Every finding on record at Landmark Medical Center

Based on interview and record review, the facility failed to maintain documentation related to staff's COVID-19 (respiratory illness caused by the SARS-COV 2 virus) vaccination for one Pharmacy Consultant (PC), one Registered Dietician (RD) and one Physician (MD). This deficient practice had the potential to increase the risk of acquiring Covid-19 and spread of infection in the facility.Findings: During a review of the facility's employee COVID 19 immunization (the action of making a person resistant to a particular infectious disease) records, there was no documentation indicating the PC, RD and MD received or declined the required COVID 19 vaccination, or any documentation that they were provided information on the benefits and potential risks of the COVID 19 vaccination. During an interview with the Infection Prevention Nurse (IPN) on 8/27/2026 at 3:37 p.m., the IPN stated the IPN was responsible for offering vaccination to facility staff upon hire. The IPN stated the IPN did not require the independent contractors such as the PC, RD and MD to complete the vaccination form. The IPN stated staff who completed the vaccination form were the ones that were on the payroll. During a concurrent interview and record review on 8/27/2026 at 3:45 p.m. with the IPN, the facility's undated Policy and Procedure (P&P) titled, Covid-19 and Influenza Vaccination Policy and Procedure was reviewed. The P&P indicated vaccination included all paid and unpaid employees, indirectly employed contractors or consultants, students, trainees, and volunteers who may work on-site regardless of whether they directly care for residents. The IPN stated all staff were required to have immunizations because they could transmit contagious disease to staff and residents of the facility. The IPN stated the facility consultants went inside the residents' rooms to conduct assessment and were in close contact with the residents but did not have immunization records in the Vaccination / Immunizations staff binder. Further review of the P&P indicated HCP who decline or have not yet obtained the updated Covid-19 and Influenza vaccines must provide the employer, on a form provided by their employer, a written declaration that they have declined the updated Covid-19 and Influenza vaccination. The P&P indicated the IPN will maintain an updated list of all staff's vaccination record.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) had accurate assessment when Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/2/2026 coded Resident 1 received insulin (hormone that helps move sugar from the blood into the body's cell) but Resident 1 did not. This failure had the potential to negatively affect Resident 1's plan of care and delivery of necessary care and services.Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness characterized by disturbances in thought) and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control). During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 was cognitively intact (ability to understand). The MDS indicated Resident 1 received one insulin injection during the last seven days or since admission/entry or reentry if less than seven days from assessment date. During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 7/1/2026 to 7/31/2026, the MAR indicated Resident 1 did not receive any insulin injections. During a concurrent interview and record review on 8/28/2026 at 9:40 am with Minimum Data Set Coordinator (MDSC) Resident 1's MDS dated [DATE] was reviewed. The MDS indicated Resident 1 received one insulin injection. The MDSC stated Resident 1 was not prescribed insulin injection. The MDSC stated it was very important to document accurately because the MDS was reported to Centers for Medicare and Medicaid Services (CMS). During an interview on 8/28/2026 at 10:00 am with the Director of Nursing (DON), the DON stated it was important that the MDS submissions were accurate because they reflected the resident's data and were submitted to CMS as a requirement. During a review of the facility's Policy and Procedure (P&P) titled, Minimum Data Set (MDS), dated September 2024, the P&P indicated, the facility would ensure MDS assessments were accurate, complete, and supported by the resident's clinical record. The P&P indicated, MDS would be completed in accordance with current CMS MDS 3.0 Resident Assessment Instrument (RAI) User's Manual and applicable regulatory requirements.

Based on interview and record review, the facility failed to follow the physician's order to record the hours of sleep for one of one sampled resident (Resident 50) on 8/23/2026 during the evening shift from 3pm-11pm. This deficient practice had the potential to result in adverse consequences and negatively affect Resident 50's quality of life. Findings: During a review of Resident 50's admission Record (AR), the AR indicated Resident 50 was admitted to the facility on [DATE] with diagnosis including schizophrenia (a mental illness characterized by disturbances in thought), insomnia (inability to sleep), and major depressive disorder (persistent feeling of sadness and loss of interest). During a review of Resident 50's Order Summary Report (OSR) dated 2/20/2026, the OSR indicated for staff to record Resident 50's number of hours slept during 3pm-11pm shift and 11pm-7am shift. During a review of Resident 50's Care Plan (CP) for insomnia dated 2/20/2026, the CP indicated a goal for Resident 50 to sleep a minimum of 6 hours per night with interventions including staff to record the number of hours slept during 3pm-11pm and 11pm-7am shifts. During a review of Resident 50's Minimum Data Set (MDS- a resident assessment tool) dated 8/14/2026, the MDS indicated Resident 50 was cogitatively intact (ability to think) and was independent with eating, oral, toileting and personal hygiene, showers and upper and lower dressing. During a record review and interview with the Director of Nursing (DON) on 8/26/2026 at 2:36 p.m., the DON stated the Treatment admission Record (TAR) did not indicate Resident 50's number of hours of sleep was recorded/documented on 8/23/2026 during 3pm-11pm shift. The DON stated the physician's order was for staff to record the number of hours of sleep during 3pm-11pm shift and 11pm-7am shift due to Resident 50's diagnosis of insomnia. The DON stated the DON was unsure why the staff did not record Resident 50's hours of sleep on 8/23/2026. The DON stated the field on Resident 50's TAR for the 3-11pm shift on 8/23/2026 was left blank. The DON stated staff should have recorded Resident 50's hours of sleep on 8/23/2026 during 3-11pm shift, per physician's order. During an interview with License Vocational Nurse (LVN1) on 8/26/2026 at 3:15 p.m., LVN1 stated LVN1 was the licensed nurse on the shift on 8/23/2026 during the evening shift (3pm-11pm). LVN1 stated that on 8/23/2026 LVN1 failed to complete the documentation in the TAR for hours of sleep for Resident 50, during the 3pm-11pm shift. LVN1 stated it was important to document the hours of sleep to determine if the medication Resident 50 was taking was working. LVN1 also stated that if Resident 50 did not get enough sleep, Resident 50's mental health could deteriorate. During a review of the facility's Policy and Procedure (P&P) titled, Physician's Order Policy dated 9/2024, the P&P indicated physician/provider orders will be accurately entered into PointClickCare (PCC- web based charting) and carried out as ordered. Licensed nursing staff are responsible for accurately receiving, entering, and carrying out Medical and Psychiatric Provider orders in accordance with this policy and facility procedures. During a review of the facility's P&P titled, Clinical Documentation and Chart Entries Policy dated 9/2024, the P&P indicated, All clinical documentation will be completed in the resident's electronic medical record in PCC. Documentation will be accurate, relevant, and reflect the resident's condition, care provided, treatments, medications, observations, and significant changes in condition.

Based on interview and record review, the facility failed to re-evaluate the risk of elopement (any situation where a resident leaves the facility premises or a designated safe area without the staff's knowledge and necessary supervision) for one of one sampled resident (Resident 6) after Resident 6 returned to the facility from an episode of absence without leave (AWOL - person missing or not where they are supposed to be) on 8/10/2026. This deficient practice had the potential for staff to be unaware of Resident 6's risk of elopement and could increase the risk of another AWOL or elopement.Findings: During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental condition that causes both a loss of contact with reality [psychosis] and mood problems) and insomnia (sleep disorder that makes it hard to fall asleep or stay asleep.) During a review of Resident 6's Elopement Risk Assessment (ERA) dated 6/16/2026, the ERA indicated instructions to complete the ERA upon admission or per facility policy. The ERA indicated Resident 6 had a history of AWOL and staff (in general) were aware of Resident 6's elopement risk. During a review of Resident 6's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/9/2026, the MDS indicated Resident 6 had moderately impaired cognition (ability to understand and process information) and disorganized thinking (rambling or irrelevant conversation and unclear or illogical flow of ideas). The MDS indicated Resident 6 was independent (resident completes the activity by themselves with no assistance from a helper) for activities of daily living (tasks of everyday life such as eating, dressing, hygiene.) During a review of Resident 6's untitled Care Plan (CP) revised on 8/9/2026, the CP indicated Resident 6 had AWOL'd from home pass and was found walking on a beach. The CP indicated Resident 6 refused to get in the vehicle back to the facility. The CP interventions included assisting Resident 6 to associate behaviors with consequences. During an interview on 8/28/2026 at 10:07 AM with the Director of Nursing (DON), the DON stated in general, a resident had to meet certain criteria to be able to go out on pass (OOP - when a resident is temporarily allowed to leave a care facility with official permission) with family and the resident was expected to be back to the facility by 8PM of the same day. During an interview on 8/28/2026 at 10:24 AM with the Quality Assurance Nurse (QAN), the QAN stated Resident 6 left OOP with family on 8/9/2026 and AWOL'd from the family and did not return to the facility until the next day on 8/10/2026. During a concurrent interview and record review on 8/28/2026 at 10:41 AM with the Quality Assurance Nurse (QAN), Resident 6's medical record (MR) was reviewed. The QAN stated a new ERA needed to be completed upon Resident 6's return from an AWOL episode on 8/10/2026 but it was not done. The QAN stated it was important to complete a new ERA so that staff could re-evaluate and be aware of the risk or likelihood of another AWOL or elopement episode which could potentially lead to a resident becoming physically hurt. During a review of the facility's Policy and Procedure (P&P) titled, Elopement, Risk Reduction Strategies, and Management of Missing Residents, revised 4/2024, the P&P indicated under Documentation: AWOL assessment will be done.

Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for three of five sampled residents (Residents 3, 6 and 8) when on 5/20/26 Resident 4 punched Resident 3 in the right eye area suddenly and without warning while Resident 3 was passing through the hallway. Also, during that same day after Resident 4 punched Resident 3 on 5/20/26, while staff escorted Resident 4 to Resident 4's room, Resident 4 punched Resident 4's roommate (Resident 8) on the left side of the head while Resident 8 was lying in bed. On 5/27/26 Resident 7 hit Resident 6's face while returning from smoke break. These failures resulted in Resident 3 and Resident 8 being subjected to physical abuse by Resident 4 and Resident 6 being subjected to physical abuse by Resident 7 while under the care of the facility. Resident 3 sustained bruising and discoloration on the right eye. Resident 8 suffered aching pain to left side of the head. Resident 6 suffered a laceration to the left side of the cheek and a bloody nose.Findings: 1a. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included paranoid schizophrenia (a type of schizophrenia [mental disorder] associated with feelings of being persecuted or plotted against) and major depressive disorder (persistent feeling of sadness and loss of interest). During a review of Resident 3's MDS (MDS - a resident assessment and care screening tool) dated 5/5/26, the MDS indicated Resident 3 had the capacity to understand and make decisions. The MDS also indicated Resident 3 was independent (resident completes the activity by themselves with no assistance from a helper) for eating, oral and toileting hygiene, shower/bathe self, upper body dressing putting on/taking off footwear and required supervision (helper provides verbal cues and or touching contact assistance) for personal hygiene. During a review of Resident 3's IDT Notes (IDTN-Interdisciplinary Team- notes from various specialties documenting the residents progress and response to treatments) dated 5/20/26 at 12:07 PM, the IDTN indicated Resident 3 was walking behind a peer (Resident 4) when the peer (Resident 4) turned around and hit Resident 3 on the right side of Resident 3's face. Resident 3 had some discoloration to the right eye. During a review of Resident 3's Pain Evaluation (PE) dated 5/20/26, the PE indicated Resident 3's pain was due to a peer (Resident 4) punching Resident 3 in the right eye. The PE also indicated Resident 3 had constant aching pain to the right eye and Resident 3 was grimacing and moaning from the pain. During a review of Resident 3's untitled Care Plan (CP) dated 5/20/26, the CP indicated Resident 3 was at risk for skin discoloration or bruising related to being hit on the right eye by a peer (Resident 4) without provocation. During a review of Resident 3's Progress Notes (PN) dated 5/21/26 at 8:57 AM, the PN indicated Resident 3's Counselor asked Resident 3 what happened. The PN indicated that Resident 3 stated, Resident 3 was walking by the East Nurses Station and Resident 4 bent over and socked Resident 3 in the eye. The PN also indicated Resident 3 stated Resident 3 was worried that Resident 4 would hit Resident 3 again. 1b.During a review of Resident 4's AR, the AR indicated Resident 4 was admitted to the facility on [DATE], with a diagnosis that included schizoaffective disorder (a mental condition that causes both a loss of contact with reality [psychosis] and mood problems) bipolar type (extreme mood swings) and nightmare disorder (a sleep condition with vivid dreams of threats to safety or survival). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognition was moderately impaired. The MDS also indicated Resident 4 was independent for eating, oral and toileting hygiene, shower/bathe self, upper body dressing putting on/taking off footwear and required supervision for personal hygiene. During a review of Resident 4's PN dated 5/21/26 at 9:01 AM, the PN indicated Resident 4 stated after Resident 4 hit Resident 3, Resident 4 went to Resident 4's room and hit Resident 4's roommate (Resident 8). The PN also indicated Resident 4 stated Resident 4 was listening to Resident 4's spiritual father telling Resident 4 to hit them to prove that Resident 4 was worthy, trustworthy and [NAME]. During a concurrent review of Resident 4's IDTN dated 5/24/26 at 9:40 PM, the IDTN indicated Resident 4 stated Resident 4 would continue to try and kill the peer (Resident 8) Resident 4 assaulted on 5/20/26. The IDT also indicated Resident 4 stated Resident 4 would continue to hit others. 1c. During a review of Resident 8's AR, the AR indicated Resident 8 was admitted to the facility on [DATE] with a diagnosis that included schizoaffective disorder bipolar type and borderline personality disorder (a mental health condition characterized by severe instability in emotions, self-image, and behavior). During a review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8 had the capacity to understand and make decisions. The MDS also indicated Resident 8 was independent for eating, oral and toileting hygiene, shower/bathe self, upper body dressing putting on/taking off footwear and required supervision for personal hygiene. During a review of Resident 8's PE dated 5/20/26 at 10:05 AM, the PE indicated Resident 8's pain was due to a peer (Resident 4) hit Resident 8 on the left side of the head. The PE also indicated Resident 8 was tearing and moaning from the pain. During a review of Resident 8's IDT notes dated 5/20/26 at 12:10 PM, the IDT notes indicated Resident 8 was struck on the head by roommate (Resident 4). Resident 8 was seen as visibly upset with being struck by Resident 4 and was crying. During a review of Resident 8's PN dated 5/21/26 at 8:55 AM, the PN indicated Resident 8 stated Resident 8 was sitting on Resident 8's bed writing in Resident 8's journal when Resident 4 went inside the room and punched Resident 8 on the left side of Resident 8's head. 2a. During a review of Resident 6's AR, the AR indicated Resident 6 was admitted to the facility on [DATE] with a diagnosis that included schizoaffective disorder bipolar type and major depressive disorder. During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 had the capacity to understand and make decisions. The MDS also indicated Resident 6 was independent for eating, oral and toileting hygiene, shower/bathe self, upper body dressing putting on/taking off footwear and required supervision for personal hygiene. During a review of Resident 6's PE dated 5/27/26 at 9:00 AM, the PE indicated Resident 6's pain was due to a peer (Resident 7) punching Resident 6 on the face. The PE also indicated Resident 6 had constant pain and was grimacing from the pain. During a review of Resident 6's IDT notes dated 5/27/26 at 11:43 AM, the IDT notes indicated Resident 6 was seen and evaluated by the physician after peer (Resident 7) punched Resident 6 on the left side of Resident 6's face. Resident 6 sustained an abrasion to the left cheek and was noted with bleeding from the nose. During a concurrent review of Resident 6's IDT notes dated 5/27/26 at 10:31 PM, the IDT notes indicated Resident 6 stated that Resident 6 got hit by Resident 7. Resident 6 stated that it all happened while Resident 6 was in line getting mouthwash. Resident 6 stated Resident 6 turned around and Resident 7 hit Resident 6 with Resident 7's fist. 2b. During a review of Resident 7's AR, the AR indicated Resident 7 was admitted to the facility on [DATE], with diagnoses that included paranoid schizophrenia and major depressive disorder. During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 had the capacity to understand and make decisions. The MDS also indicated Resident 7 was independent for eating, oral and toileting hygiene, shower/bathe self, upper body dressing putting on/taking off footwear and required supervision for personal hygiene. During a review of Resident 7's IDT notes dated 5/27/26 at 8:43 AM, the IDT notes indicated that while returning back to the unit from smoke break, Resident 7 was passing by the nurse's station to get Resident 7's toothpaste and mouthwash when peer (Resident 6) kept taking to Resident 7. The IDT notes indicated Resident 7 unprovoked punched peer (Resident 6) on the left side of the face (nose and cheek) and began arguing stating that peer (Resident 6) kept annoying Resident 7 because Resident 6 talked too much. During an interview with Certified Nursing Assistant 2 (CNA2) on 5/29/26 at 10:54 AM, CNA 2 stated that on 5/20/26 Resident 3 was walking by and Resident 4 hit Resident 3 in the face. CNA 2 stated Resident 3 was not bleeding but did have a red bruise on the cheek and needed an ice pack and got Tylenol for pain. During an interview with CNA 2 on 5/29/26 at 11:07 AM, CNA 2 stated on 5/27/26 after the morning smoke break, Resident 6 and Resident 7 were walking back inside the facility from smoke break. CNA 2 stated Resident 6 was talkative and friendly. CNA 2 stated Resident 7 was impulsive and unpredictable at times and had expressed aggressive physical tendencies towards staff and peers. CNA 2 stated while Resident 6 was waiting to get a mouthwash, Resident 7 who was unprovoked punched Resident 6 in the face. CNA 2 stated Resident 6 began to yell that Resident 7 had hit Resident 6. CNA 2 stated Resident 7 stated Resident 7 hit Resident 6 because Resident 6 was talking too much and was annoying. CNA 2 stated Resident 6 sustained a cut on the cheek and a bloody nose. During an interview with Licensed Vocational Nurse 1 (LVN1) on 5/29/26 at 11:38 AM, LVN1 stated Resident 4 was making verbal threats against Resident 8. LVN 1 stated Resident 4 stated Resident 4 would kill Resident 8 because the voices told Resident 4 to do so. LVN 1 stated Resident 4 stated Resident 4 was going to kill Resident 8 that night. LVN1 stated Resident 4 stated the voices made Resident 4 hit Resident 4's peers (Resident 3 and Resident 8). During an interview with LVN 1 on 5/29/26 at 11:43 AM, LVN 1 stated Resident 6 was very musical and chatty. LVN1 stated Resident 7 had a very short temper and had assaulted other peers in the past. LVN1 stated Resident 7 admitted to hitting Resident 6 out of frustration. LVN1 stated it was not acceptable that Resident 7 hit Resident 6. During an interview with the Director of Nursing (DON) on 6/3/26 at 9:32 AM, the DON stated Resident 7 had numerous past histories of physical altercations with multiple residents and a physician. The DON stated Resident 7 was unpredictable when it came to physical aggression. The DON stated Resident 7 should not have hit Resident 6 out of impulse or because Resident 7 was annoyed by Resident 6. The DON also stated Resident 4 had hit multiple residents (Resident 3 and Resident 8). The DON stated it was not acceptable for Resident 4 to hit Resident 4's peers (Resident 3 and Resident 8). The DON stated Resident 4 was transferred out to General Acute Care Hospital (GACH) for further evaluation and higher level of care. During an observation of Resident 3's face while in the hallway near the front nurse's station and a concurrent interview on 6/3/26 at 9:35 AM with Resident 3, Resident 3 stated Resident 4 punched Resident 3. Resident 3 stated Resident 3 was walking by the hallway when Resident 4 punched Resident 3 in the face with a Big punch to the right eye. Resident 3 stated Resident 3 was in pain and complained of 9 to 10 pain (on a pain scale of 0 to 10, 10 being worst pain and 0 indicated no pain). Resident 3's face had a purple-bluish mark near Resident 3's right eye, approximately half inch in size. During a review of the facility's Policy and Procedure (P&P) titled, Physical Assault, dated 9/2015, the P&P indicated the facility would provide a safe and secure environment. Examples of physical assault are, but not limited to punches, kicks, spitting, throwing objects, pushing, grabbing of clothes or person to cause personal harm. During a review of the facility's undated P&P titled Recognizing Sign and Symptoms of Abuse/Neglect, the P&P indicated the facility will not condone any form of resident abuse or neglect.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2) received adequate supervision and was not left unattended by facility staff following a resident altercation with Resident 1, in accordance with the facility's Policy and Procedure (P&P) titled Policy for Timely and Accurate 1:1 Monitoring and every 15 Minutes Monitoring Documentation in Point Click Care (PCC- electronic health record), by failing to: 1. Enter the physician's order for 1:1 monitoring for Resident 2 for two (2) hours, followed by every 15 minutes monitoring for 2 hours, in PCC.2. Provide a 1:1 Sitter (a trained staff member assigned to directly observe a single resident continuously within direct line of sight) after Resident 2 assaulted Resident 1. These deficient practices had a potential for Resident 2 to potentially assault Resident 1 again or another resident/staff causing harm or injury.Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought, perception, emotions and behavior, often causing a disconnection from reality) and major depressive disorder ( mental condition characterized by persistent sadness, low mood, and a loss of interest in activities). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment and screening tool) dated [DATE], the MDS indicated Resident 1 had intact cognition (ability to understand). The MDS indicated Resident 1 was independent for eating, oral and toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and required supervision (helper provides verbal cues) for personal hygiene. During a review of Resident 1's Care Plan Report (CPR) initiated on [DATE], the CPR indicated Resident 1 was pinched on the upper arm by a peer (Resident 2) who believed Resident 1 had a spider on Resident 1. During a review of Resident 1's Progress Notes (PN) dated [DATE] at 11:07 AM, the PN indicated Resident 1 reported to staff Resident 2 came from behind and told Resident 1 that there was a spider on Resident 1's arm and pinched Resident 1's arm hard. During a concurrent record review of Resident 1's PN dated [DATE] at 4:29 PM, the PN indicated Resident 1 was nervous around Resident 2. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of schizophrenia, nightmare disorder (a sleep disorder characterized by frequent, vivid, and terrifying dreams that cause significant distress and disrupt sleep) and insomnia (persistent difficulty falling asleep). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had intact cognition. The MDS indicated Resident 2 was independent for eating, oral and toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and required supervision for personal hygiene. During a review of Resident 2's Physician's Order (PO) dated [DATE] at 11:00 AM, the PO indicated 1:1 monitoring for Resident 2 for 2 hours then every 15 minutes monitoring for 2 hours due to physically assaultive behavior towards peer. Document in PCC (electronic health record) or on 1:1 monitoring form. During a review of Resident 2's PN dated [DATE] at 11:27 AM, the PN indicated staff reported to the Charge Nurse at approximately 11:00 AM that Resident 2 walked up behind Resident 1 and pinched Resident 1's left upper arm. The PN indicated the physician was notified with new order for Resident 2 for 1:1 for 2 hours then Q15 minutes for 2 hours related to physically assaultive behavior. During a review of the facility's investigation follow up report dated [DATE], the report indicated a new physician order for Resident 2 for 1:1 monitoring for two hours, followed by every 15-minute monitoring for two hours was received but the 1:1 monitoring was not executed in accordance with facility protocol due to an error by the Charge Nurse. The 1:1 monitoring was not entered in the PCC resulting in a lapse in documentation and execution of the monitoring process. During an interview with the facility's Registered Nurse Supervisor (RSN) on [DATE] at 9:15 AM, the RSN stated there was a 1:1 order to monitor Resident 2's aggressive behavior. The RSN stated the Charge Nurse did not enter the order in PCC and did not assign a sitter to Resident 2. The RSN stated Resident 2 was not monitored for aggressive behavior and Resident 2 did not have a sitter assigned potentially causing Resident 2 to assault residents or staff. During an interview with the facility's Charge Nurse on [DATE] at 9:24 AM, the Charge Nurse stated the Charge Nurse called the physician and received an order for 1:1 sitter order for Resident 2 but the Charge Nurse did not put the 1:1 order in PCC and did not assign a sitter. The Charge Nurse stated it was the facility's policy to add the 1:1 order in PCC when there was a resident altercation. The Charge Nurse stated anything could have happened since Resident 2 was not placed on 1:1 as ordered. During a concurrent interview with the Director of Nursing (DON) on [DATE] at 10:41 AM, the DON stated it was the policy of the facility to call the physician and get a 1:1 order for the aggressor. The DON stated, since the Charge Nurse did not place the 1:1 order in PCC, Resident 2 did not have a 1:1 and could have assaulted another resident. The DON stated Resident 2 was left unmonitored for more than 2 hours after the order for 1:1 was obtained from the physician. During a review of the facility's P&P's titled, Policy for Timely and Accurate 1:1 Monitoring and Q15 min Monitoring documentation in Point Click Care, revised 8/2022, the P&P indicated, An order for 1:1 Monitoring and Q: 15 min. monitoring will be obtained by the ordering provider, noted, carried out for, but not limited to the following reasons: assaultive behavior, self-harm, suicidal ideations, severe agitation, safety, and new admission. The Licensed Nurse will then initiate the 1:1 or Q:15 Min. Monitoring in Point Click Care in the 'Tasks section of the EHR, and the CNA assigned to the resident will do the required documentation every 15 mins and will have direct line of sight for the resident receiving the monitoring.

