk around the facility. A review of the facility's Post Event Assessment form, dated 4/15/17, indicated that upon assessment Resident 1 sustained an abrasion (superficial skin injury) to the bridge of the nose, right side of the upper lip swelling, right hand base of thumb and right cheek redness. The report indicated Resident 1 stated she was trying to talk to Resident 2 and suddenly she (Resident 2) began striking her for no reason. Resident 1 stated, I don't know why she hit me, I was just standing there talking to her. A review of Resident 1's X-Ray results performed on 4/15/17 at 10 p.m., indicated the resident sustained [REDACTED]. A review of the GACH's report, dated 4/16/17, and timed at 1:50 p.m., indicated Resident 1 had nasal pain after an assault with [DIAGNOSES REDACTED]. The GACH's emergency room (ER) note, dated 4/16/17 and timed at 1:44 a.m., indicated Resident 1 had nasal trauma after being attacked at a facility, with a moderate level of pain that worsen by touching and/or movement. The CT scans ((computed tomography scan) makes use of computer-processed combinations of many X-ray measurements taken from different angles) of the nose and head were done to rule-out intracranial bleeding (IC) and was negative for IC bleed, but positive for nasal fracture. At 5:05 p.m., on 9/18/17, during a telephone interview, CNA 2 stated he found Resident 1 on her knees and bleeding from her nose. CNA 2 stated he saw Resident 2 near Resident 1, but was not aware of what had happened at the time, since he was coming from the dining room. A review of the facility's policy and procedure titled, Assaultive Precaution, revised on 8/26/16, indicated the facility would place residents, who demonstrate assaultive behaviors or threatening to assault others, on assaultive precautions.

Based on interview and record review, the facility failed to follow its policy and resident's plan of care to ensure adequate supervision and care was provided for one of six sampled residents (Resident 1). Resident 1 was physically abused by Resident 2 in an unsupervised area of the facility resulting in injury (Crossed referenced to F223). This deficient practice of residents' not being supervised resulted in Resident 1 being physically abused with mental anguish, transferred to a general acute care hospital (GACH) and diagnosed with [REDACTED]. Findings: A review of Resident 1's Admission Face Sheet Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 4/6/17, indicated Resident 1 had severe cognitive (thought process) and memory impairment. The MDS indicated Resident 1 ambulated without any assistive devices and did not required staff oversight at any time during locomotion on/off unit. On 5/1/17 at 3:03 p.m., during a concurrent observation and interview, in the presence of the Clinical Director (CD), Resident 2 stated while smiling, I don't remember pushing or hitting anyone. During the concurrent interview, the CD stated Resident 2 has aggressive behaviors towards others. A review of Resident 2's Admission Face Sheet Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated [DATE], indicated Resident 2's cognition was intact and had no memory impairments. The MDS further indicated Resident 2 required the use of a walker for ambulation and did not require staff oversight at any time during locomotion on/off unit (how resident moves between locations). On 5/1/17 at 3:30 p.m., during an interview, the Director of Nursing (DON) stated Resident 2 had a history of [REDACTED]. The DON stated there was no staff present during the incident but two residents (Residents 3 and 4) witnessed the incident. The DON stated, The hall should have been monitored to prevent residents from getting hurt. A review of Resident 2's care plan, dated 7/20/16, and titled, Mental Health Recovery- altercations in Mood and Behavior, potential for aggressive behaviors, indicated the staff should monitor episodes of mood swings every shift, record, and do monthly summaries. A review of a Licensed Progress Note, dated 4/14/17, and timed 3:30 p.m., indicated Resident 2 was severely agitated and hard to be redirected. On 5/1/17 at 4:11 p.m., during an interview in the presence of the DON, Resident 3 stated that while waiting in the hallway to go on a smoking break, Resident 2 punched Resident 1 in the face six (6) times and then dragged Resident 1 down to the floor using her clothing for no reason. Resident 3 stated that Resident 1 was bleeding from her nose and there was no staff around supervising them. Resident 3 stated she too felt afraid of Resident 2 because of Resident 2's aggressive behavior. A review of Resident 3's Admission Face Sheet Record indicated the resident was admitted to the facility on [DATE]. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's MDS, dated [DATE], indicated Resident 3's cognition was intact and had no memory problems. At 4:35 p.m., on 5/1/17, during a concurrent interview and record review, the DON stated she was not aware of the resident's (Resident 1) nasal fracture. The DON stated Resident 2 should had been monitored for her aggressive behavior. On 8/7/17 at 1:28 p.m., during an interview, Resident 4 could not remember the incident between Residents 1 and 2. Resident 4 was asked if the staff monitored the residents and the resident stated, Some of the times we are monitored and sometimes other times we are not. A review of Resident 4's (Admission Face Sheet Record) indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 4's MDS, dated [DATE] indicated the resident's cognition was intact and had no memory problems. On 9/15/17 at 10 a.m., during an interview, Resident 1 did not remember being hit in the face by Resident 2. On 9/15/17 at 12:33 p.m., during a concurrent interview and record review, Registered Nurse 1 supervisor (RN 1) stated that the incident between Residents 1 and 2 occurred in the hallway near Station 2. RN 1 stated Resident 1 was bleeding from her nose and she immediately notified Resident 1's physician (MD) and received orders for x-ray. RN 1 stated that Resident 2 was aggressive. A review of the facility's form titled, Workers assignment Sheet 3 PM-11 PM for Station 2, dated 4/15/17, indicated that there was no staff assigned to monitor the hallway at 6 p.m., on 4/15/17, (on the day of the incident). On 9/15/17 at 12:48 p.m., during an interview, Certified Nurse Assistant 1 (CNA 1) stated she did not see the incident between Residents 1 and 2, because she was in the dining room. CNA 1 stated, Resident 2 was strong and aggressive while Resident 1 was calm and just walked around the facility. On 9/18/17 at 4:38 p.m., during an interview and review of the facility's daily staff assignment record, Director of Staff Development (DSD) stated that at 6 p.m., on 4/15/17, there was no supervision in the hallway where Residents 1 and 2 were because the staff was taking residents to the dining room for dinner and they were not expecting residents to be outside in the hallway. A review of Resident 1's care plan, dated 10/15/16, and titled, Living a Meaningful Life .Resident 1 wanders throughout the milieu (environment) often getting lost, indicated the staff's intervention included encouraging the resident to engage in 1:1 interaction with staff and peers. A review of the facility's Post Event Assessment form, dated 4/15/17, indicated that upon assessment Resident 1 sustained an abrasion (superficial skin injury) to the bridge of the nose, right side of the upper lip swelling, right hand base of thumb and right cheek redness. The report indicated Resident 1 stated she was trying to talk to Resident 2 and suddenly she began striking her for no reason. Resident 1 stated, I don't know why she hit me, I was just standing there talking to her. A review of Resident 1's X-Ray results performed on 4/15/17 at 10 p.m., indicated the resident sustained [REDACTED]. A review of the GACH's report, dated 4/16/17, and timed at 1:50 p.m., indicated Resident 1 was seen for nasal pain after an assault with [DIAGNOSES REDACTED]. The GACH's emergency room (ER) note, dated 4/16/17 and timed at 1:44 a.m., indicated Resident 1 had nasal trauma with a moderate severity level and pain made worse by touching and movement. The CT scans ((computed tomography scan) makes use of computer-processed combinations of many X-ray measurements taken from different angles) of the nose and head were done to rule-out intracranial bleeding (IC) and was negative for IC bleed, but positive for nasal fracture. On 9/18/17 at 4:56 p.m., during a telephone interview, Licensed Vocational Nurse 1 (LVN 1) stated a staff found Resident 1 on her knees bleeding from her nose. At 5:05 p.m., on 9/18/17, during a telephone interview, CNA 2 stated he found Resident 1 on her knees and bleeding from her nose. CNA 2 stated he saw Resident 2 near Resident 1, but was not aware of what happened since he was coming from the dining room when he found the resident. A review of the facility's policy and procedure titled, Assaultive Precaution, revised on 8/26/16, indicated the facility would place residents, who demonstrate assaultive behaviors or threatening to assault others, on assaultive precautions. A review of the facility's policy and procedure titled, Rounds, revised on 8/10/06, indicated the facility's staff would conduct hourly rounds. A review of the facility's policy and procedure titled, Zone Management- to enhance the safety of the milieu (social environment), revised on 9/13/06, indicated that zone monitoring system prioritizes visual supervision and antecedent management in order to minimize the likelihood for intrusive, aggressive, or risky behaviors in the facility.

Based on observation, interview, and record review, the facility failed to protect two of two residents of the same sex (Residents 1 and 2) from sexual and physical abuse. Resident 1 was not protected from unwanted sexual advances from Resident 2. Resident 2 was not protected from physical abuse from Resident 1. The facility failed to assess, monitor, and develop a plan of care to address Resident 2's history of inappropriate sexual behavior, after Resident 1 made several complaints about Resident 2's inappropriate behavior and made several requests for a room change. These failures resulted in Resident 1 being sexually assaulted by Resident 2 (Resident 2 stuck his finger in Resident 1's crotch) and Resident 2 being physically assaulted by Resident 1 (Resident 1 reacted by punching Resident 2's head). Resident 1 sustained a right fractured hand (broken bone) and Resident 2 had facial scratches. Findings: On 7/13/15, at 10:50 a.m., during a recertification survey, an entity reported incident (ERI) was reported regarding a resident to resident altercation. On 7/13/15, at 1:50 p.m., during an interview, a certified nurse assistant (CNA 1) stated Resident 2 put his hand into Resident 1's crotch area (the bottom of the pelvis, the region of the body where the legs join the torso, and is often considered to include the groin and genitals) and the two residents got in a fight. On 7/13/15, at 2:05 p.m., during an interview, a registered nurse supervisor (RN 1) stated on Saturday, 7/11/15, at approximately 3:05 p.m., Resident 1 came to the nurses ' station and complained that his hand hurt. Resident 1 stated he had a fight with his roommate (Resident 2) because Resident 2 put his hand in his crotch. RN 1 stated Resident 1 was transferred out to the hospital for an evaluation due to the complaint of pain in his hand. RN 1 stated Resident 2 had scratches on his right cheek with a small amount of blood. On 7/14/15 at 1 p.m., during an interview, the director of nursing (DON) stated according to Resident 1, Resident 2 was lying on the bed naked, sticking his finger out and asked Resident 1, Do you want some of it? Resident 1 stated Resident 2 then stuck his finger in his crotch area, so he (Resident 1) punched Resident 2. The DON stated Resident 1 sustained a hand fracture as a result of hitting Resident 2. A review of the facility's investigation report, dated 7/11/15, indicated on 7/11/15, at 3:15 p.m., Resident 1 approached Nurses Station 2 and complained that his right hand was hurting. Resident 1 stated he broke his hand while fighting with his roommate (Resident 2). Resident 1 stated while he was opening his closet, Resident 2 came close to him and attempted to hug him. Resident 1 stated he told Resident 2,Don't hug me man, Resident 2 flicked him off and he punched Resident 2 in the back of the head. According to the facility's investigation report, the facility's staff interviewed Resident 2 and he stated, I came close to him and stuck my 3rd finger into his crotch area and he (Resident 1) got mad and hit me in the back of my head. Resident 2 walked away from the facility's staff and refused further interview. Resident 1 was transferred to a general acute care hospital (GACH) for a hand x-ray. The facility's physician reported to the nurses, Resident 1 sustained a [MEDICAL CONDITION] right fifth metacarpal bone (the bone below the pinky finger). A review of Resident 1's interview statement taken by the facility's DON, dated 7/13/15, and timed at 7:55 a.m., indicated when Resident 1 walked into his room, Resident 2 was lying on the bed naked, soliciting sex from him. Resident 2 then got up and stuck his middle finger up in his (Resident 1's) crotch. Resident 1 stated he was heterosexual (sexually attracted to people of the opposite sex) and Resident 2 was gay (a homosexual). Resident 1 punched Resident 2 on the head and both residents started fighting. The two residents rolled over each other on the floor. Resident 1 stated he stopped the fight when Resident 2 told him that it was enough. Resident 1 stated he walked out of the room and reported the incident to staff. On 7/14/15, at 7:10 a.m., during an observation, Resident 2 was lying in bed awake and alert, but refused to be interviewed. A review of Resident 2's Admission Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's Minimum Data Sheet (MDS), an assessment and care screening tool, dated 4/9/15, indicated Resident 2 was cognitively impaired (trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), but was independent in his activities of daily living (ADLs). A review for Resident 2's annual psychiatric evaluation, dated 7/13/15, and timed at 8:40 a.m., indicated the resident was admitted to a psychiatric hospital on [DATE], for displaying sexually inappropriate behavior at his board and care facility. A review of Resident 2's nursing care plans indicated the resident did not have a plan of care to address his history of displaying unwanted sexually inappropriate behavior. On 7/14/15, at 2:20 p.m., during an observation, Resident 1 was sitting in the facility's activity room with a right hand sling (a device hanging from the neck to hold the hand up). Resident 1's right hand was swollen with greenish colored bruises on the back of the right hand. On 7/14/15, at 2:25 p.m., during an interview, Resident 1 stated about five days prior (two days prior to the incident) he had told the administrator and the social worker that he wanted Resident 2 to move out of his room. Resident 1 stated he told the administrator and social worker that Resident 2 tried to have sex with him. Resident 1 stated Resident 2 would say, Let's make love, and stated Resident 2 had put his hands on him twice before the incident (Resident 1 could not remember the dates and times when the incidents occurred). Resident 1 stated he saw Resident 1 lying in the bed naked. Resident 1 stated the facility's staff offered him to move to another room, but he needed a room with a private bathroom (one room with one bathroom, used by two residents) due to his medical condition requiring self-catheterization (insert a tube/catheter into the bladder to drain the urine out of the body) throughout the day. Resident 1 stated other rooms had shared bathrooms (two rooms with one bathroom, used by eight residents). Resident 1 stated a semi-private bathroom would provide a cleaner environment, decreased the risk of his recurrent urinary tract infection. Resident 1 stated, on the day of the incident (7/11/15), he walked into his room, Resident 2 was lying in the bed and said, Do you want some of this? Resident 1 stated he ignored Resident 2, then Resident 2 stood up, walked from behind him and stuck his finger up in his crotch. Resident 1 stated putting a finger up in his crotch was an assault and he (Resident 1) stated he reacted by putting Resident 2 on the floor and hitting Resident 2's head. A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Sheet (MDS), an assessment and care screening tool, dated 5/21/15, indicated Resident 1's cognition was intact (a person does not have trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). According to the MDS, Resident 1 did not have short or long-term memory problems and was independent in his ADLs. A review for Resident 1's psychiatric notes, dated 6/24/15 at 1:52 p.m., indicated the resident was doing well; no interim of changes or events; continued to go to groups and play his guitar. The psychiatrist documented Resident 1's only complaint was his roommate (Resident 2) was gay. Resident 1 told the psychiatrist (a physician who specializes in psychiatry, in the [DIAGNOSES REDACTED]. Resident 1 stated Resident 2 should be moved and that he deserves to stay in his room. The psychiatrist's note indicated for the facility's staff to work with Resident 1 to resolve the issue. A review of another of Resident 1's psychiatric note, dated 7/1/15, and timed at 3:05 p.m., indicated the resident was doing well, no interim changes or events. It was documented Resident 1's only complaint was that his roommate bothers him and was gay and crazy. According to the note, Resident 1 told the psychiatrist, that he spends most of his time out of the room, going to groups, so he had not got into any fights with his roommate. A review of Resident 1's nursing care plans, indicated the resident did not have a care plan in place to address the resident's concern regarding his roommate ' s constant attempts to solicit sexual behavior from him after Resident 1 complained about Resident 2's inappropriate sexual behaviors. A review of the physician's orders [REDACTED]. A review of Resident 1's x-ray results, dated 7/11/15, and timed at 7:30 p.m., indicated Resident 1 sustained a comminuted fracture (break or splinter of the bone into more than two fragments) of the fifth metacarpal diaphysis (intermediate part of the skeletal hand located between the phalanges (are digital bones in the hands and feet) of the fingers and the carpal bones of the wrist). On 7/11/15, at 8:45 p.m., Resident 1 had a physician's orders [REDACTED]. A review of the GACH's note, dated 7/11/15, indicated Resident 1 had a metacarpals fracture (boxer's fracture, breaks in the neck of the second and third metacarpal bones) and a hand splint was applied (a device that support injured limbs; to keep bones from moving while they heal). The GACH's note indicated for Resident 1 to immediately follow-up with an orthopedist (a physician who specialized in bones) and the primary care physician in two to three days and to return to the emergency department (ED) if the symptoms worsen. A review of the nurses' note, dated 7/12/15, and timed at 2:36 a.m., indicated Resident 1 returned to the facility from the ED via gurney at 2 a.m., with a [DIAGNOSES REDACTED]. Resident 1 was temporarily placed in another room. A review of the nurses' note, dated 7/12/15, and timed at 11:02 p.m., indicated Resident 1 requested a room change due to feeling uncomfortable, in his current room. The resident became upset, yelled at the staff and stated it was unfair that he had to move instead of his roommate, (Resident 2), who initiated the whole incident by trying to touch him in a sexual manner. The nurses' note indicated Resident 1's nurse advised the resident that he could return to his previous room, with Resident 2, if he chooses to do so. Resident 1 declined and stated not with that faggot. On 7/14/15, at 3:10 p.m., during an interview with the facility's social worker, she stated Resident 1 requested to have Resident 2 moved to another room. The social worker stated Resident 1 verbalized that he thought Resident 2 was gay and wanted to have sex with him (Resident 1). A review of Resident 2's medical record indicated there was no documented evidence Resident 2 was counseled about his inappropriate sexually behavior related to the facility's abuse policy. There was also no documented evidence that the facility asked Resident 2 to make a room change, due to Resident 1's need to have a semi-private bathroom. On 7/14/15, at 3:20 p.m., during an interview, the facility's clinical director stated Resident 1 had talked about room changing, but there was no open bed available for a male resident. The clinical director stated when there was a room available, Resident 1 refused to move, because Resident 1 requested for his roommate (Resident 2) to move. The clinical director stated since Resident 1 was the one who requested for the room change, he had to move, not his roommate. A review of the facility's policy, dated 4/10/13, titled Policy and Procedure on Abuse Reporting, defined sexual abuse as sexual harassment, sexual coercion and sexual assault are examples. The policy also indicated that each resident had the right to be free from abuse (including physical and sexual abuse). The policy stipulated Residents must not be subjected to abuse by anyone, including but not limited to, other residents.