Based on interview and record review, the facility failed to provide services to prevent resident-to-resident abuse (intentional bodily injury that includes slapping, pinching, choking, kicking, shoving, grabbing, and punching) for two of five sampled residents (Resident 3 and Resident 5), according to the facility's policy and procedure (P&P) titled, Residents Right to Human Care, and the facility's five-day Follow-up Investigation Report (FUIR - mandatory follow-up report long-term care facilities must submit to the State Survey Agency within five working days of an abuse/neglect incident, detailing investigation results, corrective actions taken, and if the allegation was verified) dated 12/1/2025 by failing to: 1. Ensure Resident 4, who had a history of resident-to-resident abuse and was experiencing increasingly agitated behavior, did not hit Resident 3 over the head with a food tray on 11/23/2025 at approximately 7:30 am. 2. Ensure Resident 4, who had a history of resident-to-resident abuse on 11/23/2025, continued to be placed on one-to-one (1:1) monitoring (one trained staff provides continuous monitoring, close supervision to prevent harm, requiring constant vigilance even during sleep, and ensuring immediate intervention) until Resident 4 was transferred to a higher level of care due to ongoing impulsive (acting on sudden urges or desires without thinking through the consequences, often leading to risky, poorly conceived, or regrettable actions) and assaultive (actions or tendencies to physically attack or aggressively confront others, ranging from verbal threats and intimidation to physical violence like hitting, kicking, or biting, and involves intent to harm, damage, or intimidate) behaviors. 3. Ensure Resident 4 did not hit Resident 5 on the top of the head and pull Resident 5's hair on 11/29/2025 at approximately 8:50 pm. As a result of these failures, Resident 4 assaulted Resident 3 while Resident 3 was eating breakfast. Resident 4 assaulted Resident 5 while on the facility's patio during a smoke break. Resident 5's hair was pulled and hit on the back of the head by Resident 4. This failure caused Resident 5 experiencing pain to Resident 5's head, and made Resident 5 feel unsafe and afraid that another resident will assault Resident 5. This failure caused psychosocial (mental, emotional, social, and spiritual effects) discomfort to Resident 5. Findings: a. During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 10/30/2024 with diagnoses that included schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms like hallucinations or delusions, and mood disorder symptoms, such as depression or mania), bipolar (mental illness that causes unusual shifts in a resident's mood, energy, activity levels, and concentration) type, unspecified temporal mandibular joint (TMJ- refers to the jaw joint connecting your jawbone to your skull) disorder, and insomnia (common sleep disorder marked by difficulty falling asleep, staying asleep, or getting quality rest, leading to daytime fatigue, concentration issues, and irritability). During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 10/31/2025, the MDS indicated Resident 3 had intact cognition (ability to think, remember, and function). The MDS indicated Resident 3 experienced hallucinations (false perceptions of things that are not real, involving the senses of sight, sound, smell, taste, or touch) and delusions (fixed belief that persists despite evidence of the contrary). During a review of Resident 3's Progress Notes (PN) dated 11/23/2025, timed at 1:36 pm, the PN indicated at approximately 7:30 am, Resident 3 was hit over the head with a meal tray by peer (Resident 4) while eating breakfast in the dining room. The PN indicated Resident 3 experienced, A little bit of pain. During an interview on 12/5/2025 at 12:05 pm, with Resident 3, Resident 3 stated, I don't remember when it [incident with Resident 4] happened, but it was [another resident] that hit me. Resident 3 stated, I was just sitting, eating my breakfast when [Resident 4] came to me and just hit me on my head with the tray. Resident 3 stated Resident 4 did not say anything to Resident 3 before hitting Resident 3. Resident 3 stated, It hurt a little, but I was in shock more. I don't know why [Resident 4] did that to me. b. During a review of Resident 4's AR, the AR indicated the facility admitted Resident 4 on 10/10/2025 with diagnoses that included schizoaffective disorder, unspecified anxiety disorder (persistent feeling of dread or panic that can interfere with daily life), and recurrent, unspecified, major depressive disorder (common and serious illness that negatively affects how one feels, thinks and acts). During a review of Resident 4's MDS dated [DATE], the MDS indicated had moderately impaired cognition. The MDS indicated Resident 4 experienced hallucinations and delusions. During a review of Resident 4's untitled Care Plan (CP), initiated 11/16/2025, the CP indicated Resident 4 was resident-to-resident abuser (related to diagnosis of schizoaffective disorder, depressive type). The CP indicated on 11/23/2025, Resident 4 hit [Resident 3] with food tray on the head. The CP indicated on 11/29/2025, Resident 4 hit and pulled [Resident 5] hair unprovoked. The CP goals indicated Resident 4 would discuss triggers leading to assaulting others during one-to-one counseling session once weekly by 1/10/2026. The CP interventions indicated on 11/23/2025, to remind Resident 4 of their behavior, and verbally prompt Resident 4 to verbalize feelings rather use assaultive behavior toward peers. On 11/29/2025, the interventions indicated to work with Resident 4 to review identifying triggers by writing a list of triggers that spark agitated behavior toward peers, and 1:1 monitoring until further order. During a review of Resident 4's PN dated 11/2025, the PN indicated the following notes: 1. On 11/23/2025, timed at 7 am, Resident 4 was observed punching the bathroom door with bilateral (both) fists. 2. On 11/23/2025, timed at 7:10 am, Resident 4 was observed punching the bathroom door with bilateral (both) fists. 3. On11/23/2025, timed at 8:36 am, at approximately 7:30 am, during breakfast in the dining room, Resident 4 hit Resident 3 on the head with a food tray without provocation. The PN indicated Resident 4 was, Already agitated earlier this morning, and was on 1:1 observation during the time of incident. The PN indicated Resident 4 was being aggressive towards staff and was unable to control Resident 4's actions. The PN indicated Resident 4 was placed on five-point restraint (a type of mechanical restraint that secures a patient at all five points- both wrists, both ankles, and the chest/waist to prevent severe self-harm or to others). The PN indicated Resident 4 received a new order for 1:1 until further order due to physically assaultive behavior and suicidal ideations. 4. On11/25/2025, timed at 3:50 pm, the PN indicated Resident 4 unprovoked, assaulted staff, and nonreceptive to staff redirection. The PN indicated Resident 4 continued kicking and threatening staff. 5. On 11/26/2025, timed at 10:03 pm, Resident 4 remained on 1:1 monitoring related to assaultive behavior towards staff and peers. 6. On 11/28/2025, timed at 10:22 pm, Resident 4 remained on 1:1 monitoring related to assaultive behavior and suicidal ideation. 7. On 11/28/2025, timed at 11:52 pm, Resident 4's physician was informed Resident 4 no longer had suicidal ideation, discontinued Resident 4's 1:1 monitoring and placed Resident 4 on every 15-minute monitoring. The PN did not indicate if Resident 4 continued to display assaultive behavior. 8. On 11/29/2025, timed at 9:29 pm, at approximately 8:50 pm Resident 4 went behind Resident 5 and started hitting and grabbing Resident 5's hair on the back of the head, unprovoked. The PN indicated staff immediately separated Resident 4 and Resident 5 but Resident 4 continued assaulting staff and struggled against Crisis Prevention Institute's (CPI) NVCI. During a review of Resident 4's phone orders (PO), dated 11/2025, the PO indicated the following orders: 1. 11/23/2025, timed at 7:45 am, the PO indicated Resident 4 was ordered 1:1 (monitoring) until further order (UFO) due to physical assaultive behavior towards the peer. 2. 11/28/2025, timed at 11:54 pm, the PO indicated Resident 4's order for 1:1 monitoring related to physically assaultive behavior towards the peer and suicidal ideation until further order was discontinued by the Director of Nursing (DON). The PO indicated the discontinue reason was 1:1 monitoring was changed to every 15 minutes monitoring. 3. 11/29/2025, timed at 9:13 pm, the PO indicated Resident 4 was ordered 1:1 monitoring until further order for safety related to assaultive behavior. c. During a review Resident 5's AR, the AR indicated the facility admitted Resident 5 on 10/2/2025 with diagnoses that included schizoaffective disorder, bipolar type, uncomplicated nicotine (addictive ingredient in cigarettes) dependence to cigarettes, and uncomplicated alcohol abuse. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had intact cognition. The MDS indicated Resident 5 experienced hallucinations and delusions. During a review of Resident 5's PN dated 11/2025 and 12/2025, the PN indicated the following notes: 1. On 11/29/2025, timed at 10:10 pm, the PN indicated at approximately 8:50 pm during smoke break, Resident 4 went behind Resident 5 and started hitting and pulling Resident 5's hair on the back of the head unprovoked. 2. On 12/1/2025, timed at 2:21 pm, the PN indicated Resident 5 discussed feelings of safety die to an incident that occurred with Resident 4. The PN indicated Resident 5 stated, [Resident 4] just pulled my hair and hit me during smoke break. The PN indicated Resident 5 stated, I was trying to see what kind of cigarette [Resident 4] was smoking but then looked down when I passed [Resident 4]. The PN indicated Resident 5 stated, I don't feel safe. During an interview on 12/5/2025 at 12:16 pm, with Resident 5, when asked about the incident [with Resident 4] Resident 5 stated, I'm okay, but I don't feel safe. Resident 5 stated Resident 4 hit Resident 5 on the top right side of the head and pulled the top of Resident 5's hair. Resident 5 stated, It really hurt. I didn't like [Resident 5] did that to me. I'm afraid that someone else might hit me now. What if someone does? Resident 5 repeated, It really hurt when [Resident 5] did it and it makes me afraid someone else is going to hit me. I don't like it. I don't feel safe here anymore. During an interview on 12/5/2025 at 1:36 pm, with Registered Nurse (RN) 1, RN 1 stated (in general) during 1:1 supervision CNAs were required to keep an arm's length from the resident with the order to maintain safety to the resident and to others. RN 1 stated Resident 4 was on 1:1 monitoring for assaultive behavior, but after several days, because Resident 4 did not want to harm others, they asked for the MD to remove the order. During an interview on 12/5/2025 at 2 pm, with the DON, the DON stated it was all residents' right to be free from abuse. The DON stated on 11/23/2025, the facility substantiated Resident 4 hit Resident 3 on the head with a food tray. The DON stated Resident 4 had been having issues with physical aggression and assaultive behavior since being admitted . The DON stated the purpose of 1:1 monitoring was for residents with suicidal ideation (thoughts of self-harm or ending one's life) and for physical aggression to make sure that the resident on monitoring was not going to hit another resident or staff. The DON stated 1:1 monitoring was used to stop the escalation of a resident's behavior to prevent residents and staff from being harmed. The DON stated the FUIR was a legal document. The DON stated if the FUIR regarding the 11/23/2025 incident indicated Resident 4 would not be removed from 1:1 monitoring until transfer to higher level of care, Resident 4 should not have been taken off it on 11/28/2025. The DON stated on 11/29/2025, Resident 4 hit Resident 5's head and pulled Resident 5's hair. The DON stated it was possible that if Resident 4 had not been removed from 1:1 monitoring as indicated in the FUIR, it was possible Resident 5 may not have been hit in the head and had Resident 5's hair pulled by Resident 4. The DON stated because Resident 4 was hurt, Resident 4 was afraid and did not feel safe. The DON stated it was possible the feelings could cause psychological harm to Resident 4. During an interview on 12/5/2025 at 1:02 pm, with Certified Nurse Assistant (CNA) 3, CNA 3 stated CNA 3 observed Resident 4 grab Resident 4's food tray with food on the tray, stand up after first sitting down, and hit Resident 3 on the head with the tray. CNA 3 stated Resident 4 tried to hit Resident 3 again, but CNA 3 stopped Resident 4. CNA 3 stated CNA 3 used Nonviolent Crisis Intervention (NVCI- widely used training program for safely managing disruptive behavior using verbal de-escalation and physical techniques as a last resort) to prevent further altercations. CNA 3 stated CNA 3 held Resident 4's arms to guide Resident 4 to Resident 4's room. CNA 3 stated Resident 4 was placed on 1:1 monitoring after the incident occurred. CNA 3 stated 1:1 monitoring was a way to prevent residents from hurting themselves or others. CNA 3 stated, We have to prevent any accident or incident from occurring, so we always have to be watching them (residents). During an interview on 12/5/2025 at 1:21 pm, with Licensed Vocational Nurse (LVN) 3, LVN 3 stated LVN 3 was in the medication room preparing medications for residents when Resident 4 hit Resident 3 with the food tray. LVN 3 stated LVN 3 assessed both residents and put Resident 4 on 1:1 monitoring. LVN 3 stated, We took [Resident 4] off 1:1 (monitoring) like a week or so later because [Resident 4] was no longer suicidal, ironically. LVN 3 stated Resident 4 was also on 1:1 monitoring for assaultive behavior. LVN 3 stated after Resident 4 was taken off 1:1 monitoring, another incident occurred. LVN 3 stated Resident 4 was agitated and did not want to be at the facility. LVN 3 stated 1:1 monitoring was, So important, for the safety of the residents and others. During a review of the facility's FUIR dated 12/1/2025, the FUIR indicated Resident 4 was involved in a substantiated incident of resident-to-resident abuse. The FUIR indicated Resident 4 was placed on 1:1 monitoring due to ongoing agitation and expressed suicidal ideation. The FUIR indicated Resident 4 would remain on 1:1 supervision (monitoring) until transfer to higher level of care was completed. During a review of the facility's P&P titled, Residents Rights to Human Care, revised 2/2021, the P&P indicated resident had the right to be free from abuse, neglect, and harm. The P&P indicates residents would be treated with dignity and respect.