Based on observation, interview, and record review the facility failed to follow their own abuse policy. The facility failed to protect one of 30 (Resident 20) sampled residents from being assaulted by another resident, staff members failed to report the first assault, and staff members failed to protect Resident 20 from another assault by the same resident. (20 and 21) Resident 21, who was identified as having a history of aggressive behaviors, hit Resident 20 on 9/22/13 in the right face/jaw which resulted in pain, surgery and hospitalization to repair the broken jaw. The facility staffs who were witnesses to the incident did not report this incident to the charge nurse. The facility did not reassess Residents 21 after the incident which left Resident 20, other residents and staff at risk for further harm. There was no documented evidence the facility placed Resident 21 on assaultive precautions ((where staff document the whereabouts of the resident usually from a distance) prior to the physical assault when on 9/19/13 he demonstrated irritable/angry mood, followed nurses and made threatening remarks to harm, and was difficult to be redirected. Almost a month later on 10/29/13 in another incident Resident 21 struck Resident 20 on the right side of his head with a closed fist, which resulted in the resident falling forward and hitting the wall which resulted in an abrasion to the right arm. Findings: A review of Resident 20's clinical records, indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. shakes rapidly and uncontrollably). The MDS assessment, dated 6/18/13, indicated Resident 20 was alert and oriented, needing supervision with personal hygiene and bathing, used a walker as a mobility device, and was continent (had control) of bowel and bladder functions. A review of Resident 21's clinical records indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the initial rehabilitation notes, dated 5/10/12, indicated Resident 21 said he was missing his front teeth due to a fight at another facility. The MDS assessment, dated 8/2/13, indicated Resident 21 was alert and oriented, had moderate difficulty with his hearing, exhibited behaviors of hallucination and delusions (a belief held with strong conviction despite clear and obvious evidence that it is not true or false belief), needed supervision with hygiene and bathing, and was continent (had control) of bowel and bladder functions. A review of Resident 21's care plan for aggressive behaviors, due to feeling threatened when his personal space is invaded, dated 8/13/13, indicated the goal was he will demonstrate appropriate behaviors and he will not have any incidents of pushing, hitting, slapping, or being assaultive towards others (peers and staff). The recovery steps were for the staff to monitor the Resident 21 ' s mood and behaviors since he demonstrates impulsive reactions/behaviors when mood is irritable and or angry, and when people are invading his space or not listening to his request for space the staff will redirect the resident to a quiet place away from people and stimuli when they observe him escalating and arguing with peers/others. The review of Resident 21's social services monthly notes indicated the following: a. On 8/13/13, Resident 21 was involved in an incident on the patio where he pushed a male peer. Resident 21 was placed on assuasive precautions every 15 minutes (where staff documents the whereabouts of the resident usually from a distance) and his peer passes (allowing the resident to leave the facility for a period of time with other residents) were placed on a hold. The social worker counseled the resident about his behaviors but he got angry and irritable, demonstrated disorganized thought processes, exhibited paranoid thinking, and was verbally aggressive and accusatory towards the social worker because his peer pass had been taken away. b. On 9/12/13, Resident 21 was upset when he was not able to get the approval from his conservator in time to go out on pass with his brother. c. On 9/19/13, Resident 21's brother canceled his family pass. The resident demonstrated, irritable/angry mood, intrusive and disruptive behaviors with the nurses, exhibited by following a nurse around making threats to harm her. The resident was difficult to redirect. After the incident the resident was never placed on any assault precautions and the care plan for aggressive behaviors was not revised. d. A review of the social work monthly notes, dated 9/20/13, indicated Resident 21 went on an unsupervised peer pass (outside of the facility with other residents). The notes indicated the resident left his group and did not return until later (time unknown). The resident ' s brother came to visit but according to the notes the resident was very agitated (behavior not specifically described) when his brother left. The notes failed to describe Resident 21 ' s manifested agitated behavior and what the facility did to address the agitation in order to protect other residents, staff and visitors. A review of the facility's investigation report involving an assault (resident hit another resident), dated 9/22/13, indicated at around 5:20 p.m., the staff was passing out coffee in the yellow room when Resident 21 walked in and asked for a cup of coffee. The staff informed Resident 21 of his dinner schedule which was at 6 p.m. in the dining room. Resident 20 who was sitting in the yellow room got up and blocked the coffee cart with his body to prevent Resident 21 from grabbing the coffee. Resident 21 got upset and struck Resident 20 in the face/jaw. A review of the license nurses notes, for Resident 20 and 21, dated 9/22/13, failed to indicate a re-assessment of the residents after the assault incident. Neither residents was put on any precautions nor were their care plans revised. A review of the hospital history and physical, dated 9/26/13, indicated Resident 20 was admitted because of a severely displaced right mandibular (lower jaw bone) angel fracture which resulted in open reduction with internal fixation (surgically repairing the bone). The notes further indicated the resident received pain medication and antibiotic for the procedure. On 10/7/13 at 11:53 a.m., the ADON stated everyone witnessing an incident is responsible for reporting but the assault of Resident 20 by Resident 21 was not reported to the charge nurse. All staff that witnessed this incident but did not report it to the charge nurse was suspended. When asked was the two residents assessed by a licensed nurse after the incident, the ADON did not answer. When asked was Resident 20, other residents, staff, and visitors protected against further attacks by Resident 21, the ADON did not answer. When asked what type of interventions could have been instituted that may have prevented this assault from happening, the ADON said maybe the mental health worker could have served Resident 21 a cup of coffee and then re-directed him back to the regular dining room. A day after the incident the social work monthly notes, dated 9/23/13, indicated Resident 21 demonstrated an increase in delusional thinking, irritable mood, impulsive and aggressive behaviors. Resident 21 became hyper verbal, argumentative, cursing at staff, and was very paranoid. The resident was counseled for the incident of hitting Resident 20 the previous day and was placed on assault precautions every 15 minutes. On 1/13/14 at 5:04 p.m., in an interview with CNA 2 said he was in the big dining room when he heard noises from the yellow room and saw both residents on the floor. Resident 21 was beating Resident 20 right before he started to separate them. When asked if anyone reported this incident to the charge nurse, he said he thought the other 2 employees who were in the yellow room reported the incident. On 3/20/14 at 3 p.m., Resident 20 was sitting on his seated walker outside in front of the building. The resident said he was in the yellow room when Resident 21 came in and asked for coffee. Since Resident 21 always steals their coffee, he got up and stood in front of the coffee cart when Resident 21 came to his side and hit his face with a closed fist. Resident 20 tripped Resident 21 continue to hit him while they were both on the floor. Resident 20 said after they were separated he went to his room but he had so much pain that it prevented him from sleeping. Resident 20 said the next morning he came to the nurse ' s station and told the nurse he thinks he has a broken jaw that is when they sent him to the hospital for surgery. Resident 20 said Resident 21 hit him again almost a month after he broke his jaw. He said Resident 21 hit his head with a closed fist so hard it made him lose his balance, hit the wall, skinned his arm and fell to the ground. A review of the facility's post event physical assessment form, dated 10/29/13 at 8:30 a.m., indicated Resident 21 was outside in the smoking patio when he hit Resident 20 again. Resident 20 was hit on the right side of his head with a closed fist. Resident 20 fell and hit himself on the wall sustaining abrasions to his left arm. A review of a revised facility's policy and procedure titled, abuse reporting, dated 7/8/13, indicated all abuse reports will be reported immediately to the administrator and DON and or the designee. Staff is required to intervene, identify and correct situations where any type of abuse or suspected crimes may have occurred. The facility's policy for assault precautions, revised 2/9/05, indicated in order to ensure the safety and well-being of all the residents, the residents demonstrating assaultive behaviors or threatening to assault other persons will be placed on assault precautions. The licensed nurse or IDT will initiate formal assault precautions when a resident behavior is judged to be an imminent or ongoing danger to others. The nursing staff shall monitor the resident according to the predetermined level of precaution; level I thirty (30) minute checks, level II fifteen (15) minute checks and level III is 1:1 observation. The resident will not be allowed to leave the facility except for medical and or court appointments with staffs accompanying the resident at all times.

Based on observation, interview, and record review the facility failed to provide care and services to prevent mental anguish and neglect for 1 of 1 resident (Resident 1). Resident 1, who had a rash with itching for 26 days without an anti-itch agent ordered, was not provided the necessary care and services as indicated on the physician and physician assistant certified book (MD/PAC) when the resident was up late at night requesting [MEDICATION NAME] for itching. The resident had a rash for over 40 days since admission, that was not addressed until the survey team addressed the resident's concerns. These failures resulted in the resident not being adequately treated for [REDACTED]. See F441 for more information for Resident 1. Findings: At 1:25 p.m., on November 6, 2013, while the survey team was touring the patio area. A resident (Resident 1) complained the nurses were more interested in doing their paperwork then providing her treatment to her rash. The survey team, the acting director of nursing, and the facility's medical director assessed the resident's rash in her room on November 6, 2013 at 2:56 p.m. There were multiple pin-point areas, reddish in color patches noted in varying stages of healing observed on the back, buttocks, and multiple sores in various degrees were noted to the arms, breasts (including areolas (area around the breast)), stomach, lower legs, and axilla (under arm)area. Multiple areas were observed opened with sores to posterior (back) left arm and axilla area. Resident 1 stated, "They itch so bad." The acting DON stated she was unaware the rash had spread, she stated, "I thought it was just on the resident's arms." Upon completion of the resident's skin assessment with the medical director, acting DON, and the surveyors. The resident redressed and stated, "I was diagnosed with [REDACTED]. I scratch all the time and can't sleep at night. I have a lot of bugs in my hair too and I had lice and scabies before many years ago and received treatment." Resident 1 became tearful and began to cry while sitting in the wheelchair. The resident started screaming, "It's a bug. I want to leave this place. My rash is a bug and it itches. I want to go to the ER. I have shown two to three doctors this rash when they came to visit and I still have it." A review of a general acute care hospital (GACH) records dated September 6 and 10, 2013, indicated under physical examination the resident had a small papular (small, somewhat pointed elevation of the skin) rash on the dorsal (top of hand) surface of her hand with no burrowing marks. On November 6, 2013, at 3:40 p.m., LVN 1 was interviewed regarding Physician 1's notification of the resident's change in condition regarding the rash with itching. LVN 1 stated, "The doctor comes on Thursday so I didn't call him when I saw the rash yesterday and it was all over her body. Actually it's