Based on observation, interview, and record review, the facility failed to provide supervision every hour for two of six sampled residents (Resident 3 and Resident 6) in accordance with the facility's policy and procedure (P&P) titled, Policy for Hourly Monitoring, by failing to ensure Certified Nurse Assistant (CNA) 1, CNA 2, CNA 3, and CNA 6 had visually seen and identified Resident 3 and Resident 6 between the hours of 12 am and 4 am on 10/18/2025, 10/19/2025, and 10/20/2025. This failure resulted in Resident 3 and Resident 6 not being visually checked during hourly monitoring on 10/18/2025 at 12 am and from 2 am to 4 am, on 10/19/2025 at 1 am, and from 3 am to 4 am, and on 10/20/2025 from 12 am to 4 am, and had the potential to result in Resident 3 and Resident 6 harming themselves, harming each other, and being susceptible to abuse. Cross Reference: F842Findings: a. During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 6/20/2025 with diagnoses that included schizophrenia (serious mental illness in which people interpret reality abnormally), insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep), 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 Follow Up Question Report (FUQR - used by facility to document hourly visual monitoring of residents), dated 10/17/2025 to 10/20/2025, the FUQR indicated Resident 3 was monitored hourly. The FUQR indicated during the night shift (11 pm to 7 am) on 10/17/2025, Resident 3 was monitored hourly by CNA 1 between the hours of 12 am and 1 am, and 3 am on 10/18/2025. The FUQR indicated CNA 6 monitored Resident 3 on 10/17/2025 at 11 pm, and 10/18/2025 at 2 am and 4 am. The FUQR indicated during the night shift on 10/18/2025, CNA 1 monitored Resident 3 hourly between the hours of 11 pm and 4 am (on 10/19/2025). The FUQR indicated during the night shift on 10/19/2025, CNA 1 monitored Resident 3 hourly between the hours of 11 pm and 4 am (on 10/20/2025). b. During a review of Resident 6's AR, the AR indicated the facility admitted Resident 6, to the facility on 5/4/2021 and was readmitted on [DATE], with diagnoses that included paranoid schizophrenia, major depressive disorder, and anxiety disorder (persistent feeling of dread or panic that can interfere with daily life). During a review of Resident 6's FUQR dated 10/17/2025 to 10/20/2025, the FUQR indicated Resident 6 was monitored hourly. The FUQR indicated during the night shift on 10/17/2025, Resident 6 was monitored hourly by CNA 1 between the hours of 11 pm and 4 am (on 10/18/2025). The FUQR indicated during the night shift on 10/18/2025, CNA 1 monitored Resident 6 hourly between the hours of 11 pm and 2 am (on 10/19/2025). The FUQR indicated CNA 6 monitored Resident 3 and Resident 6 at 3 am and 4 am. The FQUR indicated during the night shift on 10/19/2025, CNA 3 monitored Resident 3 hourly between the hours of 11 pm and 4 am (on 10/20/2025). During a concurrent observation and interview on 10/21/2025 at 12:31 pm with the Program Director (PD), the facility's video surveillance from 10/17/2025 at 11 pm to 10/18/2025 at 4 am was reviewed. The PD stated the video surveillance started on 10/17/2025 from 11:00:01 pm. The PD stated the camera was positioned in the west wing hallway by the back door. The PD stated there were three doors on right side of the hall in the camera frame that were visible, and Resident 3 and Resident 6's room door was second/middle door. The PD stated CNA 1 was the only staff who was observed entering and exiting Resident 3 and Resident 6's room. The PD stated no other staff were observed entering or exiting Resident 3 and Resident 6's room. The PD stated CNA 1 entered the room on 10/17/2025 at 11pm, and again on 10/18/2025 at 1 am. The PD stated CNA 1 did not enter Resident 3 and Resident 6's room on 10/18/2025 from 12 am to 1 am, from 2 am to 3 am, and from 3 am to 4 am. PD stated no other staff member entered the room on 10/18/2025 from 12 am to 1 am, from 2 am to 3 am, and from 3 am to 4 am. During a concurrent observation and interview on 10/21/2025 at 3:12 pm with the PD, the facility's video surveillance from 10/18/2025 at 11 pm to 10/19/2025 at 4 am was reviewed. The PD stated the video surveillance started on 10/18/2025 from 11:00:04 pm. The PD stated the camera was positioned in the west wing hallway by the back door. The PD stated there were three doors on right side of the hall in the camera frame that were visible, and Resident 3 and Resident 6's room door was second/middle door. The PD stated CNA 2 was observed entering Resident 3 and Resident 6's room on 10/18/2025 at 11 pm. The PD stated CNA 2 was observed standing in the doorway of Resident 3 and Resident 6's room on 10/19/2025 at 12 am and again at 2 am. The PD stated no other staff member entered the room on 10/19/2025 from 1 am to 2 am, and from 3 am to 4 am. During a concurrent observation and interview on 10/22/2025 at 9:16 am with the PD, the facility's video surveillance from 10/19/2025 at 11 pm to 10/20/2025 at 4 am was reviewed. The PD stated the video surveillance started on 10/19/2025 from 11:00:04 pm. The PD stated the camera was positioned in the west wing hallway by the back door. The PD stated there were three doors on right side of the hall in the camera frame that were visible, and Resident 3 and Resident 6's room door was second/middle door. The PD stated CNA 3 was observed entering and exiting Resident 3 and Resident 6's room on 10/19/2025 at 11pm. The PD stated no staff member, or residents were observed entering or exiting the room on 10/20/2025 from 12 am to 4 am. The PD stated CNA 3 was observed on CNA 3's phone most of the video. During a telephone interview on 10/22/2025 at 12:12 pm with CNA 3, CNA 3 stated CNA 3 went into Resident 3 and Resident 6's room on 10/19/2025 not long after CNA 3's shift started. CNA 3 stated both Resident 3 and Resident 6 were sleeping. CNA 3 stated CNA 3 sat in a chair by the room next door to Resident 3 and Resident 6. CNA 3 stated, I usually check my residents every hour, but I didn't check them every hour that night I guess, but I documented I did. CNA 3 stated CNA 3 could not see into Resident 3 and Resident 6's room if CNA 3 was on CNA 3's phone. CNA 3 stated when CNA 3 did hourly checks on residents, CNA 3 must go inside the residents' room to check on them. CNA 3 stated, It's really hard to see both residents from the doorway. When you're in the doorway, you can't visualize both residents. During a telephone interview on 10/22/2025 at 1:12 pm with CNA 1, CNA 1 stated CNA 1 worked the night shift of 10/17/2025. CNA 1 stated, I was supposed to check on [Resident 3 and Resident 6] every hour, but I was very tired that night. CNA 1 stated, I documented I checked on [Resident 3 and Resident 6] every hour or something like that. CNA 1 stated it was important to actually check on the residents to make sure they were safe. CNA 1 stated if CNA 1 did not check on the residents to make sure they were safe they could get sick, fall out of bed, get hurt, and that it was possible for the roommates to hurt each other. CNA 1 stated, I'm supposed to look at them. During an interview on 10/22/2025 at 2:09 pm with the Director of Staff Development (DSD), the DSD stated that unless otherwise indicated, all residents were monitored hourly. The DSD stated that staff were supposed to visualize each resident for their safety and to ensure they were alive, well, and breathing. The DSD stated this was done 24 hours a day, seven days a week. The DSD stated if staff were not checking on the residents, Anything could happen. The DSD stated residents could be choking, or not breathing, and that hourly checks ensured their safety to prevent them from harm. The DSD stated it was possible a resident could abuse their roommate if staff were not checking on the residents every hour. During an interview on 10/22/2025 at 2:47 pm with Licensed Psychiatric Technician (LPT) 1, LPT 1 stated CNAs were supposed to do hourly visual checks on residents. LPT 1 stated it was important for CNAs to do hourly visual checks because incidents like suicide could happen. LPT 1 stated, We need to make sure they're (residents) alive and assess their behavior. LPT 1 stated incidents like resident-to-resident abuse could occur if staff were not checking on the residents hourly. During an interview on 10/22/2025 at 2:56 pm with the Director of Nursing (DON), the DON stated the facility's standard was to check on residents every hour. The DON stated whoever documented the monitoring must lay eyes (to see or look at the resident) on the resident or visualize the resident, To make sure they (residents) were okay. The DON stated if CNAs or staff were not visualizing the residents every hour it posed a safety risk to the residents. The DON stated if not visualized hourly residents could fall and be unable to ask for help, residents could go into another resident's room, and it could put the residents at risk for resident-to-resident abuse. During a review of the facility's P&P titled, Policy for Hourly Monitoring of Residents, dated 5/2024, the P&P indicated it was the policy of the facility to provide an atmosphere that was safe and secure for all residents and staff. The P&P indicated that each CNA was assigned a zone or area in the unit and would observe the location of resident assigned in their section, each hour, and document the location in the facility's electronic medical record (EHR). The P&P indicated in documenting resident location in the EHR, staff were making an honest and accurate entry that they visually saw and identified the resident. The P&P indicated the monitoring allowed the staff to account for each resident and ensured that each resident was free from distress.

Based on observation, interview, and record review, the facility failed to ensure accurate documentation of the Follow Up Question Report (FUQR - used by facility to document hourly visual monitoring of residents) for two of six sampled residents (Resident 3 and Resident 6) according to the facility's policy and procedure (P&P) titled, Policy for Hourly Monitoring of Residents, by failing to ensure CNA 1, CNA 2, CNA 3, and CNA 6 did not falsify (change something in order to deceive people) Resident 3's and Resident 6's FUQR. CNA 1, CNA 2, CNA 3, and CNA 6 documented on Resident 3's and Resident 6's FUQR they had visually seen and identified Resident 3 and Resident 6 between the hours of 12 am and 4 am on 10/18/2025, 10/19/2025, and 10/20/2025. Resident 3 and Resident 6 were not visually checked during hourly monitoring on 10/18/2025 at 12 am and from 2 am to 4 am, on 10/19/2025 at 1 am, and from 3 am to 4 am, and on 10/20/2025 from 12 am to 4 am. This failure had the potential for Resident 3 and Resident 6 not to receive adequate supervision, and for Resident 3's and Resident 6's care not to be accurately evaluated for procedural and guidelines compliance, and the need for staff education and training to be evaluated. Cross Reference: F689Findings: a. During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 6/20/2025 with diagnoses that included schizophrenia (serious mental illness in which people interpret reality abnormally), insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep), 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 Follow Up Question Report (FUQR - used by facility to document hourly visual monitoring of residents), dated 10/17/2025 to 10/20/2025, the FUQR indicated Resident 3 was monitored hourly. The FUQR indicated during the night shift (11 pm to 7 am) on 10/17/2025, Resident 3 was monitored hourly by CNA 1 between the hours of 12 am and 1 am, and 3 am on 10/18/2025. The FUQR indicated CNA 6 monitored Resident 3 on 10/17/2025 at 11 pm, and 10/18/2025 at 2 am and 4 am. The FUQR indicated during the night shift on 10/18/2025, CNA 1 monitored Resident 3 hourly between the hours of 11 pm and 4 am (on 10/19/2025). The FUQR indicated during the night shift on 10/19/2025, CNA 1 monitored Resident 3 hourly between the hours of 11 pm and 4 am (on 10/20/2025). b. During a review of Resident 6's AR, the AR indicated the facility admitted Resident 6, to the facility on 5/4/2021 and was readmitted on [DATE], with diagnoses that included paranoid schizophrenia, major depressive disorder, and anxiety disorder (persistent feeling of dread or panic that can interfere with daily life). During a review of Resident 6's FUQR dated 10/17/2025 to 10/20/2025, the FUQR indicated Resident 6 was monitored hourly. The FUQR indicated during the night shift on 10/17/2025, Resident 6 was monitored hourly by CNA 1 between the hours of 11 pm and 4 am (on 10/18/2025). The FUQR indicated during the night shift on 10/18/2025, CNA 1 monitored Resident 6 hourly between the hours of 11 pm and 2 am (on 10/19/2025). The FUQR indicated CNA 6 monitored Resident 3 and Resident 6 at 3 am and 4 am. The FQUR indicated during the night shift on 10/19/2025, CNA 3 monitored Resident 3 hourly between the hours of 11 pm and 4 am (on 10/20/2025). During a concurrent observation and interview on 10/21/2025 at 12:31 pm with the Program Director (PD), the facility's video surveillance from 10/17/2025 at 11 pm to 10/18/2025 at 4 am was reviewed. The PD stated the video surveillance started on 10/17/2025 from 11:00:01 pm. The PD stated the camera was positioned in the west wing hallway by the back door. The PD stated there were three doors on right side of the hall in the camera frame that were visible, and Resident 3 and Resident 6's room door was second/middle door. The PD stated CNA 1 was the only staff who was observed entering and exiting Resident 3 and Resident 6's room. The PD stated no other staff were observed entering or exiting Resident 3 and Resident 6's room. The PD stated CNA 1 entered the room on 10/17/2025 at 11pm, and again on 10/18/2025 at 1 am. The PD stated CNA 1 did not enter Resident 3 and Resident 6's room on 10/18/2025 from 12 am to 1 am, from 2 am to 3 am, and from 3 am to 4 am. PD stated no other staff member entered the room on 10/18/2025 from 12 am to 1 am, from 2 am to 3 am, and from 3 am to 4 am. During a concurrent observation and interview on 10/21/2025 at 3:12 pm with the PD, the facility's video surveillance from 10/18/2025 at 11 pm to 10/19/2025 at 4 am was reviewed. The PD stated the video surveillance started on 10/18/2025 from 11:00:04 pm. The PD stated the camera was positioned in the west wing hallway by the back door. The PD stated there were three doors on right side of the hall in the camera frame that were visible, and Resident 3 and Resident 6's room door was second/middle door. The PD stated CNA 2 was observed entering Resident 3 and Resident 6's room on 10/18/2025 at 11 pm. The PD stated CNA 2 was observed standing in the doorway of Resident 3 and Resident 6's room on 10/19/2025 at 12 am and again at 2 am. The PD stated no other staff member entered the room on 10/19/2025 from 1 am to 2 am, and from 3 am to 4 am. During a concurrent observation and interview on 10/22/2025 at 9:16 am with the PD, the facility's video surveillance from 10/19/2025 at 11 pm to 10/20/2025 at 4 am was reviewed. The PD stated the video surveillance started on 10/19/2025 from 11:00:04 pm. The PD stated the camera was positioned in the west wing hallway by the back door. The PD stated there were three doors on right side of the hall in the camera frame that were visible, and Resident 3 and Resident 6's room door was second/middle door. The PD stated CNA 3 was observed entering and exiting Resident 3 and Resident 6's room on 10/19/2025 at 11pm. The PD stated no staff member, or residents were observed entering or exiting the room on 10/20/2025 from 12 am to 4 am. The PD stated CNA 3 was observed on CNA 3's phone most of the video. During a telephone interview on 10/22/2025 at 12:12 pm with CNA 3, CNA 3 stated CNA 3 went into Resident 3 and Resident 6's room on 10/19/2025 not long after CNA 3's shift started. CNA 3 stated both Resident 3 and Resident 6 were sleeping. CNA 3 stated CNA 3 sat in a chair by the room next door to Resident 3 and Resident 6. CNA 3 stated, I usually check my residents every hour, but I didn't check them every hour that night I guess, but I documented I did. CNA 3 stated CNA 3 could not see into Resident 3 and Resident 6's room if CNA 3 was on CNA 3's phone. CNA 3 stated when CNA 3 did hourly checks on residents, CNA 3 must go inside the residents' room to check on them. CNA 3 stated, It's really hard to see both residents from the doorway. When you're in the doorway, you can't visualize both residents. During a telephone interview on 10/22/2025 at 1:12 pm with CNA 1, CNA 1 stated CNA 1 worked the night shift of 10/17/2025. CNA 1 stated, I was supposed to check on [Resident 3 and Resident 6] every hour, but I was very tired that night. CNA 1 stated, I documented I checked on [Resident 3 and Resident 6] every hour or something like that. CNA 1 stated it was important to actually check on the residents to make sure they were safe. CNA 1 stated if CNA 1 did not check on the residents to make sure they were safe they could get sick, fall out of bed, get hurt, and that it was possible for the roommates to hurt each other. CNA 1 stated, I'm supposed to look at them. During an interview on 10/22/2025 at 2:09 pm with the Director of Staff Development (DSD), the DSD stated that unless otherwise indicated, all residents were monitored hourly. The DSD stated that staff were supposed to visualize each resident for their safety and to ensure they were alive, well, and breathing. The DSD stated this was done 24 hours a day, seven days a week. The DSD stated if staff were not checking on the residents, Anything could happen. The DSD stated residents could be choking, or not breathing, and that hourly checks ensured their safety to prevent them from harm. The DSD stated it was possible a resident could abuse their roommate if staff were not checking on the residents every hour. During an interview on 10/22/2025 at 2:47 pm with Licensed Psychiatric Technician (LPT) 1, LPT 1 stated CNAs were supposed to do hourly visual checks on residents. LPT 1 stated it was important for CNAs to do hourly visual checks because incidents like suicide could happen. LPT 1 stated, We need to make sure they're (residents) alive and assess their behavior. LPT 1 stated incidents like resident-to-resident abuse could occur if staff were not checking on the residents hourly. During an interview on 10/22/2025 at 2:56 pm with the Director of Nursing (DON), the DON stated the facility's standard was to check on residents every hour. The DON stated whoever documented the monitoring must lay eyes (to see or look at the resident) on the resident or visualize the resident, To make sure they (residents) were okay. The DON stated if CNAs or staff were not visualizing the residents every hour it posed a safety risk to the residents. The DON stated if not visualized hourly residents could fall and be unable to ask for help, residents could go into another resident's room, and it could put the residents at risk for resident-to-resident abuse. During a review of the facility's P&P titled, Policy for Hourly Monitoring of Residents, dated 5/2024, the P&P indicated it was the policy of the facility to provide an atmosphere that was safe and secure for all residents and staff. The P&P indicated that each CNA was assigned a zone or area in the unit and would observe the location of resident assigned in their section, each hour, and document the location in the facility's electronic medical record (EHR). The P&P indicated in documenting resident location in the EHR, staff were making an honest and accurate entry that they visually saw and identified the resident. The P&P indicated the monitoring allowed the staff to account for each resident and ensured that each resident was free from distress. During a review of the facility's P&P titled, [Facility] Policy on Documentation in Point Click Care (EHR), updated 1/2022, the P&P indicated all entries were to be made by the nurse who provided the nursing care or made the observation.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Residents 1), who had a history of major depressive disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life) was properly and adequately monitored in accordance with the facility's policies and procedures (P&P).This failure potentially resulted in Resident 1 gaining the opportunity to hang himself to attempt suicide (the act of intentionally causing one's own death) while inside Resident 1's room (Area 2) and resulted in Resident 1 to be resuscitated (to revive from apparent death or from unconsciousness) and transferred to the General Acute Care Hospital (GACH) where Resident 1 was declared brain dead two days later.During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood and behavior), bipolar (extreme mood swings between periods of mania [elevated mood] and depression) type, other psychoactive substance abuse (the harmful or hazardous use of drugs that alter brain function, affecting mood, perception, cognition, and behavior), uncomplicated, and major depressive disorder, recurrent, unspecified.During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 1 had a flat affect (lack of emotional expression), was confused, and with tangential thought process (a pattern of thinking where a person's thoughts frequently stray from the main topic of conversation or question).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was intact. The MDS indicated, Resident 1 had potential indicators of psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) behavior such as hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS indicated, Resident 1 was independent in activities of daily living and was taking antipsychotic and antidepressant drugs and had one day of psychological therapy (any licensed mental health professional).During a review of Resident 1's Order Summary Report (OSR), active orders as of [DATE], the OSR indicated, an order on [DATE] for Q (every) 15 (fifteen) min (minute) monitoring UFO (until further order) d/t (due to) AWOL (away without leave- when a patient leaves the facility without permission) attempt. The OSR indicated, an order on [DATE] to transfer Resident 1 via 911 (emergency response system) ambulance with bed hold (a resident's right to keep a bed vacant and available for seven days after their transfer to the hospital in anticipation of their return to the facility) to the GACH ER (Emergency Department) r/t (related to) being found unresponsive m/b (manifested by) resident attempting suicide by hanging.During a review of the GACH's ED Note Physician (EDN), dated [DATE], timed at 7:56 AM, the EDN indicated, Resident 1 was found in cardiac arrest (the heart suddenly and unexpectedly stops beating) at the facility, LKW (last known well) between 6:30 AM and 6:40 AM, found at 6:59 AM hanging from a sprinkler head and had ligature marks (a type of pressure mark or abrasion on the neck caused by a ligature [the act of binding or tying up with a cord or other material in cases of hanging or strangulation around neck]). EMS (Emergency Medical Services) reported that Resident 1 was cyanotic (a bluish discoloration of the skin caused by a shortage of oxygen in the blood) and unresponsive in full cardiac arrest on EMS's arrival at the facility and Resident 1's initial heart rhythm was asystole (flatline - when the heart's electrical system fails entirely causing the heart to stop pumping). EMS was able to obtain ROSC (Return of Spontaneous Circulation - the moment when a patient in cardiac arrest regains their own heartbeat and blood flow) in the field but Resident 1 had another cardiac arrest. During a review of Resident 1's Progress Notes (PN), dated [DATE], timed at 8:38 AM, the PN indicated, at approximately 7 AM the Licensed Psychiatric Technician (LPT) was called on the radio (walkie-talkie device) by a staff (unnamed) to Area 2. The PN indicated, the LPT entered Area 2 and observed Resident 1 hanging from the water sprinkler by a sheet and a code blue (an emergency code for a patient needing resuscitation) was called.During a review of the GACH's Discharge Summary (DS), dated [DATE], timed at 18:48 PM, the DS indicated, Resident 1's multiple discharge diagnoses included strangulation via asphyxiation (when you don't get enough oxygen in your body) resulting in cardiac arrest. The DS indicated, Resident 1's prolonged downtime (an extended period during which a patient experiences cardiac arrest) and evidence of cerebral edema (swelling of the brain) on the head CT (computed tomography - a diagnostic imaging test) showed findings consistent with brain death and clinical examination consistent with brain death. Resident 1 was declared brain dead on [DATE] at 2:55 PM.During an observation on [DATE] at 9:08 AM with the Program Director (PD) while inside Area 2, Area 2 was a 2-bed occupancy room with both beds having designated drapes (privacy curtains). Area 2 had ceiling mounted sprinklers (pendent fire sprinklers - water sprinkler that sticks out from the ceiling) inside the room entrance, above both beds and in the restroom. The sprinkler's head was about 4-5 inches long below the ceiling. (or: The sprinkler's head stuck out 4-5 inches from the ceiling).During an interview on [DATE] at 9:36 AM with Certified Nursing Assistant (CNA) 2, CNA 2 stated, when CNA 2 entered Area 2 before 7 AM, CNA 2 found Resident 1 hanging with a bed sheet (CNA 2 gestured around neck) with Resident's 1 head down, eyes closed, both knees slightly bent and both feet slightly on the floor. CNA 2 stated, CNA 2 tried to wake Resident 1 up and called for help using CNA 2's radio. CNA 2 stated, CNA 3 and the Licensed Vocational Nurse (LVN) 2 came in right away and unhooked Resident 1 who was dangling with the sheet'' and staff started CPR (cardiopulmonary resuscitation - an emergency, life-saving technique used when a person's heart has stopped and is not breathing) until the paramedics (medical professionals who specializes in emergency treatment) arrived. CNA 2 stated, CNA 2 could not remember the date of the incident. CNA 2 stated Resident 1 was on q15 monitoring for AWOL. CNA 2 stated, the q15 monitoring process included the staff had to visibly see Resident 1 every 15 minutes to check and to ensure where Resident 1 was. CNA 2 stated, staff also checked the residents (in general) inside the resident's room to make sure where they are for the q15 room check (the facility's policy on checking the resident's room every 15 minutes).During an interview on [DATE] at 10:15 AM with CNA 3, CNA 3 stated, CNA 3 heard CNA 2 on the radio calling out the Licensed Psychiatric Technician (LPT) and a code blue. CNA 3 stated, CNA 3 immediately went to Area 2 and saw Resident 1 hanging from the sprinkler with Resident 1 positioned slightly slumped over, head down, both knees slightly bent and both feet slightly on the floor and Resident 1 was more pale white in color. CNA 3 stated, the distance between Resident 1's neck to the sprinkler was about a foot long. CNA 3 stated, CNA 3 pulled Resident 1 up while LVN 2 and CNA 2 released the sheet around Resident 1's neck and placed Resident 1 on the floor to start CPR immediately. CNA 3 stated, Resident 1 had always been on q15 minute monitoring for AWOL.During a record review on [DATE] at 11:28 AM with the Director of Staff Development (DSD), the facility's Surveillance Video Footage (SVF,) titled, Conference Room, dated [DATE], timed from 6:39 AM to 7:33 AM was reviewed. The SVF indicated, CNA 2 was sitting in a chair at Area 3 doorway while monitoring the Area 1 hallway. The SVF indicated, the following timeline:6:39:00 AM Area 2 had 2 white chairs outside of Area 2 and CNA 1 seated at Area 3 doorway.6:43:09 AM Resident 1 came out of Area 2 with both hands inside pants pocket and walked towards the south direction in Area 1 hallway passed CNA 1.6:43:54 AM Resident 1 turned around and entered Area 2. CNA 1 remained seated at Area 3 doorway.6:59:26 AM CNA 2 entered Area 2.7:00:32 AM CNA 2 came out to Area 2 doorway and flagged for help.7:00:51 AM LPT entered Area 2.7:00:56 AM CNA 4, LVN 2 and CNA 3 entered Area 2.7:07:28 AM Paramedics arrived heading towards Area 2.7:33:09 AM Resident 1 in gurney transported and taken by paramedics.During a concurrent interview and record review on [DATE] at 2:35 PM with the DSD, the facility's P&P titled, Q:15 Minute Monitoring, dated 6/2024 was reviewed. The P&P indicated, the facility provided an atmosphere that was safe and secure for all residents and staff. The facility would make every effort to ensure that residents and staff would be safe and secure in a structured environment. A tool to assist in providing a safe and secure environment was q15-minute checks and the CNA assigned to the resident placed on q15-minute checks would seek, find, and document location and condition of the resident every 15 minutes during their shift, and must be done in a timely manner. The P&P indicated, the staff implementing the q15-minute checks must maintain a clear and direct line of sight at time of documentation of q15-minute checks. The P&P indicated when documenting that the resident was located in the Point Click Care POC portal, staff were making an honest and accurate entry that staff visually saw and identified the resident. The DSD stated that the staff had to physically go inside the room to check on the resident for the safety and wellness of the resident. The DSD stated that the facility also had a q15-minute room check for all the residents where staff must go inside room to room to check and scan a device mounted inside the room.During a concurrent interview and record review on [DATE] at 3:24 PM with the DSD, CNA 1's Personnel Action Request (PAR), dated [DATE] was reviewed. The PAR indicated, CNA 1 was terminated from the facility for violating company policy on safety and infection (the invasion and growth of germs in the body) control. The PAR indicated, CNA 1 failed to follow responsibilities on q15 room check. The PAR indicated, on [DATE] from 6:00 AM to 7:00 AM q15 minute room check must be done at least four times within the hour and CNA 1 did not do all four times. The PAR indicated, the following timeline: 06:00 AM went into Area 2 to get a resident (unnamed) out for medication (did not perform q15 minute room check)6:11 AM positioned himself (CNA 1) in the doorway of Area 306:15 AM still sitting in the doorway of Area 3 (did not perform q15 minute room check6:23 AM went into Area 2 and came back to sit down in the doorway of Area 36:30 AM still sitting in the doorway of Area 3 (did not perform q15 minute room check)6:45 AM still sitting in the doorway of Area 3 (did not perform q15 minute room check)6:50 AM calling residents for breakfast in Area 1, but did not check Area 26:55 AM left his area unattended. The DSD stated, the facility's SVF showed that CNA 1 did not get up to check Area 2 and was the main reason why CNA 1 was terminated. During a phone interview on [DATE] at 8:14 AM with CNA 1, CNA 1 stated I got let go by the facility for not doing the routine q15 room check and q15 monitoring on Resident 1. CNA 1 stated that the last time CNA 1 entered Area 2 on [DATE] was before the time between 6:30 AM and 6:35 AM to answer the call light that came on from Area 2. CNA 1 stated, Resident 1 and Resident 2 did not say anything when CNA 1 answered the call light. During a concurrent interview and record review on [DATE] at 10:47 AM with the DSD, the facility's SVF titled, Conference Room, dated [DATE], timed at 6:00 AM to 6:43 AM was reviewed. The SVF indicated, the following timeline:6:00:00 AM CNA 1 walking in Area 1 hallway.6:05:33 AM CNA 1 passed by Area 2.6:13:13 AM CNA 1 seated at Area 3 doorway.6:23:34 AM CNA 1 entered Area 2.6:24:00 AM CNA 1 came out of Area 2, looked up at the call light above door.6:24:10 AM CNA went back to sit at Area 3 doorway.6:39:00 AM Area 2 had 2 white chairs outside of Area 2 and CNA 1 seated at Area 3 doorway.6:43:09 AM Resident 1 came out of Area 2 with both hands inside pants pocket and walked towards the south direction in Area 1 hallway passed CNA 1.6:43: 54 AM Resident 1 turned around and entered Area 2.The DSD stated, the last time CNA 1 entered Area 2 was at 6:23:34 AM. The DSD stated, CNA 1 only went inside Area 2 once when CNA 2 should have at least entered Area 2 four times in that hour window (6:00 AM to 7:00 AM) to check on Resident 1 and Area 2. The DSD stated that CNA 1 was terminated for falsification of documentation. The DSD stated, CNA 1 documented for checking Resident 1 and Area 2 (q15 monitoring and q15 room check) when CNA 1 did not. The DSD stated, staff (in general) should physically enter the resident's room to ensure residents were safe and sound, that they're (residents) breathing, and to check the surrounding. During an interview on [DATE] at 12:18 PM with CNA 2, CNA 2 stated, Resident 1's privacy curtains were drawn (closed) around Resident 1's bed up to the middle of the footboard when CNA 1 found Resident 1 hanging. CNA 1 stated, the staff had to visibly check see them with your eyes, the residents every 15 minutes for the q15 monitoring. CNA 1 stated that the staff must go inside the resident's room every 15 minutes to check whether the resident was inside the room or not to check for the resident's safety.During an interview on [DATE] at 12:36 PM with the Director of Nursing (DON), the DON stated, staff were supposed to check and locate the resident for the q15 monitoring and staff must get up and go inside the room to check on the resident even if the room was empty for the q15 room check to ensure resident's safety. The DON stated, CNA 1 was terminated from the facility for not following the facility's policy on the q15 room check and based on the facility's SVF CNA 1 did not get up and checked the room. The DON stated staff were supposed to get up and really check the resident's room.During an interview on [DATE] at 1:15 PM with the LPT, the LPT stated, the LPT heard CNA 2 called the LPT on the radio to come to Area 2. The LPT saw Resident 1 hanging with Resident 1's sheet tied to the sprinkler in the ceiling and the LPT called for a code blue. The LPT stated, CNA 1 was supposed to have eyes on Resident 1 for the q15 monitoring that was more than the checking, that Resident 1 was in the facility and assessing his behavior for Resident 1's safety. The LPT stated, staff had to physically go inside the resident's room for the q15 room check for resident's safety and glancing only at the resident's room was not a q15 room check.During a review of Resident 1's Care Plan (CP - provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan]), titled, Poor Impulse Control - AWOL, dated [DATE], the CP indicated, one of the interventions was to place Resident 1 on additional q15 monitoring.During a review of Resident 1's Follow Up Question Report (Q15 Monitoring Log - ML) dated [DATE] - [DATE], the ML indicated, CNA 1 documented Resident 1was monitored q15 from [DATE] at 23:00 PM to [DATE] at 6:45 AM.During a review of the facility's P&P titled, Security Wand 15 Minute Room Checks, dated 2021, the P&P indicated, room checks would include the staff knock before entering the room, check bathroom (open the door after knocking), pull curtains back to visually see the resident. During a review of the facility's P&P titled, Resident Rights to Humane Care, revised date 2021, the P&P indicated, residents must be provided with the highest quality of care and dignity and the right to be free from abuse, neglect and harm. During a review of the facility's P&P titled, Zoning and Supervision, updated [DATE], the P&P indicated, the monitoring allowed the staff to account for each person and made sure that each resident was free from distress. The P&P indicated, to check the rooms as scheduled and check the residents who were asleep to assure they were free of distress and for the NOC (night) shift to supervise surroundings and to be alert and pay attention to resident activity for the entirety of shift while on duty. During a review of the facility's undated P&P titled, Timely and Accurate 1:1 Monitoring and Q:15 Monitoring Documentation in Point Click Care, the P&P indicated, in documenting that the resident was located in the Point Click Care POC portal, staff were making an honest and accurate entry that staff visually saw and identified the resident.