worst, but I thought because she received [MEDICATION NAME] (used to treat and prevent fungal infections) on Friday and Saturday (November 1 and 2, 2013) it would get better." A review on Resident 1's face sheet indicated the resident was admitted to facility on September 27, 2013, at 12:05 p.m. from a general acute care hospital (GACH). The resident's [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS), an admission assessment (a standardized assessment and care screening tool) with an assessment reference date of October 7, 2013, indicated the resident was able to express ideas and wants and had clear comprehension of understanding verbal content. The MDS functional status (activities of daily living), under Section G indicated Resident 1 required set-up help only for dressing, personal hygiene, bathing, and walking. An initial nursing documentation of Resident 1's skin assessment, dated September 29, 2013, two days after the resident was admitted , was placed in the physician and physician assistant certified communication book (MD/PAC) indicating the resident had red pin point marks to bilateral arms, abdomen, back, and lower legs with itching. Resident 1's physician ordered a dermatology consult on November 7, 2013, although he did not suspect scabies, but indicated to "Rule Out Scabies." [MEDICATION NAME] by mouth ([MEDICATION NAME] used to treat itching), for the resident's complaint of itching was also ordered, as well as a topical steroid cream. On November 8, 2013, at 9:50 a.m., while in Resident 1's room, she stated while smiling happily, "Thank you!, I feel much better. I'm not itching as much and I did see my doctor yesterday!" On November 8, 2013, at 2:55 p.m., CNA 1 stated she had been caring for Resident 1 since her admission in September 2013. She stated resident's shower times are based on room assignments and Resident 1's shower time was on the evening shift (3-11 p.m.). CNA 1 stated, "I told the charge nurse (LVN 1) about two to three weeks ago that the patient complained of a rash with itching." A review of the medical director's administrative note, with a dictated date of November 7, 2013, indicated Resident 1's skin assessment was conducted on November 6, 2013. The note under "Subjective", indicated the patient complained of on and off rash and itching symptoms. He indicated the resident reported symptoms that started at the prior hospital before she was transferred to the facility. The medical director documented under "Objective" the resident's skin examination there was diffuse maculopapular (flat, red area on the skin that is covered with small confluent bumps) rash on the upper extremity, shoulder and arms with no drainage. The note indicated the resident's mood was "angry." Under Assessment: he documented "Given diagnosing and treating rashes is out of writer's scope of practice (he is a psychiatrist)," we will work with nursing to communicate concerns and observations to primary care physician. The medical director's plan included, nursing staff agreeing to assess patient's roommates for any concerns for itching or rash and any institutional infection issues. On November 12, 2013, at 9:06 a.m., a review of a dermatology consult indicated Resident 1 was seen on November 11, 2013, and diagnosed with [REDACTED]. A follow-up appointment was given for December 2, 2013, at 2:30 p.m., for Resident 1. A review of the facility's policy, revised on April 10, 2013, titled, "Policy and Procedure on Abuse Reporting" indicated any form of mistreatment of [REDACTED]. The policy defined neglect as a failure to provide the care necessary to aviod physical harm, mental anguish or illness, or deterioration of resident's physical or mental condition.

Based on observation, interview, and record review, the facility failed to maintain an Infection Control Program to identify and prevent the spread of infection when a case of scabies (a highly contagious skin condition caused by an infestation of the itch mite Sarcoptes scabiei) was not diagnosed or adequately treated for [REDACTED]. Resident 1 was admitted more than 40 days with an undiagnosed reddened, itchy pin-point rash with multiple, failed attempts to resolve the symptoms and discomfort. Resident 1's roommate (Resident 2) also developed a rash with itching on November 7, 2013. Resident 1's infection spread, became infected, and itched, disrupting the resident's sleep. Eventually, a dermatologist diagnosed Resident 1 as having scabies and prescribed medication on November 11, 2013, 46 days after admission. Resident 2, Resident 1's roommate, developed a red pin-point rash with severe itching on both of her hands. The facility's Infection Control Program failed to perform surveillance and investigation to prevent the onset and spread of infection that resulted in pain, loss of sleep, and the risk for transmission of infection. Findings: At 1:25 p.m., on November 6, 2013, a resident (Resident 1) approached the team yelling, "The nurses here don't care and they do their paperwork first before helping me." As the team re-entered the facility from the patio area walking towards the nursing station, Resident 1 continued to follow behind in the wheelchair. At the nurse's station, a licensed vocational nurse (LVN 1) and the acting director of nursing (DON) were present. Resident 1 stated, "The nurses don't give me my treatment for [REDACTED]." Resident 1 pointed towards LVN 1 identifying her as the individual. LVN 1 stated, "Treatments are given in the afternoon and the resident only mentioned today she wanted her treatment in the morning." On November 6, 2013 at 1:35 p.m., while at the nursing station the acting DON reviewed the treatment record for Resident 1 and stated, "The resident is receiving an antibiotic treatment by mouth for a skin infection." On November 6, 2013, at 1:45 p.m., after obtaining consent, Resident 1's skin infection was observed by the DON and 4 surveyors. Resident 1 had multiple pin-point patches, reddish in color on the back, buttocks, arms, axilla (armpits), breasts, stomach, and lower legs. Many areas of non-intact skin were noted. Resident 1 stated, "They itch so badly." DON stated, "I thought it was just on the resident's arms," and affirmed that she was unaware the infection had spread. On November 6, 2013, at 2:25 p.m., during telephone interview, Physician 1 (the resident's attending physician) was asked about Resident 1's infection, including his assessment. Physician 1 stated, "I don't know if she is my patient or not. I have so many patients. If I ordered a treatment for [REDACTED]. I will come tomorrow to see her." On November 6, 2013, at 2:40 p.m., a document review of Resident 1's Physical Examination, dated September 6 and 10, 2013, from the general acute care hospital (GACH), indicated she had small papular (small, pointed elevation of the skin) rash on the dorsal (top) surface of her hand with no burrowing marks. After Resident 1's consent, on November 6, 2013, at 2:56 p.m., Physician 2 (the facility's medical director) was asked to assess the resident's infection. Resident 1 stated, "I was diagnosed with [REDACTED]. I scratch all the time and can't sleep at night. I have a lot of bugs in my hair too." Physician 2 assessed the resident's hair and asked the resident questions, including if she had ever heard of lice or scabies. Resident 1 responded, "I had lice and scabies before, many years ago, and received treatment." Resident 1 became tearful and began to cry. The resident started screaming, "It's a bug. I want to leave this place. My rash is a bug and it itches. I want to go to the ER. I have shown two to three doctors this rash when they came to visit and I still have it." A review of the Los Angeles County Department of Public Health (CDPH), Acute Communicable Disease Control Program on Scabies Prevention and Control Guidelines, indicated it is essential to have a policy to screen newly admitted patients for scabies during the initial assessment (especially if transferred from another healthcare facility) and immediately placing any suspect patient on contact isolation until examined for scabies (this guideline was given to the facility during an inservice by the CDPH in 2013). According to the Centers for Disease Control and Prevention, common signs and symptoms of scabies are intense itching, especially at night, and a pimple-like (papular) itchy rash. The itching and rash each may affect much of the body such as the arm, armpit, fingers, nipple, waist, and buttocks. The rash can include tiny blisters (vesicles) and scales. Scratching the rash can cause skin sores; sometimes these sores become infected by bacteria. (http://www.cdc.gov/parasites/scabies/gen_info/faqs.html#signs <http://www.cdc.gov/parasites/scabies/gen_info/faqs.html>). At 3:15 p.m., on November 6, 2013, pictures were taken of Resident 1's rash after permission was granted by the resident's conservator (a court appointed person or organization to oversee the care and decision of the resident) per the administrator. Pictures of Resident 1 ' s front and back were taken and printed by the facility ' s medical record staff. On November 6, 2013, at 3:40 p.m., LVN 1 was asked how Physician 1 was notified of Resident 1's change in condition, i.e., the infection, rash, and itching. LVN 1 stated, "The doctor comes on Thursday so I didn't call him when I saw the rash and it was all over her body. Actually it's worse, but I thought because she received [MEDICATION NAME] (a medication to treat and prevent fungal infections) on Friday and Saturday (November 1 and 2, 2013) it would get better. I put it in the doctor's communication book only. The patient hasn't been on a treatment for [REDACTED]. She came to the facility with the rash. I knew the doctor would have just told me to wait for him to see her on Thursday (November 7, 2013.) I probably should have called him." A review on Resident 1's clinical records Face Sheet, indicated the resident was admitted to facility on September 27, 2013, at 12:05 p.m., from a general acute care hospital (GACH). The resident's [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS/a standardized assessment and care screening tool) with an assessment reference date of October 7, 2013, indicated the resident was able to express ideas and wants and had clear comprehension of understanding of verbal content. The MDS functional status (activities of daily living), under Section G indicated Resident 1 required set-up help only for dressing, personal hygiene, bathing, and walking. A review of Resident 1's skin assessment, in the physician and physician assistant certified communication book (MD/PAC), dated September 29, 2013, two days after admission, indicated the resident had red pin point marks to bilateral arms, abdomen, back, and lower legs with itching. A review of several "Shower Day Skin Inspection" forms, one dated October 12, 2013, indicated small spots drawn on a full body diagram to illustrate the resident had a rash to bilateral arms, abdomen, and legs. On October 19 and 23, 2013, the Shower Day Skin Inspection form indicated the resident had a full body rash. Review of the facility's policy and procedure (P/P), titled Prevention and Control of Scabies, revised December 24, 2012, included the following: An infested person will complain of pruritus (itching), which intensifies at bedtime under the warmth of the blankets. Skin lesions are generally seen on the hands, wrists, elbows, folds of armpits, and female breasts. Lesions may be more predominate on areas of the skin having contact with moist sheets, such as the back and buttocks. A typical scabies rash is characterized by red, raised bumps (papules). A review of Physician 1's note, dated November 7, 2013, indicated the following: Resident 1's chief complaint was a skin rash with itching. Papules, skin lesions, and scales were observed. Scabies was ruled out because there were no burrows or warts. A review of the facility's P/P, titled Prevention and Control of Scabies, Signs and Symptoms, revised December 24, 2012, indicated the following: pustules, burrows, blisters, or nodules are seldom seen because the skin is often excoriated due to the intensity of itching and scratching. On November 8, 2013 at 8:25 a.m., the DON stated, "If there is a change in condition the nurses should notify the physician by the telephone or if the physician was present then they should let the physician know. I only assessed the resident's arm because that's the only place I knew she had a rash." The acting DON stated Resident 1 was seen on Thursday, November 7, 2013, by the attending physician (Physician 1), after the survey team questioned the staff regarding the rash. She stated Physician 1 did not suspect scabies; however, Physician 1 ordered a dermatology consult to rule out scabies, topical creams, and [MEDICATION NAME] ([MEDICATION NAME] used to relieve itching). The acting DON stated she was the infection control nurse and that she conducted random resident skin checks, including Resident 1's roommate (Residents 2 and 16), after