Based on interviews and record review, the facility failed to ensure an environment free from physical abuse for two of six sampled residents (Resident 38 and 52) when: A. Resident 38 was punched (hit with a closed fist) by Resident 7 while unsupervised in the dining room on 8/13/2025.B. Resident 52 was hit by Resident 44 on the left side of the face on 8/12/2025. This deficient practice resulted in physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) to Residents 38 and 52 and mild pain (may be annoying and noticeable, but it doesn't keep you from performing normal activity) on Resident 52's left cheek. Additionally, there was potential for psychosocial harm to both residents.Findings: A. During a review of Resident 7’s admission Record (AR), the AR indicated the facility admitted Resident 7 on 11/6/2024, with diagnoses that included paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and low back pain. During a review of Resident 7’s Minimum Data Set (MDS – a resident assessment tool), dated 8/1/2025, the MDS indicated Resident 7’s cognition (the ability to think and process information) was intact. The MDS indicated Resident 7 was independent (resident completes the activity by themselves with no assistance from helper) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and was independent with mobility . During a review of Resident 38’s AR, the AR indicated the facility admitted Resident 38 on 5/8/2025, with diagnoses that included 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), obesity (excessive body fat), and psychoactive substance abuse (when drug-taking becomes a problem and the drug changes how your brain works, affecting your mood, thoughts, behavior, and perception). During a review of Resident 38’s MDS, dated [DATE], the MDS indicated Resident 52’s cognition was intact. The MDS indicated Resident 52 was independent with ADL and was independent with mobility. During a review of Resident 7’s Progress Notes, dated 8/13/2025, the progress notes indicated, at approximately 4:55 PM, Resident 38 was in the dining room with the rest of his peers waiting for dinner to be served. The notes indicated, a male peer [Resident 7] suddenly punched Resident 38 on his left cheek unprovoked who was sitting at a table away from him [Resident 7]. The notes indicated that staff intervened and separated both residents [placing them in] a safe environment. The notes indicated, upon assessment, Resident 7 stated, “he keeps bothering me, asking me for money”. Then he went into my face, so I punched him.” The notes indicated, “Resident 38 was talking to someone else at the time and remained seated on his chair. Resident 38 stated, “I don’t know him, and he does not know me. I’m new here. He just punched me out of nowhere.” During an interview on 8/18/2025 at 11:18 AM, Resident 7 stated Resident 7 had an altercation with Resident 38 in the dining room while waiting for dinner. Resident 7 stated he could not recall the exact date or time. Resident 7 stated he reported Resident 38 kept asking him for money “over and over again,” which made Resident 7 upset. Resident 7 stated Resident 7 became angry, lunged at Resident 38, and punched him in the face with a closed right fist. Resident 7 stated Resident 38 was asking Resident 7 for money on several occasions, and Resident 7 was tired of it. During an interview on 8/18/2025 at 11:27 AM, Resident 38 stated that a few days ago, while sitting in the dining area waiting for dinner, Resident 7 suddenly walked up and punched him on the left cheek. Resident 38 stated Resident 38 did not remember the exact date or time, only that it was during dinner. Resident 38 stated Resident 38 had no problems with Resident 7, and [the incident] happened suddenly without warning. Resident 38 stated Resident 38 did not know why it [Resident 7 punched Resident 38] happened, and that [the incident] left him feeling frustrated, upset, and angry because Resident 38 was punched without reason. Resident 38 stated when staff spoke with Resident 38, they told him Resident 7 said Resident 38 was asking for money, Resident 38 denied this, stating. “I don’t ask him for money.” Resident 38 stated being caught off guard. Resident 38 stated staff were not directly inside the dining room [during the time of the incident]. During an interview on 8/20/2025 at 4:07 PM, Certified Nursing Assistant (CNA) 2 reported that on 8/13/2025, at approximately 5 PM CNA 2 was at the doorway of the dining room, letting residents in one by one while sanitizing their hands. CNA 2 reported the residents were in a single-file line. CNA 2 stated CNA 2 did not notice any unusual behavior or conflicts between Resident 7 and Resident 38. CNA 2 stated unfortunately there were no staff directly inside the dining room at the time [during the time of the incident]. CNA 2 stated staff were in the hallways or on route to the dining area for dinner-time monitoring. CNA 2 stated the incident may have been prevented if staff had already been inside the dining room monitoring the residents. CNA 2 stated CNA 2 did not witness the incident, only the aftermath, both residents were standing, and staff intervened to separate them. CNA 2 stated it was challenging to monitor residents entering the dining room and maintaining full control of the dining area while also sanitizing the resident’s hands at the same time. CNA 2 stated, ideally, staff should be present inside the dining room as residents gathered for mealtimes. During an interview on 8/21/2025 at 10:27 PM with the Director of Nursing (DON), the DON stated, ideally, staff should be inside the dining room as residents lined up at the doorway to have their hands sanitized. The DON stated this allowed staff to observe residents as they gathered in the dining area and may have helped avoid conflicts. The DON stated with proper monitoring, staff could potentially have intervened in time to prevent issues from arising, such as the incident between Resident 7 and Resident 38. The DON stated this practice was essential to maintain a safe and secure environment. B. During a review of Resident 52’s AR, the AR indicated Resident 52 was admitted to the facility on [DATE] with multiple diagnoses including paranoid schizophrenia and insomnia (sleep disorder characterized by difficulty falling or staying asleep despite having adequate time and opportunity to do so). During a review of Resident 52’s Initial Medical History & Physical (H&P), dated 8/6/2025, the H&P indicated Resident 52 did not have the capacity to understand and make informed decisions. During a review of Resident 52’s MDS, dated [DATE], the MDS indicated Resident 52 had intact cognition with inattentive or disorganized thinking (rambling, unclear or illogical flow of ideas). The MDS indicated Resident 52 could independently bathe, eat, and walk at least 150 feet. During a review of Resident 52’s 1:1 (one resident supervised by one staff) Counseling Progress Note (CN), dated 8/12/2025, the CN indicated Resident 52 stated Resident 44 was walking near Resident 52 and Resident 52 attempted to move out of the way. The CN indicated Resident 44 hit Resident 52. During a review of Resident 52’s Pain Evaluation (PE), dated 8/12/2025, the PE indicated the condition that caused pain was being hit on the left cheek by a peer [Resident 44]. The PE indicated Resident 52’s pain was mild (pain that may be annoying and noticeable, but it doesn’t keep you from performing normal activity) and Tylenol (medication used to treat pain) was administered for mild pain. During a review of Resident 44’s AR, the AR indicated Resident 44 was admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder, bipolar type and insomnia. During a review of Resident 44’s MDS, dated [DATE], the MDS indicated Resident 44 had intact cognition with inattentive or disorganized thinking. The MDS indicated Resident 44 could independently bathe, eat and walk at least 150 feet. During a review of Resident 44’s Psychiatric Assessment (PA), dated 8/7/2025, the PA indicated Resident 44 had a normal, appropriate thought process and was compliant with medications. During a review of Resident 44’s 1:1 CN, dated 8/13/2025, the CN indicated Resident 44 stated Resident 44 had been having “a bad day,” when Resident 52 got in the way of Resident 44 and Resident 44 aggressively told Resident 52 to move. Resident 44 stated in the CN that Resident 52 replied by cursing at Resident 44 and both residents hit each other at the same time. During an interview on 8/20/2025 at 2:21 PM with Resident 44, Resident 44 stated Resident 52 was blocking the doorway to Resident 44’s room and Resident 52 cursed at Resident 44. Resident 44 stated Resident 52 attempted to hit Resident 44 but missed and Resident 44 responded by hitting Resident 52 on the left side of the face with a closed fist. Resident 44 stated Resident 44 hit Resident 52 for blocking the way and cursing at Resident 44. During an interview on 8/20/2025 at 2:37 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 44 was not experiencing any acute (sudden) behavioral episodes prior to the physical altercation with Resident 52. During an interview on 8/20/2025 at 2:54 PM with CNA 5, CNA 5 stated CNA 5 witnessed Resident 44 hit Resident 52 on 8/12/2025. CNA 5 stated CNA 5 witnessed Resident 44 walk towards Resident 44’s room when Resident 52 got in the way and both residents tried to get past each other but were moving in the same direction. CNA 5 stated Resident 44 then entered the room and suddenly hit Resident 52 on the left side of the head. During a review of the facility’s P&P titled, “Physical Assault,” revised 9/2015, the P&P indicated: the facility is to provide a safe and secure environment. The P&P indicated due to the population worked with there will be some physically assaultive behaviors. The P&P indicated all forms of abuse, including resident-to resident assaults, must be reported immediately to the charge nurse, the director of nursing, the administrator, the conservator, and the doctor. The P&P indicated some examples of physical assault are, but not limited to punches, kicks, spitting, throwing objects, pushing, grabbing of clothes or person to cause personal harm, etc. The P&P indicated physical Abuse is defined as willful infliction of injury; unreasonable confinement, intimidation; punishment with resulting physical harm, pain or mental anguish; or deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The P&P indicated physical Abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment.

Based on observation, interview, and record review, the facility failed to develop or implement individualized person-centered care plans (CP) for four of four sampled residents (Resident 1, Resident 7, Resident 13, and Resident 47) by failing to ensure:A. CPs titled, Compliance with Activities of Daily Living [ADL, term used in healthcare that refers to self-care activities] and Oral/Dental Care, were implemented for Resident 13. On 8/18/2025, Resident 13 was observed with a dry crust around the lips and build up and discoloration on Resident 13's upper and lower teeth.B. A CP was developed that addressed smoking for Resident 7.C. A CP was developed for Resident 1 and Resident 47 that addressed the resident's diagnoses of Post Traumatic Stress Disorder (PTSD- a mental health condition that can develop after experiencing or witnessing a traumatic event).These failures had the potential to result in unmet individual needs for Resident 1, 7, 13, and 47 and the potential to result in the residents not receiving the necessary care and services to achieve an optimal level of function.Cross Reference F699Findings: A. During a review of Resident 13’s admission Record (AR), the AR indicated Resident 13 was admitted to the facility on [DATE] with diagnosis that included schizoaffective (a mental disorder effecting how a person thinks and feels) bipolar (a mental disorder with periods of depression and periods of elevated mood) disorder and cigarettes nicotine dependence. During a review of Resident 13’s CP, titled Compliance with Activities of Daily Living [ADL, term used in healthcare that refers to self-care activities], initiated on 7/29/2024, the CP’s interventions indicated to prompt [Resident 13] to get up and shower, brush teeth, comb hair etc. During a review of Resident 13’s CP titled “Oral/Dental Care,” initiated on 7/29/2024, the CP’s goal indicated to remove soft plaque (a sticky, colorless film of bacteria [living organism that can cause an infection] that forms on the teeth and gums) deposits and calculus (hard mineralized deposit that forms on the teeth over time) from [Resident 13’s] teeth. The CP’s interventions indicated to prompt the resident to complete grooming task which included oral hygiene; provide supervision/assistance with oral hygiene as needed, report any unusual observations (dry lips, sores, bad breath, etc) to charge nurses, and for Certified Nurse Assistance (CAN’s) to document that oral hygiene was given and any unusual observations. During a review of Resident 13’s Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 7/29/2025, the MDS indicated Resident 13 was cognitively (ability to understand and process information) intact, had clear speech, and was able to understand and be understood. The MDS indicated Resident 13 needed supervision/touch assistance (helper provides cues as resident completes the activity) with personal hygiene (practices and habits that maintain cleanliness and prevent the spread of germs [bathing, brushing teeth]). During an observation and concurrent interview on 8/18/2025 at 12:10 PM, Resident 13 had red/brown flakes on the edges of Resident 13’s mouth. Resident 13 had tan brownish colored build up on the upper and lower teeth. Resident 13 stated Resident 13’s teeth often bled. During an interview with CNA 3, on 8/21/2025 at 11:30 AM, CNA 3 stated CAN 3 gave Resident 13 toothbrushes, but CNA 3 did not ensure Resident 13 brushed Resident 13’s teeth. CAN 3 stated CNA 3 was not informed to monitor Resident 13’s oral hygiene or to remind Resident 13 to brush their teeth. During an observation and concurrent interview with the Director of Nursing (DON), on 8/21/2025 at 12:31 PM, the DON stated Resident 13 had a dry brown crust around the lips. The DON stated Resident 13’s upper and lower teeth had a light brown to brown colored accumulation of plaque. The DON stated the facility staff were responsible for encouraging Resident 13 of hygiene (brush teeth, shower). The DON stated it was important to follow the CP to ensure proper interventions were being done and to update/adjust the CP when needed. During a review of the facility’s policy and procedure (P&P) titled “Nursing Services Policy,” revised on 7/16/2024, the P&P indicated the facility’s nursing services will provide the care and services to attain or maintain the highest quality of care practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. The P&P indicated the facility provided necessary care and services to will that a resident’s abilities in activities of daily living do not diminish…. B. During a review of Resident 7’s AR, the AR indicated the facility admitted Resident 7 on 11/6/2024, with diagnoses that included paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and low back pain. During a review of Resident 7’s Smoking – Safety Screen, dated 11/6/2024, the smoking – safety screen indicated Resident 7, smoked three times a day and was safe to smoke per the facility’s supervision protocol. During a review of Resident 7’s MDS, dated [DATE], the MDS indicated Resident 7’s cognition was intact. The MDS indicated Resident 7 was independent (resident completes the activity by themselves with no assistance from helper) with ADLs and was independent with mobility. During an observation on 8/18/2025 at 12:17 PM, Resident 7 was observed smoking out in the patio with staff supervision. During an observation on 8/19/2025 at 12:22 PM, Resident 7 was observed smoking out in the patio with staff supervision. During an interview and a concurrent record review on 8/19/2025 at 1:37 PM, Resident 7’s CPs were reviewed with Registered Nurse (RN) 1. RN 1 stated Resident 7’s CPs did not include a smoking CP. RN 1 stated all residents who smoked should have a CP [that addressed smoking] to ensure safety, compliance, and smoking cessation education. RN 1 stated CPs guided staff in providing quality care and carrying out interventions. During an interview on 8/21/2025 at 10:27 AM, with the DON, the DON stated smoking CPs were necessary to ensure resident safety, reinforce compliance with the facility P&P, and provided education on smoking cessation. The DON stated CPs supported staff in delivering consistent, quality care. During a review of the facility’s P&P titled, Smoking Safety Screen Policy, updated on 7/2019, the P&P indicated: · CP review: Ensure a specific plan of care addressing nicotine dependence and use is in place and tailored to the resident’s needs. C. During a review of Resident 1’s AR, the AR indicated the facility admitted Resident 1 on 8/4/2022, with diagnoses that included PTSD, schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) bipolar type (mood swings that range from the lows of depression to elevated periods of emotional highs), and major depressive disorder. During a review of Resident 1’s MDS, dated [DATE], the MDS indicated Resident 1’s cognition was moderately impaired. The MDS indicated Resident 1 was independent with ADL and was independent with mobility. During a review of Resident 47’s AR, the AR indicated the facility admitted Resident 47 on 7/16/2025, with diagnoses that included PTSD, schizophrenia (a mental illness that is characterized by disturbances in thought), and depression (a medical illness causing persistent feelings of sadness, hopelessness, and loss of interest in activities that once brought joy). During a review of Resident 47’s MDS, dated [DATE], the MDS indicated Resident 47’s cognition was intact. The MDS indicated Resident 47 was independent with ADL and was independent with mobility. During an interview and concurrent record review 8/20/2025 at 3:10 PM, with Licensed Vocational Nurse (LVN) 2, Resident 1 and Resident 47’s admission Records and CPs were reviewed with LVN 2. LVN 2 stated Resident 1 and Resident 47 had documented medical diagnoses of PTSD in the admission medical record. LVN 2 stated Resident 1 and Resident 47 did not have CPs for PTSD. LVN 2 stated CPs should have been created because the residents had documented diagnoses of PTSD. LVN 2 stated CPs were important because they addressed signs and symptoms, maintained resident well-being, provided coping strategies, and guided staff in delivering consistent care for the residents. During an interview on 8/21/2025 at 10:27 AM, the DON stated staff should have created and implemented a CP for residents with a PTSD diagnosis because the CP allowed staff to manage their symptoms, ensured safety, recognized triggers, and provided consistent care to minimize or prevent re-traumatization, even if the cause was unknown or not disclosed. During a review of the facility’s P&P titled, “Baseline/Comprehensive Care Plan – Interdisciplinary Team [IDT, a team of health care professions who work together to establish plans of care for residents] Conference – Behavioral,” created on 11/26/2017, the P&P indicated the facility will: · Develop and implement a baseline CP for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. · Develop a comprehensive, person-centered care plan for each resident. During a review of the facility’s P&P titled, “Trauma Informed Care Policy and Procedures” created on 1/2020, the P&P indicated that trauma informed care plan will be opened if trauma is expressed or discovered any time during stay at the facility.

Based on interviews and record review, the facility failed to ensure two of two sampled residents (Residents 1 and Resident 47) received Post Traumatic Stress Disorder (PTSD- a mental health condition that can develop after experiencing or witnessing a traumatic event) care that addressed their individual experiences, necessary to minimize the risk of re-traumatization. This deficiency could have potentially resulted in emotional distress, exacerbation of PTSD symptoms, and an increased risk of behavioral or psychological harm to Residents 1 and Resident 47.Cross Reference F656Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/4/2022, with diagnoses that included PTSD, schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) bipolar type (mood swings that range from the lows of depression to elevated periods of emotional highs), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/1/2025, the MDS indicated Resident 1's cognition (the ability to think and process information) was moderately intact. The MDS indicated Resident 1 was independent (resident completes the activity by themselves with no assistance from helper) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and was independent with mobility.During a review of Resident 47's AR, the AR indicated the facility admitted Resident 47 on 7/16/2025, with diagnoses that included PTSD, schizophrenia (a mental illness that is characterized by disturbances in thought), and depression (a medical illness causing persistent feelings of sadness, hopelessness, and loss of interest in activities that once brought joy).During a review of Resident 47's MDS, dated [DATE], the MDS indicated Resident 47's cognition was intact. The MDS indicated Resident 47 was independent with ADL and was independent with mobility.During an interview and concurrent record review 8/20/2025 at 3:10 PM, with Licensed Vocational Nurse (LVN) 2, Resident 1 and Resident 47's admission Records were reviewed with LVN 2. LVN 2 stated Resident 1 and Resident 47 had documented medical diagnoses of PTSD in the admission medical record. LVN 2 stated Resident 1 and Resident 47 did not have CPs for PTSD. LVN 2 stated CPs should have been created because the residents had documented diagnoses of PTSD. LVN 2 stated CPs were important because they addressed signs and symptoms, maintained resident well-being, provided coping strategies, and guided staff in delivering consistent care for the residents. LVN 2 stated when a resident had a diagnosis of PTSD, it was important for the facility to recognize and identify the trauma, because this helped staff understand the resident's individual experiences and reduce the risk of re-traumatization. LVN 2 stated even if the residents did not disclose the exact trauma, staff were still required to address the PTSD in the plan of care [to implement the interventions]. LVN 2 recognized the facility did not create or implement a PTSD-specific plan of care for Residents 1 and 47, which placed the residents at risk for mental or emotional suffering related to their past trauma. During an interview on 8/21/2025 at 10:27 AM, the Director of Nursing (DON) stated that when residents have a diagnosis of PTSD, the facility was responsible for ensuring and developing a care plan that addressed each resident's trauma and unique experiences [with appropriate interventions] to reduce the re-traumatization. The DON stated that without a PTSD-specific care plan, residents' trauma-informed needs were not fully addressed, placing them at risk for psychological or emotional harm.During a review of the facility's policy and procedure (P&P) titled, Trauma Informed Care Policy and Procedures created on 1/2020, the P&P indicated the facility will be focused on providing culturally competent, trauma informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. Trauma is defined as resulting from an event, series of event, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individuals functioning and mental, physical, social, emotional, or spiritual well-being.