seeing Resident 1's rash on November 6, 2013. The DON stated Residents 2 and 16 were free of rash, but the findings were not documented. When asked about staff with rashes she stated," I didn't question the CNAs providing care to Resident 1, because they would have told me without me asking." The acting DON was asked on November 8, 2013, at approximately 9:35 a.m., about the facility's infection control program. She stated they do not perform or track surveillance of skin rashes and/or infections. A review of the facility's CMS 2567 (survey report by the Centers of Medicare or Medicaid Services), dated November 2012, indicated the facility were cited for failure to implement their policy, titled "Prevention and Control of Scabies" by not tracking and providing surveillance of residents and staff at risk for contracting scabies. The facility's plan of correction (POC) indicated they would provide inservice to licensed nursing staff regarding the revised scabies policy and procedure, dated December 24, 2012. The DSD (director of staff development) was asked to provide evidence of the inservices, however, no evidence was provided. According to the MD/PAC communication book and the physician's orders [REDACTED]. A review of prior physician's orders [REDACTED]. 1. October 3, 2013, [MEDICATION NAME] 25 mg by mouth (PO) and [MEDICATION NAME] ointment (antibiotic). 2. October 13, 2013, Keflex 500 mg PO (antibiotic), normal saline, and [MEDICATION NAME] ointment. 3. October 21, 2013, [MEDICATION NAME] ointment (re-ordered.) 4. October 24, 2013, Keflex 500 mg (re-ordered.) 5. November 1, 2013, [MEDICATION NAME] (antifungal) 150 mg one tablet for two days. According to the MD/PAC communication book and the physician's orders [REDACTED]. These treatments failed to provide relief for Resident 1's infection and itching. A review of Physician 1's telephone order, dated November 6, 2013, indicated the following: 1. [MEDICATION NAME] 25 mg, four times a day PRN (as needed) for itching, for 10 days. 2. Epsom salt (a combination of magnesium and sulfates used to reduce inflammation) bath every evening and soak for 15 minutes for three days. 3. 50:50 mixture of [MEDICATION NAME] cream and [MEDICATION NAME] cream 2.5 % twice daily for seven days to the affected areas. A review of Physician's 1's progress note, dated November 8, 2013, indicated the following: The resident was admitted with a rash that she self-irritated, spreading it to other sites. Topical medications, oral medications, and Epsom salt bathes were ordered. On November 8, 2013, at 9:50 a.m., Resident 2 (Resident 1's roommate) was observed in bed laying on the right side while scratching. On November 8, 2013, at 10 a.m., during an observation, LVN 2 (treatment nurse) and DON conducted a skin assessment on Resident 1's two roommates (Resident 2 and 16). Resident 2 was observed with a reddish pin-point rash to both hands with the DON and LVN 2 present, Resident 2 stated that she started to itch the day before. The DON stated she was unaware of Resident 2's rash with itching and did not tell the physician. Resident 16 denied scratching and was determined to be free of rash by the DON and LVN 2. On November 8, 2013, at 2:55 p.m., CNA 1 stated she had been caring for Resident 1 since her admission in September 2013. CNA 1 stated," I told the charge nurse (LVN 1) about two to three weeks ago that the patient complained of a rash with itching." CNA 1 was asked if she currently had a rash or itching and she denied having a rash. A review of the medical director's administrative note, dictated November 7, 2013, of Resident 1's skin assessment conducted on November 6, 2013, indicated the following: Subjective: The patient complained of on and off rash and itching symptoms. She reported the symptoms started at prior hospital before she was transferred to facility. Objective: skin examination diffuse maculopapular rash (flat, red area on the skin that is covered with small confluent bumps) on upper extremity, shoulder and arms with no drainage. Mood noted as "angry." Assessment: "Given diagnosing and treating rashes is out of writer's scope of practice" (psychiatrist), we will work with nursing to communicate concerns and observations to primary care physician. Plan: Nursing staff to assess patient's roommates for any concerns for itching or rash and any institutional infection issues (community living). On November 12, 2013, at 8:20 a.m., the acting DON stated, "The facility doesn't have an infection control log." A job description for an infection control nurse was requested and the acting DON was unaware of the job description and responsibilities of an infection control nurse. On November 12, 2013, at 8:30 a.m., during an interview and review of a written declaration LVN 1 stated, " I did not document the skin assessment that the rash had spread all over in the resident's chart or call the doctor on November 5, 2013, because I knew he would have told me he will see her on Thursday." Although the MD/PAC log also indicated the resident had complained on November 3, 2013, "Still itching, requesting something for itch." On November 12, 2013, at 9:06 a.m., the DON stated the facility's nurses did the scraping for scabies on Friday, November 8, 2013, and the specimen was sent to a laboratory. According to Centers for Disease Control and Prevention and the California Department of Public Health (CDPH), only an experienced, trained physician or nurse should perform skin scrapings for scabies mites. The DON stated, "The facility's physician assistant (PA) stated we should apply [MEDICATION NAME] (medication used to treat scabies) on the resident while waiting for the skin scraping results." However, the DON was not forthcoming, because she then stated the resident was seen by the dermatologist and diagnosed to have scabies. A review of the dermatology consult, dated November 11, 2013, indicated the resident was diagnosed with [REDACTED]. A follow-up appointment was scheduled for Resident 1 on December 2, 2013, at 2:30 p.m. The facility treated Residents 1, 2, and 16 with [MEDICATION NAME]. On November 14, 2013, at 2:20 p.m., during a telephone interview with the supervisor at the CDPH/Communicable Disease, she stated the facility had contacted them about these recent scabies cases. However, the supervisor stated her staff had recently been to the facility and provided inservice training regarding scabies and did not understand why they were not tracking the rash and following the policy that was given to them.