Based on observation, interview and record review, the facility failed to store food items in a manner that prevented food borne illness (condition caused by consuming contaminated food or beverages), in one of one kitchen (Kitchen 1), by:A. Failing to remove five of 47 apples and one of 16 onions that had spoiled (food that has deteriorated in quality and becomes unfit and/or unsafe for consumption).B. Failing to ensure employees kept personal belongings out of Kitchen 1.Findings:A. During a concurrent observation and interview on 8/18/2025 at 10:15 AM with the Dietary Supervisor (DS) in Kitchen 1, one bin containing 47 apples was observed. Five apples had a wrinkled outward appearance and/or were bruised, had broken skin with a soft texture when touched. The DS stated the apples were not good to eat anymore and should not have been in the bin. The DS stated the cook on duty inspected the produce every Thursday and it was an error for spoiled apples to be in the bin. During a concurrent observation and interview on 8/18/2025 at 10:20 AM with the DS in Kitchen 1, one bin containing 16 onions was observed. One out of 16 onions appeared flattened in a surrounding brown liquid that had a foul odor. The DS stated the spoiled onion should not have been in the bin and the spoiled produce would not be served to the residents. The DS stated spoiled food could potentially cause residents to become sick if eaten.During a review of the facility's policy and procedure (P&P) titled, Non-Refrigerated Produce Storage Inspection, dated 9/2025, the P&P indicated on Mondays and Thursdays, before produce is returned to the bins, the cook on duty will inspect all items to ensure they are safe to eat. Produce showing spoilage, damage, or that is expired will be immediately discarded according to facility protocol. B. During a concurrent observation and interview on 8/20/2025 at 12:15 PM with the DS in Kitchen 1, an employee's cellphone and keys were left unattended on top of a table across the refrigerator. The DS stated the DS had instructed employees multiple times not to leave personal items in Kitchen 1 and all personal items should be stored in the nearby locker to prevent the potential of food contamination in Kitchen 1.During an interview on 8/21/2025 at 2:57 PM with [NAME] (CK) 2, CK 2 stated employee cellphones should not be kept in Kitchen 1 because it would not be sanitary to have phones near resident food and it was against the facility's policy.During a review of the facility's policy and procedure (P&P) titled, Job Routine/ work conduct, undated, the P&P indicated all personal belongings must be kept in your [employee's] locker.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 79) was informed and provided information regarding housing alternatives after discharge. This deficient practice violated Resident 79's rights to be informed of Resident 79's treatment.Findings:During a review of admission Record (AR), the AR indicated Resident 72 was admitted to the facility on [DATE] with diagnoses that included psychosis (a mental health condition characterized by a loss of contact with reality), substance abuse (psychoactive drugs, such as alcohol, pain medications, or illegal drugs), and cigarette nicotine dependance.During a review Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 5/20/2025, the MDS indicated Resident 79 was cognitively intact, had clear speech made self-understand and understood. The MDS indicated Resident 79 was independent with eating, oral and toilet hygiene, dressing, and transfers (moving a resident from one flat surface to another).During a review of Resident 79's Social Service Quarterly -V3 (SSQ), dated 5/27/2025, the SSQ indicated Resident 79 verbalized depression due to missing the resident's family and being in the community [facility]. The SSQ indicated Resident 79 wanted to talk to someone about the possibility of leaving the facility and returning to live and receiving services in the community. The SSQ indicated the resident was in discharge planning and referrals were made to a local contact agency (LCA, an agency that provides information on available home and community-based services (HCBS), assists with transition planning, and offers case management to support a resident's move out of a nursing home and into the community).During a review of a facility email titled Referral Status Update, dated 7/3/2025, from an LCA to the Social Services Director (SSD), the email indicated Resident 79 was accepted into an outside rehabilitation program and was placed on a waiting list.During a record review of email titled (Resident 79) - Discharge Planning, dated 8/21/2025, from the LCA to the SSD, the email indicated Resident 79 was pre-approved for admission to an outside of the facility program and the LCA was expecting for a bed to become available at the program [for Resident 79]. During a concurrent observation and interview with Resident 79, inside Resident 79's room, on 8/18/2025 at 12:35 PM, Resident 79 stated I am on discharge planning (DC) and want to go home. I miss my daughter and they (the facility) are holding me here. I need someone to tell me what is going on, but no one is given me a reason why I need to stay here.During an interview and concurrent record review of Resident 79's paper and electronic medical record (chart) with the SSD, on 8/21/2025 at 11:58 AM, the SSD stated Resident 79 was accepted into a rehabilitation program on 7/2/2025. The SSD stated the SSD did not have any documentation that indicated Resident 79 was informed of Resident 79's acceptance into an outside rehabilitation program or that a projected date was set for housing. The SSD stated it was important for Resident 79 to be aware of the discharge planning and know how long the resident had to wait and for Resident 79 to move forward with Resident 79's life.A review of the facility's undated policy and procedure (P&P) titled, Resident Rights, the P&P indicated the resident has the right to participate in the development and implementation of his or her persons-centered plan of care. The P&P indicated, including the right to participate in the planning process. The P&P indicated the resident has the right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.During a review of the facility's P&P titled Nursing Services Policy, revised on 7/16/2024, the P&P indicated residents will remain actively engaged in his or her care planning process through the resident rights to participate in the development of and be informed in advance of changes in the care plan . Discharge planning - the facility has a discharge planning processing in place which addresses each resident's discharge goas and needs, including caregiver support and referrals to local contact agencies, as appropriate, and involves the resident.

Based on observation, interview, and record review the facility failed to provide a radio to one of one sampled resident (Resident 44) in a timely manner.This failure had the potential to lead to psychosocial decline, increased depression, and anxiety for Resident 44.Findings:During a review of Resident 44's admission Record (AR), the AR indicated Resident 44 was admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar type (mental health condition with a mix of symptoms including hallucinations, delusions and mood swings especially periods of very high energy and possibly depressive episodes) and insomnia (sleep disorder characterized by difficulty falling or staying asleep despite having adequate time and opportunity to do so).During a review of Resident 44's Care Plan (CP) regarding activities, initiated 6/10/2025, the CP indicated Resident 44 would be assessed for activities of interest and encouraged to participate.During a review of Resident 44's Activities- initial assessment (AIA), dated 6/10/2025, the AIA indicated Resident 44's hobbies included drawing and music. The AIA indicated it was very important for Resident 44 to listen to music.During a review of Resident 44's Minimum Data Set (MDS, a resident assessment tool), dated 6/18/2025, the MDS indicated Resident 44 had intact cognition (ability to understand and process information) with inattentive or disorganized thinking (rambling, unclear or illogical flow of ideas). The MDS indicated Resident 44 could independently (resident completes activity by themselves with no assistance from a helper) bathe, eat, and walk at least 150 feet. The MDS indicated under section F - Preferences for Customary Routine and Activities that it was very important for Resident 44 to listen to music. During a review of Resident 44's Program Monthly (PM), dated 8/6/2025, the PM indicated under CP Name: Anxiety, that Resident 44 was concerned about shopping and repeatedly asked staff when Resident 44 would be able to go shopping.During an interview on 8/20/2025 at 2:21 PM with Resident 44, Resident 44 stated Resident 44 wanted a radio to listen to music in Resident 44's room. Resident 44 stated Resident 44 had requested a radio multiple times from the Social Services Director (SSD) and had enough funds to purchase the radio but had not been given a reason why a radio still had not been provided. Resident 44 stated not having a radio was causing boredom and depression.During an interview on 8/21/2025 at 11:48 AM with the Social Service Director (SSD), the SSD stated the SSD made purchases, for residents, outside of the facility for items such as clothing, specific hygiene items, and radios on a quarterly basis since 2020. The SSD stated residents signed up on a list for shopping requests each month from the first to the tenth of the month and the SSD purchased the items if resident funds were available. The SSD stated the SSD took multiple shopping trips between 7/12/2025 and 7/30/2025 but only purchased items for the residents on the list. The SSD stated Resident 44's funds were not available during the SSD's last shopping trip. The SSD stated the next shopping trip would be sometime next month on 9/2025.During a concurrent interview and record review on 8/21/2025 at 1:47 PM with the SSD, the facility's policy and procedure (P&P) titled, Client Shopping, dated 1/2025 was reviewed. The P&P indicated the Social Service Department conduct monthly shopping outing for residents who cannot go out of the facility. These residents are newly admitted .and have not displayed appropriate behaviors for shopping in the community. These outings do not require the $100.00 minimum amount for shopping. The SSD stated Resident 44 had requested a radio after 7/10/2025 and did not sign up in time for the shopping trips that occurred on 7/2025. The SSD stated that even though the policy indicates shopping is done monthly, it is actually done quarterly because no other staff was designated to do the task and each trip could take several hours. The SSD stated Resident 44 had to wait until the next scheduled shopping trip to get a radio.During an interview on 8/21/2025 at 1:47 PM with the Administrator (ADM), the ADM stated the facility would make arrangements to obtain a radio for Resident 44 because Resident 44 had indicated to the ADM that a radio was very important and would help with Resident 44's depression.

Based on observation, interview, and record review, the facility failed to ensure eyeglasses were made available for one of one sampled resident (Resident 1) as indicated in the optometry consultation, dated 10/18/2024, and the care plan (CP) for impaired visual function. This deficient practice had the potential to result in worsening of Resident 1's vision and a psychosocial decline to Resident 1. Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/4/2022, with diagnoses that included right eye keratopathy (affects the cornea, the clear front window of the eye), bilateral (left and right) nuclear cataract (clouding/blurry vision), bilateral glaucoma (damages to the nerve of the eye) presbyopia (gradual loss of eye focusing) and schizoaffective disorder (hallucinations and mood swings).During a review of Resident 1's CP titled The resident has impaired visual function initiated on 8/4/2022, the CP's goal indicated for Resident 1 to remain in a safe environment with no injury and to use appropriate visual devises to promote participation in Activity of Daily Living (ADL, term used in healthcare that refers to self-care activities). The CP's interventions indicated to remind Resident 1 to wear Resident 1's glasses and ensure Resident 1 wore glasses that were clean and free from scratches and in good repair.During a review of a Resident 1's optometry consult, dated 10/18/2024, the consult's recommendations indicated bifocal glasses for Resident 1 and the Goal of Treatment was to improve vision and enhance Resident 1's quality of life.During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognition was moderately impaired. The MDS indicated Resident 1 was independent with ADL and was independent with mobility. The MDS indicated Resident 1's vision was severely impaired (see's colors and/or shapes) and Resident 1 needed corrective lenses (glasses).During a review of Resident 1's History and Physical (H&P), dated 8/6/2025, the H&P indicated Resident 1 needed eyeglasses.During an observation and concurrent interview with Resident 1, in the hallway, on 8/18/2025 at 12:04 PM, Resident 1 was carrying an empty case for glasses and stated Someone took my glasses! I need my glasses!During an observation and interview with Resident 1, inside Resident 1's room on 8/19/2025 at 2:56 pm, Resident 1 gave permission to search the resident's room for any glasses. Resident 1 stated there is no glasses! If I had them, I would be wearing them - I aint got no glasses. I had them a few months ago, but I don't have them now.During an observation of Resident 1's room and concurrent interview with Certified Nursing Assistant 2 (CNA 2) and Resident 1 on 8/19/2025 at 2:56 PM, CNA 2 searched Resident 1's bedside table and closet for Resident 1's glasses. CNA 2 stated there were no glasses inside Resident 1's room.During an interview with Licensed Vocational Nurse 1 (LVN 1) on 8/19/2025 at 2:59 PM, LVN 1 stated Resident 1's personal belongings were kept inside the resident's room. LVN 1 stated no personal belongings were kept in the nurse's station. LVN 1 stated LVN 1 had not seen Resident 1 wear glasses. LVN 1 stated glasses were important to see, that is basic.During an interview with CNA 3 on 8/21/2025 at 11:30 AM, CNA 3 stated I don't know if Resident 1 wears glasses. I have never seen Resident 1 with glasses.During an interview and concurrent record review with the Director of Nursing (DON), Resident 1's paper and electronic medical record was reviewed, on 8/21/2025 at 12:26 PM, the DON stated Resident 1 needed glasses. The DON stated it was important for Resident 1 to have and wear glasses to see and read.During a review of the facility's undated policy and procedure (P&P), titled Resident Rights, the P&P indicated the resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. The P&P indicated the residents have the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely.

Based on observation, interview, and record review the facility failed to accurately document a one to one (1:1- continuous observation) monitoring for two hours after an altercation (physical aggression) for one of eight sampled residents (Resident 1). This failure resulted in inadequate documentation of Resident 1's one to one monitoring as ordered by the physician. Findings: A review of Resident 1's Admission Record (AR) indicated the resident was readmitted on [DATE] with diagnoses that included schizophrenia (disorder affecting person's ability to think, feel, and behave clearly) and major depressive disorder (persistently depressed mood or loss of interest in activities). A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 9/10/24, indicated Resident 1 had moderate cognitive (ability to think, reason, and remember) impairment and mobility was independent. A review of Resident 2's AR indicated the resident was admitted on [DATE] with diagnoses that included paranoid schizophrenia (type of schizophrenia causing distrust of others) and major depressive disorder. A review of Resident 2's MDS, a resident assessment and care screening tool, dated 11/15/24, indicated Resident 2 was cognitively intact and mobility was independent. A review of Resident 1's Care Resident to Resident Abuser Care Plan, dated 11/30/24, indicated Resident 1 was assaultive to male per (Resident 2) during altercation. During a review of Resident 1's PO, dated 11/30/24, at 5:20 p.m., the PO indicated Resident 1 had a 1:1 order for two hours and then Q15 (every fifteen minutes) monitoring for two hours related to (r/t) altercation with peer one time only until 11/30/24 at 11:59 p.m. During a review of Resident 1's Progress Notes, dated 11/30/24, at 5:39 p.m., the Progress Notes indicated Resident 1 was to also be placed on 1:1 monitoring for two hours and then Q15 monitoring r/t Medical Doctor (MD 1) contacted and new order was given. During a concurrent interview, on 12/11/24, at 1:15 p.m., with the Administrator (ADM) and the Medical Records (MR), the ADM stated there was a Physician Order (PO) for a 1:1 monitoring for Resident 1, but the 1:1 monitoring was incorrectly entered in the Point Click Care (PCC- electronic documentation) documentation by staff and the facility was not able to provide documentation of the 1:1 monitoring for Resident 1. The MR stated there was no documentation that could be provided of the 1:1 monitoring for Resident 1. During an interview, on 12/11/24, at 5:54 p.m., the QA (Quality Assurance Nurse), the QA stated Licensed Vocational Nurse 2 (LVN 2) initiated the 1:1 monitoring in the task section of electronic documentation (the PCC) incorrectly. The QA stated the QA was not able to provide documentation of 1:1 monitoring for Resident 1. During a review of the facility's Policy & Procedure (P&P), titled Policy for Carrying Out Orders From Medical/Psychiatric Providers, dated August 2024, indicated the facility will carry out all orders prescribed by any Medical and/or Psychiatric Providers for all residents admitted to the facility. During a review of the facility's P&P, titled, Policy For Timely And Accurate 1:1 Monitoring And Q:15 MIN Monitoring Documentation In Point Click Care, dated, August 2022, indicated an order for 1:1 Monitoring and Q:15 Min. Monitoring will be obtained by ordering provider, noted, carried out for, but not limited to the following reasons: assaultive behavior, self-harm, suicidal ideations, severe agitation, safety, and new admission. The Licensed Nurse will then initiate the 1: 1 or Q: 15 Min. Monitoring in Point Click Care in the Tasks section of the EHR, and the CNA assigned to the Resident will do the required documentation every 15 mins and will have direct line of sight for the Resident receiving the monitoring. Once the order for the 1:1 or Q:15 Min. Monitoring is obtained the Licensed Nurse will go to the Resident's chart in PCC and click on the Tasks the Nurse will then click New Task' and choose 1:1 Monitoring or Q: 15 Min. Monitoring from the menu, 2. The Licensed Nurse will then specify the reason for the monitoring and then select the time the monitoring is to begin, 3. The documentation must be triggered immediately but no longer than 15 mins following the incident, 4. The CNA assigned to the Resident ordered the monitoring will then do the documentation every 15 minutes in the Point of Care Portal in PCC.

Based on observation, interview, and record review, the facility failed to provide immediate cardiopulmonary resuscitation (CPR - emergency lifesaving procedure, consisting of a combination of chest compressions, mouth- to-mouth, or mechanical breathing [using a device to help someone breathe], performed when the heart stops beating or beats ineffectively to restore breathing) to one of two sampled residents (Resident 1), who was a full code (when the resident's heart stops beating and/or the resident stops breathing, the resident or their representative's wishes to perform all lifesaving procedures to keep the resident alive, a full code is the default status for all patients unless they have explicitly discussed other wishes with their medical provider). On [DATE], Certified Nursing Assistant 1 (CNA 1), Licensed Psychiatric Technician (LPT 1) and Licensed Vocational Nurse 1 (LVN 1) did not provide CPR immediately when Resident 1 was found unresponsive in Resident 1's room as indicated in the facility's Policy and Procedures (P&P) titled Advance Directives [AD, legal document that provides instructions regarding medical care according to the resident's wishes and only goes into effect if the resident can no longer communicate their wishes]./Individual Health Care Instructions and Emergency Response Policy and Procedure. As a result, on [DATE] at 6:49 am, Resident 1 was pronounced expired after the paramedics (emergency medical technicians [EMT] who provide emergency medical services) performed unsuccessful CPR to Resident 1. On [DATE], while onsite at the facility, the California Department of Public Health (the Department) identified an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) regarding the facility's failure to provide immediate CPR to Resident 1 when Resident 1 was found unresponsive on [DATE], by failing to ensure CNA 1, LPT 1, and LVN 1 performed CPR immediately when Resident 1 was found unresponsive. The surveyor notified the Administrator (ADM), the Director of Nursing (DON), and the Quality Assurance Nurse (QAN) of the IJ situation on [DATE] at 3:22 pm. On [DATE], the facility submitted an acceptable IJ Removal Plan (IJRP, plan that includes interventions to immediately correct the deficient practices). While onsite at the facility, the surveyor determined the IJ situation was no longer present and confirmed/verified the facility's full implementation of the IJRP through observations, interviews, and record review. The IJ was removed on [DATE] at 5:02 pm in the presence of the QAN, and the Program Director (PD). The IJPR included the following immediate actions: On [DATE], 1.The Director of Nursing (DON) and ADM provided in-service education to all nursing staff on duty, this included 3 licensed staff and 10 CNAs. The in-service education lesson plan focused on the protocol for providing CPR to an unresponsive Resident. 2. In-service training included: o Nursing staff first on scene of the unresponsive resident will begin to administer CPR while calling for a Code Blue [an emergency code that used to indicate a patient/resident requiring immediate cardiopulmonary resuscitation] and the location of the resident. o Staff not administering CPR will call 911 immediately. o Nursing staff first on scene will not discontinue CPR until another nursing staff member that is CPR certified takes over doing CPR or paramedics arrive; whichever is first. o Staff is not to leave the unresponsive resident until expiration has been verified by paramedics. Identifying other residents at risk: on [DATE], the DON reviewed all 94 current residents' code status [a type of emergent treatment a person would or would not receive if their heart or breathing were to stop] and documentation of no advanced directive by responsible party was all residents' charts. All 94 current residents are full code status. Root Cause Analysis: on [DATE], the ADM, the DON, and the QAN conducted a root cause analysis, including: 1. Review of interviews with involved staff (CNA 1, LPT 1, LVN 1, HK [housekeeping] 1) 2. Review of facility policies and procedures related to emergency response and CPR. 3. Review of all 75 nursing staff working the floor (20 licensed staff, 51 CNA's, 4 nursing aids) to ensure all were CPR certified, 75 out of 75 nursing staff were CPR certified. The root cause analysis revealed: 1. Lack of clear understanding among all staff regarding their role in initiating CPR. 2. Insufficient emphasis on the immediacy required in emergency situations. Systemic Changes and Preventive Measures: 1. On [DATE], the facility updated its Emergency Response Policy to clearly state that any staff member who discovered an unresponsive resident must immediately alert the nearest nursing staff and remain with the resident. 2. On [DATE], the DON conducted in-service training to 3 licensed staff, 1 nursing aid, and 18 CNA's. There were 40 nursing staff that were not present for in-service training on [DATE] - [DATE], the staff not present will be in-serviced immediately upon return to the facility. 3. Code Blue Drills will be conducted randomly by the DON on a quarterly basis on various shifts to ensure proficient and competent knowledge of Emergency Response Procedures. Monitoring and Evaluation Plan: 1. The Staff Developer will conduct weekly audits of 10% of staff (across all departments when applicable) to assess knowledge of emergency response procedures and CPR protocol weekly for 3 months. 2. Emergency Response Procedures will be a part of orientation training for all new nursing staff. 3. The QAN will review all emergency response incidents within 24 hours of occurrence for proper adherence to protocol. The Staff Developer will report the monitoring plan results quarterly [during the] QAA (Quality Assessment and Assurance, a committee that meets quarterly to develop and implement appropriate plans of action to correct identified quality deficiencies) [meeting]. The QAA committee will review the effectiveness of the interventions and make any necessary adjustments to the plan. Monitoring will be on an ongoing basis until sustained compliance is achieved, as evidenced by three consecutive months of 100% compliance in all audits and drills. The administrator is responsible for full compliance. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1 on [DATE] with diagnoses that included paranoid schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real), bipolar disorder (a serious mental illness that causes unusual shifts in mood, periods of depression and periods of elevated mood) unspecified, and obesity (a chronic health condition that involves excess body fat that may impair health). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], the MDS indicated Resident 1's cognition (ability to understand and process information) was intact, had clear speech, and had the ability to understand and be understood (ability to express ideas and wants) by others. The MDS indicated Resident 1 did not have any impairments (an injury, illness, or a condition where part of your body or brain does not work as it normally should) on the upper extremities (shoulder, elbow, wrist, hand) and lower extremities (hip, knee, ankle, foot). During a review of Resident 1's Emergency Medical Technician ( EMT, trained medical professional who provides emergency medical care to people outside of a hospital) Fire Department run report (a standard document used by emergency medical service care providers), dated [DATE], timed at 6:36 am, the report indicated EMTs arrived at the facility on [DATE] at 6:43 am and were at Resident 1's bedside to evaluate Resident 1 at 6:44 am. The report indicated the EMTs found Resident 1 on the floor, unresponsive, and pulseless (without a pulse). The report's narrative indicated CPR was given to Resident 1and Resident 1's first monitored heart rhythm (electrical activity of the heart seen on a screen) was asystole (no heartbeat). The report's narrative indicated Resident 1 was dead (expired) prior to the EMTs arrival and the EMTs called a time of death (TOD) at 6:49 am. The report indicated staff alleged had seen Resident 1 ten minutes prior to the EMT's arrival but Resident 1 had rigor (fourth stage of death, recognizable sign of death characterized by stiffening of the limbs caused by chemical changes in the muscles and can occur as soon as four hours after death) and lividity (bluish purple discoloration of the skin after death). During a review of Resident 1's Progress Note (PN) written by LPT 1, dated [DATE], timed at 8:29 am, the PN indicated at 6:25 am, [CNA 1] alerted LPT 1 to check on Resident 1. The PN indicated Resident 1 was found bent over in the corner, between the bed and the closet [in Resident 1's room]. The PN indicated LPT 1 tapped Resident 1 on the back, but there was no response from Resident 1. The PN indicated Resident 1 had no vital signs (measuring the basic functions of your body temperature, blood pressure, pulse, and respirations) and [the staff] called for help, called a code blue, and CPR was started (no time specified). The note indicated paramedics arrived at the facility around 6:30 am (per the EMT report, EMT arrival time was 6:43 am), Resident 1 was pronounced expired, and the coroner's (a person who examines the circumstances surrounding a death) office was called. During a telephone interview on [DATE] at 1:28 pm, with LPT 1, LPT 1 stated CNA 1 informed LPT 1 to check on Resident 1after CNA 1 found Resident 1 unresponsive. LPT 1 stated, LPT 1 was assigned to care for Resident 1 on [DATE] during the night shift. LPT 1 stated during the shift, nothing was triggered and LPT 1 just walked by Resident 1's room. LPT 1 stated at 2 am and 4 am, LPT 1 passed by Resident 1's room and LPT 1 did not see anything unusual. LPT 1 stated, during LPT 1's shift, LPT 1 did not see Resident 1 come outside of Resident 1's room. LPT 1 stated in the early morning (no recall of exact time) LPT 1 entered Resident 1's room and saw Resident 1 faced down on the floor between the bed and closet. LPT 1 stated LPT 1 tapped Resident 1 but Resident 1 was unresponsive. LPT 1 stated LPT 1 left Resident 1's room, walked to the door leading to the east unit and instructed CNA 4 to notify LVN 1 there was an emergency. LPT 1 stated he and LVN 1 went back to Resident 1's room and started performing CPR. During a review of the facility's CPR certifications, from the International CPR Institute (a company that offers first aid certification-training and CPR training), LPT 1's certificate indicated LPT 1 successfully completed a three-hour CPR course on [DATE] (LPT 1 was able to perform CPR). According to the American Red Cross Training Services, undated, for a person who was found unresponsive and not breathing CPR should be started and an AED (automated external defibrillator, portable electric device that automatically diagnose life threatening cardiac arrhythmias [irregular heartbeat]) should be used immediately. https://www.redcross.org/take-a-class/resources/learn-first-aid/unresponsive-and-breathing-person During an interview on [DATE] at 1:48 pm with Housekeeper 1 (HK 1), HK 1 stated, today at around 6:30 am when HK 1 entered Resident 1's room, HK 1 saw Resident 1 on the floor next to Resident 1's bed and HK 1 told Resident 1 to get up and go to Resident 1's bed. HK 1 stated Resident 1's hands were blue, and HK 1 did not see Resident 1's face because it was tucked in Resident 1's chest. HK 1 stated Resident 1's bottom was facing up. HK 1 stated HK 1 told CNA 1 to check on Resident 1 because Resident 1 did not move [unresponsive] when HK 1 said anything [to Resident 1] and, something was wrong [with Resident 1]. HK 1 stated HK 1 did not touch Resident 1. During an interview on [DATE] at 1:56 pm, the DSD stated, on [DATE] at 6:25 am, the DSD went to the nurse's station to put up the [staff] assignment when CNA 1 called the DSD and told the DSD CNA 1 needed help. The DSD stated the DSD went to Resident 1's room, LPT 1 and LVN 1 were inside Resident 1's room and Resident 1 was [on the floor] kneeling toward Resident 1's head of the bed and was slumped over. The DSD stated Resident 1 was blue, not a normal color and Resident 1 had no pulse. The DSD stated LPT 1 and LVN 1 were standing next to Resident 1's body checking Resident 1, and the DSD instructed LPT 1 and LVN 1 to start CPR (to time recall of the time CPR was started) while the DSD ran outside Resident 1's room to get an oxygen [O2, colorless, odorless gas] tank, and instructed someone else (unidentified) to call 911. The DSD stated housekeepers were not CPR certified (not mandatory). During an interview on [DATE] at 2:17 pm, HK 2 stated HK 2 went inside Resident 1's room with HK 1 to clean Resident 1's restroom. HK 2 stated HK 1 started mopping Resident 1's room and HK 2 heard HK 1 talking to Resident 1 but Resident 1 was not responding. HK 2 stated HK 2 came out of the restroom to check the situation, saw Resident 1 in a baby position, and HK 2 only saw Resident 1's back. HK 2 stated HK 2 was not CPR trained-certified (unable to perform CPR). During a concurrent observation and interview on [DATE] at 2:20 pm with the DSD in the Administrator's (ADM) office desk, the DSD and surveyor watched the facility's surveillance video, dated [DATE] from 5:42 am to 7:08 am. The video showed the following sequence of events, on [DATE]: - At 6:28:00 am - HK 1 entered Resident 1's room. - At 6:28:35 am - CNA 1 entered Resident 1's room. - At 6:28:37 am - HK 1 was at Resident 1's doorframe talking to Housekeeping Supervisor (HKS). - At 6:29:02 am - CNA 1 exited Resident 1's room and walked towards the nurse's station. - At 6:29:03 am - HK 1 and HKS entered Resident 1's room. - At 6:29:33 am - CNA 1 entered Resident 1's room. - At 6:29:44 am -LPT 1 entered Resident 1's room. - At 6:30:09 am - CNA 1 exited Resident 1's room and walked down the hall. - At 6:30:20 am - HK 1 exited Resident 1's room. - At 6:30:25 - LPT 1 exited Resident 1's room. - From 6:30:25 am to 6:30:59 am - LPT 1 was pacing the hallway, then opened the east unit's door and entered the unit (to notify LVN 1). - At 6:31:05 am - CNA 1 returned and entered Resident 1's room. - At 6:31:08 am - HKS exited Resident 1's room. - At 6:31:09 am - LPT 1 entered Resident 1's room. - At 6:31:21 am - LPT 1 exited Resident 1's room and walked toward the east unit. - At 6:31:31 am to 6:31:35 am - CNA 4 and LPT 1 walked out of the east unit, walked toward Resident 1's room, and entered Resident 1's room. - At 6:32:01 am - LVN 1 entered Resident 1's the room. CNA 4 exited Resident 1's room and walked toward to east unit. - At 6:33:00 am - CNA 5 entered Resident 1's room, exited at 6:33:22 am, entered at 6:33:30 am, exited at 6:33:40 am, and entered again at 6:33:28 am. - At 6:33:27 am - the DSD entered Resident 1's room. - At 6:33:40 am - the DSD exited Resident 1's room and ran toward the nurse's station. - At 6:34:03 am - CNA 1 exited Resident 1's room. - At 6:34:12 am - LVN 1 exited Resident 1's room and walked down the hallway. - At 6:34:25 am - LPT 1 entered Resident 1's room. - At 6:34:41 am - LPT 1 walked out of Resident 1's room and stood in the hallway. - At 6:35:01 am - LPT 1 and LVN 1 walked back into Resident 1's room. - At 6:35:19 am - the Infection Preventionist (IPN) entered Resident 1's room. - At 6:35:48 am - the IPN walked out of Resident 1's room. - At 6:36:25 am - the DSD entered Resident 1's room. - At 6:36:40 am - a staff member (unidentified) brought an 02 tank into Resident 1's room. - At 6:41:51 am - LVN 1 left Resident 1's room, walked toward CNA 1, and spoke with CNA 1 in the hallway. - At 6:42:15 am - LVN 1 returned and entered Resident 1's room. - At 6:42:28 am - the DSD and LVN 1 exited Resident 1's room. - At 6:43:54 am - the EMTs entered Resident 1's room. - At 6:44:04 am - Los Angeles Fire Department (LAFD) arrived and entered Resident 1's room. - At 7:08:46 am - the police department arrived. During this interview, the DSD stated when the DSD entered Resident 1's room at 6:33 am, the DSD instructed LPT 1 and LVN 1 to start CPR because neither one had started CPR (CNA 1 found Resident 1 unresponsive at 6:28 am). The DSD stated CPR should have been started by CNA 1 because CNA 1 was the first staff member at the scene. The DSD stated CPR was important because it was the first action that had to be done after checking for breathing and checking for a pulse. During an interview on [DATE] at 4:19 pm, CNA 1 stated on [DATE] around 6:30 am, HK 1 told CNA 1 to check Resident 1 and when CNA 1 entered Resident 1's room, CNA 1 saw Resident 1 on the floor. CNA 1 stated CNA 1 called Resident 1's name three times and Resident 1 did not respond, CNA 1 left Resident 1's room to inform LPT 1. CNA 1 stated CNA 1 did not perform CPR and did not touch Resident 1 because CNA 1 did not know if Resident 1 fell or had any injuries. CNA 1 stated this was the first time CNA 1 found an unresponsive resident. CNA 1 stated CNA's (in general) were trained to provide CPR and stated when finding an unresponsive resident: CNAs needed to provide CPR by checking a pulse, starting chest compressions, and needed to call a code 99 (activated when there is a medical emergency that requires a response from clinical staff). During a review of the facility's CPR certifications, the review indicated CNA 1 had Basic life Support (BLS, a level of medical care used for patients with life-threatening condition of cardiac arrest, performed until they can be given full medical care by advanced life support providers) certification from the American Heart Association, issue date [DATE], renew by ,d+[DATE]. During a follow-up interview on [DATE] at 4:38 pm with LPT 1, LPT 1 stated when LPT 1 entered Resident 1's room and saw Resident 1 on the floor, in a fetal position (curled up into a ball while laying on one side with legs and arms bent), the situation looked like an emergency and LPT 1 decided LPT 1 needed help from LVN 1 who was more experienced. LPT 1 stated LPT 1 left Resident 1's room to the east unit and told CNA 4, who was close to the door located between west and the east unit, to notify LVN 1 there was an emergency. LPT 1 stated if Resident 1 was not breathing and had no pulse, LPT 1 needed to check Resident 1's airway, breathing, circulation, check Resident 1's pulse, and start CPR immediately. LPT 1 stated CPR could save a life and it was the last defense for Resident 1 to get oxygen and pump [blood to] the heart. During an interview on [DATE] at 6:21 am, CNA 1 stated on [DATE], CNA 1 was assigned to care for Resident 1 (11 pm to 7 am). CNA 1 stated the last time CNA 1 saw Resident 1 was at the start of CNA 1's shift at 11 pm. During this time, Resident 1 was laying on Resident 1's bed, sleeping, and snoring. CNA 1 stated CNA 1 did not see Resident 1 after 11 pm. CNA 1 stated on [DATE] CNA 1 visually checked residents assigned to CNA 1 by sitting in the hallway located two rooms away from Resident 1's room but did not actually observe Resident 1 while the resident was inside the room. During a review of Resident 1's Follow Up Question Report (hourly location of Resident 1), dated [DATE], the log indicated CNA 1 documented Resident 1 was inside Resident 1's room from [DATE] at 9 pm to [DATE] at 6 am. During an interview on [DATE] at 8:25 am, with CNA 3, CNA 3 stated it was around 6:30 am when CNA 3 was returning from the laundry area and heard CNA 1 call for help. CNA 3 entered Resident 1's room and CNA 3 saw LPT 1, LVN 1, and Resident 1 lying on the floor. CNA 3 stated LVN 1 tapped Resident 1 and LVN 1 asked Resident 1, Are you okay? CNA 3 stated CNA 3 left the room when LPT 1 and LVN 1 started to turn Resident 1 on his back and CNA 3 saw the Director of Staff Development (DSD) on the DSD's way to Resident 1's room. During an interview with the Quality Assurance Nurse (QAN), on [DATE] at 11:30 am, the QAN was asked for Resident 1's POLST (a written medical order from a physician, nurse practitioner, or a physician assistant which specifies what a patient's lifesaving treatment wishes are). The QAN stated Resident 1 did not have a POLST and stated all residents residing at the facility were considered full codes unless there was an AD. The QAN stated Resident 1 did not have an AD. During a telephone interview on [DATE] at 1:30 pm, LVN 1 stated, on [DATE], LVN 1 went to Resident 1's room when LVN 1 was notified [by CNA 4] there was a medical emergency. LVN 1 stated LVN 1 saw Resident 1 on the floor with Resident 1's face down and told Resident 1 to get up but Resident 1 did not respond. LVN 1 stated Resident 1 had no pulse, was not breathing, and LVN 1 instructed the staff who were inside the room (unidentified) to call 911. LVN 1 stated Resident 1 was turned over and there was yellowish, clear liquid (approximately half a cup) with small spots of blood underneath Resident 1. LVN 1 stated the DSD came to Resident 1's room and instructed them (LVN 1 and LPT 1) to start CPR and Resident 1 was turned on Resident 1's back. LVN 1 stated LVN 1 initiated CPR but could not recall what time LVN 1 initiated CPR. LVN 1 stated it was around 6:30 am when CNA 4 informed him there was a medical emergency. During an interview on [DATE] at 2:49 pm, with the Director of Nursing (DON), the DON stated the facility staff needed to check responsiveness by calling the resident's name and if there was no response, staff needed to tap the resident, if there was still no response, staff needed to check for airway, breathing, and circulation. The DON stated if there was no pulse and no breathing, staff needed to call a code blue and start CPR to restart circulation and keep the heart beating. During a review of the facility's undated P&P titled, Advance Directive/Individual Health Care Instructions, the P&P indicated each resident will receive and the facility must provide the necessary care and services to attain or maintain the highest possible practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care by providing basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directive. During a review of the facility's P&P titled, Emergency Response Policy and Procedure dated ,d+[DATE], the P&P indicated the facility will provide basic life support, including (Cardiopulmonary Resuscitation) CPR, to all residents requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advanced directives. The P&P indicated all residents of [the facility] are full code status unless otherwise indicated in an advanced directive that is given to the facility by the resident's responsible party.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) and Licensed Vocational Nurse 1 (LPT 1) made hourly visual checks for five of five sampled residents (Resident 1, 2, 3, 4, and 6) during the night shift (11 pm to 7 am) as indicated in the facility's Policy and Procedures (P&P). This deficient practice had the potential to result in unmet needs, untimely assistance from staff, and distress to Residents 1, 2, 3, 4, and 6. Cross Reference F678 Findings: During a review of Resident 4's Admission Record (AR), the AR indicated the facility admitted Resident 4 on 12/1/2021 with diagnoses that included major depressive disorder (persistent feeling of sadness and loss of interest.) During a review of Resident 1's AR, the AR indicated the facility admitted Resident 1 on 4/15/2022 with diagnoses that included paranoid schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real), bipolar disorder (a serious mental illness that causes unusual shifts in mood, periods of depression and periods of elevated mood) unspecified, and obesity (a chronic health condition that involves excess body fat that may impair health). During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 11/25/2022 with diagnoses including schizoaffective disorder, major depressive disorder, and insomnia. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 6/8/2023 with diagnoses that included schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder) bipolar type, and insomnia (sleep disorder than can make it hard to fall asleep or stay asleep.) During a review of Resident 6's AR, the AR indicated the facility admitted Resident 6 on 11/9/2023, with diagnoses that included schizoaffective disorder, insomnia and overweight. During an interview on 9/21/2024 at 6:21 am, CNA 1 stated, CNA 1 was assigned to care for Resident 1 during the night shift (11 pm to 7 am) on 9/19/2024. CNA 1 stated CNA 1 was assigned to monitor Resident 4 one to one (one staff to one resident) and was assigned to care for residents in rooms 30 to 37 (Residents 1, 2, 3, 4, and 6). CNA 1 stated on 9/20/2024 CNA 1 checked the residents assigned to CNA 1, by sitting in the hallway by Resident 4's room and observed when residents left their rooms (CNA 1 did not conduct visual checks in resident rooms). CNA 1 stated CNA 1 visually checked 1, 2, 3, 4, and 6, inside rooms, at the start of CNA 1's shift (11 pm) and did not conduct visual checks after that. CNA 1 stated Resident 1 was laying on Resident 1's bed, sleeping, and snoring. During a follow-up interview on 9/21/2024 at 6:52 am with CNA 1, CNA 1 stated at the start CNA 1's shift on 9/19/2024, CNA 1 visually checked the residents and opened the curtains to check if the residents were in their bed sleeping. CNA 1 stated the facility process was for CNAs (in general) to use a clicker (security wand, scanned inside resident room and documents visual resident monitoring) but that night (9/19/2024 to 9/20/2024) there was no clicker available due to the clicker being fixed. CNA 1 stated the clicker was used to show staff entered resident rooms to visually check the residents. CNA 1 stated because CNA 1 was monitoring Resident 4 one to one, CNA 1 had to document Resident 4's location every 15 minutes. CNA 1 stated CNA 1 stayed in the hallway close to Resident 4's room and from where CNA 1 was sitting, CNA 1 could not see inside Residents 1, 2, 3, 4, or 6's rooms. During an interview on 9/21/2024 at 7:02 am, with Licensed Psychiatric Technician 1 (LPT 1), LPT 1 stated LPT 1 started his shift at 11 pm. LPT 1 stated LTP 1 was finished with clerical work at 11:45 pm and visually checked on 3 residents (unidentified) who were considered critical because they had recent incidents such as suicide ideation. LPT 1 stated LPT 1 did not visually check Resident 1 because Resident 1 was not identified as critical and stated the CNA's (in general) checked the residents who were in the CNA's assigned zones. LPT 1 stated the assignment on the unit was already made by the Director of Staff Development and on 9/19/2024 during the 11pm to 7am shift, there were four certified nursing assistants and two were assigned to do one to one monitoring for two residents. LPT 1 stated LPT 1 did not know CNAs used a clicker and LPT 1 was a new staff and was still learning the facility's process. During an interview on 9/21/24 at 11:46 am, LVN 3 stated the CNA assignments were completed by the DSD and there were usually 3 CNAs assigned during the night shift. LVN 3 stated two CNAs monitored every shift, one did one to one monitoring and document the resident's location every 15 minutes. LVN 3 stated, there routine monitoring conducted hourly, done by the CNAs who were not doing one to one monitoring. During a review of the night shift Nursing Staffing Assignment and Sign-In Sheet dated 9/19/2024, the staffing assignment indicated there were four CNA's working: one CNA did one to one monitoring and 3 CNAs were assigned zones. The staffing assignment indicated CNA 1 was assigned to 13 rooms. The staffing assignment indicated Resident 4 was on one-to-one monitoring. During an interview on 9/21/2024 at 2:49 pm, the Director of Nursing (DON) stated the staff that saw (visual checks) the resident would document on that resident. The DON stated, hourly monitoring indicated the location of the resident and details including whether in bed, dining area, or in the hallway. The DON stated it was facility practice for the staff to conduct rounds (check on residents) and the DON suggested the use of a flashlight. The DON stated, the staff needed to visually check [look at] the resident's location. During a review of Resident 1's Hourly Location on 9/20/2024, the Hourly Location indicated CNA 1 documented Resident 1 was inside Resident 1's room from 9/19/2024 at 11 pm to 9/20/2024 at 06 am. During a review of the facility's P&P titled, Policy for Hourly Monitoring of Residents dated 5/2024, indicated it is the policy of the facility to provide an atmosphere that is safe and secure for all residents and staff. The P&P indicated the CNA will observe the location of each resident assigned in their section, this monitoring allows the staff to account for each resident and ensures that each resident is free from distress. During a review of the facility's P&P titled Zoning Policy dated 12/3/2020, the P&P indicated the facility will provide an atmosphere that is safe and secure for the clients and staff. CNAs are scheduled to a specific unit, the CNA will observe the location of each resident assigned in their section and mark the location in their hourly sheet. This monitoring allows the staff to account for each person and makes sure that each resident is free from distress. The P&P indicated every shift will conduct hourly in-room inspection in teams of two, one staff at doorway of room to supervise hall and witness co-workers' entrance to room and one staff to enter room to conduct a visual inspection of room. During a review of the facility's P&P titled Security Wand dated 2021, the P&P indicated the staff will check each resident room every 15 minutes by tapping the security wand on the black disk located on the wall, over the intercom speaker. This method of monitoring will allow for a safer environment for the residents. This new system will take the place of hourly room checks as the rooms are being checked every 15 minutes. Hourly Resident location remains in place with no changes. During a review of the facility's P&P titled, Policy for Hourly Monitoring of Residents, dated 5/2024, the P&P indicated the facility was to provide an atmosphere that was safe and secure for all residents and staff. The P&P indicated each CNA was assigned to a zone in the unit and the CNA would observe the location of each resident assigned in their section, each hour, and document the location of the resident.

Based on observation, interview, and record review, the facility failed to have a system in place to ensure safeguarding of all prescribed medications including controlled medications (medications with a high potential for abuse) for 17 of 17 Resident (Residents 18, 20, 25, 27, 28, 34, 37, 45, 51, 55, 57, 71, 84, 97, 148, 150, and 151) by failing to: 1. Maintain accountability records for all controlled substances/medications that were disposed of or destroyed with the unused supply between 1/1/2024 through 8/8/2024 and ensure each resident's individual controlled drug record (CDR, any Schedule 2 through Schedule 5 controlled drugs [potential for abuse and/or addiction] received or supplied by a pharmacy) for each controlled medication was used for accurate accountability of controlled medications for 6 of 6 sampled Residents (Residents 34, 71,97, 148, 150 and 151). Controlled medications included lorazepam and clonazepam (medications used to treat anxiety, a mental disorder characterized by persistent feelings of worry, nervousness, or unease strong enough to interfere with daily activities), zolpidem (medication used to treat insomnia, difficulty falling asleep), lacosamide and clobazam (medication used to treat seizures, a sudden rush of abnormal electrical activity in your brain). 2. Ensure medication carts and cabinets contained controlled medications and biologicals, were maintained locked, and not left unattended when not in use to prevent the potential for unauthorized access to medications that included noncontrolled medications stored in medication carts in two of two nursing stations (West Nursing Station Medication Cart and East Nursing Station Medication Cart) for 11 of 11 sampled Residents (Residents 18, 20, 25, 27, 28, 37, 45, 51, 55, 57 and 84). 3. Ensure the access keys were not the same keys to access other medications and controlled medications and were not stored inside the medication carts and failed to ensure licensed nurses (all licensed nurses) maintained possession of the keys to controlled medications and the keys were not left inside of an unlocked medication cart in the East Nursing Station. These deficient practices resulted in a facility wide system failure to secure and accurately account for and reconcile controlled medications for Residents 18, 20, 25, 27, 28, 34, 37, 45, 51, 55, 57, 71, 84, 97, 148, 150 and 151. The failure placed the facility at risk for medication errors, residents to receive more or less medication than prescribed, adverse reactions (harmful or unpleasant reaction, resulting from an intervention related to the use of a medication) such as: falls, hospitalization s, harm, and inability to readily identify the loss or drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. On 8/8/2024, while onsite at the facility, the California Department of Public Health (the Department) identified an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) regarding the facility's failure to ensure safeguarding of controlled medications. The survey team notified the Administrator (ADM), the Director of Nursing (DON), the Registered Nurse Supervisor (RNS), the Quality Assurance Nurse (QAN), the Social Services Designee (SSD), the Director of Staff Development (DSD), and the Infection Preventionist (IP) of the IJ situations on 8/8/2024, at 3:07 PM due to the facility failure to maintain countability for controlled medications for Residents 34, 71, 97, 148, 150 and 151, and failure to keep controlled medications locked/secured for Residents 18, 20, 25, 27, 28, 37, 45, 51, 55, 57 and 84. On 8/9/2024, the facility submitted an acceptable IJ Removal Plan (IJRP, plan that includes interventions to immediately correct the deficient practices). While onsite at the facility, the survey team determined the IJ situation was no longer present and confirmed/verified the facility's full implementation of the IJRP through observations, interviews, and record review. The IJ was removed on 8/9/2024 at 7:13 PM in the presence of the ADM, the DON, the QAN, and the DSD. The IJPR included the following immediate actions: 1. All controlled medications for the 17 sampled residents were immediately secured in a locked box within the medication cart. 2. A routine count sheet was created for each resident that received controlled medications. 3. All routine narcotic medications were moved to a locked box within the medication cart with individual counting sheets for each medication. 4. On 8/8/2024, the DON and the new Pharmacy Consultant (Pharm 3) conducted a facility-wide audit to identify all residents that received controlled medications. All 95 residents were considered at risk due to the systemic nature of the deficiency. The same immediate actions taken for the 17 sampled residents were implemented for all residents that received controlled medications. 5. On 8/08/2024, a root cause analysis was conducted, including interviews with nursing staff, review of medication administration records, and analysis of current policies and procedures. The analysis revealed: a. Lack of a robust system for controlled medication accountability b. Inadequate staff training on controlled medication management c. Insufficient security measures for medication storage 6. Effective 8/8/2024, a new controlled medication accountability system was implemented: a. Individual counting sheets for each resident's-controlled medication. b. Dual nurse sign-off (process that required two licensed nurses to approve or initiate a change) for waste (leftover or unused medications that were discarded) or refusal of controlled medications. c. Shift change audits of controlled medications. 7. On 8/08/2024, all controlled medications were stored in a locked box within a locked drawer in the medication cart. 8. As of 8/8/2024, narcotic keys were kept with the charge nurse and stored on their person until endorsed to the next licensed nurse during shift change. The DON would have a key to the discontinued medication box, and in the DON's absence, the RN supervisor would be the designated person to hold the key. 9. As of 8/8/2024, Licensed nurses would submit discontinued medications to the DON as soon as possible after the medication were discontinued or when the resident was discharged . If the discontinuation occurred during the weekend, the licensed nurse would hold the discontinued medications in the locked box and continue counting until submitted to the DON. 10. On 8/8/2024, the DON completed an inventory of all controlled medications currently on hand in the facility. 11. On 8/09/2024, discontinued controlled medications were stored in a locked box bolted inside a locked drawer in the DON's office 12. As of 8/9/2024, the DON would count discontinued controlled medications with the licensed nurse and document the receipt on the narcotic sheet. 13. On 8/9/2024, a new pharmacy consultant from the facility's pharmacy provided in service training to all licensed staff on controlled medication management, storage, counting, documentation, and wasted controlled medication procedures. The staff that were not able to attend the in-service training would be in-serviced on 8/13/2024 at 11 AM by the new pharmacy consultant. The staff that were unable to attend and [reason] why would be indicated on the in-service training sign-in sheets attached. 19 licensed staff were able to attend [the] in-service training and 5 were out due to school, other jobs, vacation, and medical [leave]. On 8/9/2024 available licensed staff did return in-service training [regarding] shift change narcotic count sheets, the sheets should not be signed ahead of time, and controlled substances must follow a pour (placing/pouring the correct medication dose into a medication cup) and sign [sign off] protocol. The DON would do return in-service training every shift for licensed staff unable to attend on 8/9/2024 until all licensed staff [were] in-serviced. 14. On 8/9/2024, the facility would review policies on Medication Storage in the Facility, Medication Ordering and Receiving from Pharmacy, Controlled Medications, and Controlled Substance Prescriptions to reflect new procedures. The Monitoring and Evaluation Plan indicated: 1. Beginning 8/8/2024, the DON conducted audits of controlled medication management: a. Every shift for the next 48 hours (until 8/9/2024) b. Twice weekly for three weeks (until 8/31/2024) c. Weekly thereafter beginning 8/31/2024. The DON would review all discrepancies identified during the audits, notify the Medical Director and pharmacy as needed, and document the findings for Quality Assurance and Assessment (QAA, provides framework for evaluating a facility's systems to prevent deviation and to correct inappropriate care processes, responds to quality deficiencies identified in the facility) review. 2. Beginning 8/9/2024, the DON would oversee the disposal (discarding unused drugs) of discontinued controlled medications in collaboration with the facility's pharmacist. 3. Beginning on 8/9/2024, the destruction of medical records would be kept in accordance with Title 22 (state regulations). The Director of Nursing would report the monitoring plan results to the QAA Committee monthly. The QAA Committee would monitor on an ongoing basis until sustained compliance is achieved and report results in quarterly QAA meetings. Findings: 1. During a concurrent observation of the controlled medication storage inside the DON's office, and interview with the DON, on 8/7/2024 at 3:03 PM. The DON stated the DON's office was shared with the DSD and the IP. The DON stated controlled medications awaiting disposal were stored in a cabinet inside of the DON's office and the DSD kept the key to the cabinet. The cabinet was observed unlocked. The DON stated the DON placed the controlled medications, awaiting disposal, on top of a box inside of a cabinet. The DON stated the DON did not have a designated or secure location to store controlled medications awaiting disposal. During a concurrent interview with the DON and record review on 8/7/2024 at 3:08 PM, the CDR forms for Residents 34, 71, 97, 148, 150 and 151 indicated the following: a. Resident 34's CDR form with a pharmacy fill date of 2/7/2024, labeled for zolpidem tartrate 10 milligram (mg, unit of measurement) tablet, indicated a total of 30 tablets. The CDR form did not indicate signatures from licensed nurses to show the date, time, and quantity for each dose of zolpidem removed for administration to Resident 34. b. Resident 71's CDR form with a pharmacy fill date of 6/20/2024, labeled for lorazepam 1 mg, 1 tablet taken every 6 hours PRN (as needed), indicated a total quantity of 39 tablets and a disposed quantity of 36 tablets. The form indicated the DON and Pharm 1 signed on the bottom left of the form, dated 7/30/2024 for the disposal of 36 tablets. The CDR form did not indicate signatures from licensed nurses to show the date, time, and quantity for each dose of lorazepam removed for administration to Resident 71. c. Resident 97's CDR form with a pharmacy fill date of 1/24/2024, labeled for clonazepam 1 mg, indicated a total quantity of 75 tablets of clonazepam and a disposed quantity of 30 out of 75 tablets. The form indicated the DON and Pharm 1 signed on the bottom left of the form, dated 2/17/2024 for the disposal of 30 tablets. The CDR form did not indicate signatures from licensed nurses to show the date, time, and quantity for each dose of clonazepam removed for administration to Resident 97. d. Resident 148's CDR form with a pharmacy fill date of 1/10/2024, labeled for lorazepam 1 mg, indicated a total quantity of 90 lorazepam tablets and a disposed quantity of 30 tablets. The form indicated the DON and Pharm 1 signed on the bottom left of the form, dated 2/22/2024 for the disposal of 30 tablets. The CDR form did not indicate signatures from licensed nurses to show the date, time, and quantity for each dose removed for administration to Resident 148. e. Resident 150's CDR form with a pharmacy fill date of 4/17/2024, labeled lorazepam 1 mg, tablet with instructions to administer one tablet by mouth twice daily indicated there were 58 lorazepam tablets and the disposal quantity was 29 out of 58 tablets. The form indicated the DON and Pharm 1 signed the form, dated 5/21/2024, on the bottom left to indicate the disposal of 29 tablets. The CDR form included a handwritten note that indicated, given routinely. The form did not indicate signatures from licensed nurses to show the date, time, and quantity for each dose removed for administration to Resident 150. f. Resident 151's CDR forms with pharmacy fill date of 2/7/2024, labeled for lacosamide 200 mg, give one tablet by mouth twice a day, indicated a total quantity of 60 tablets. The CDR form did not indicate signatures for the disposal of the medications nor signatures from licensed nurses to show the date, time, and quantity for each dose of lacosamide removed for administration to Resident 15. During a concurrent interview with the DON and record review on 8/7/2024 at 3:08 PM, the DON stated the signatures on the bottom of the CDR forms belonged to the DON and Pharm 1. The DON stated discontinued and expired controlled medications were last destroyed on 7/30/2024 with Pharm 1. The DON stated the section for dispensed medications on the CDR forms labeled for individual residents were left blank. The DON stated the facility did not accurately account for the discontinued and expired controlled medications. During an interview with the DON on 8/7/2024 at 3:15 PM, the DON stated both the DON and Pharm 1 would not go back to compare Residents' (Residents 34, 71, 97, 148 150 and 151's) MARs with each CDR form to ensure all doses of controlled medications were administered as ordered by the physician and to address the discrepancy between the original quantity and the disposal of medications. The DON stated, the DON and Pharm 1 did not verify or account for the disposal/destruction of controlled medications for each dose of controlled medication that were not recorded on the CDR forms. The DON stated the licensed nurses did not document on the CDR forms when controlled medications were removed and administered to the residents. The DON stated when Pharm 1 came to the facility to dispose controlled medications with the DON, the DON and Pharm 1 did not go back to compare with the residents' MAR or any residents' medical records. The DON stated the facility did not have a system to ensure all doses of the controlled medications were administered to the residents or to reconcile or account for the discrepancy between the original quantity delivered to the facility and the quantity destroyed. The DON stated the facility did not have a system to account for each dose of controlled medication being wasted, refused, or not administered to a resident as prescribed. The DON stated there was no shift change audit (a controlled medication reconciliation document signed by two nurses during shift change) done between the oncoming nurse (nurse starting the shift) and the outgoing nurse (nurse leaving) to verify that all controlled medications inside the medication carts were accurate and accounted for before endorsing the medication carts from one nurse to the next nurse. During a concurrent observation of the medication cart in the [NAME] Nursing Station and interviews with LVN 3 and LVN 4 on 8/7/2024 at 3:40 PM, there were controlled medications stored together with noncontrolled medications in the medication cart. LVN 3 showed a large binder located on the [NAME] Nursing Station that was filled with CDR forms and had prescription labels from the facility's dispensing pharmacy. LVN 4 stated licensed nurses never filled the CDR forms out to account for each dose of controlled medications removed for administration to the residents. LVN 4 stated the licensed nurses did not count the controlled medications during shift change before endorsing the medication carts to the nurses from the next shift. During an interview on 8/7/2024 at 3:50 PM with LVN 3 and LVN 4, LVN 4 stated LVN 4 would not have any idea if controlled medications were missing, diverted for personal use, or if all the controlled medications for each resident were accounted for because nurses did not count the controlled medications between shifts. LVN 3 stated the licensed nurses would not know if controlled medications became missing or were misused because the medications were kept among the noncontrolled medications, and the controlled medications were not counted each day. During a telephone interview on 8/8/2024 at 8:19 AM with the DON and Pharm 1, Pharm 1 stated the facility's licensed nurses were supposed to document on the controlled drug count down sheet (CDR) each time they remove a controlled medication for resident administration. Pharm 1 stated the nurses were also expected to verify the controlled medications with two nurses during the change of shift to make sure the controlled medication count was accurate before the outgoing nurse endorsed (hands over the medication cart key) to the oncoming nurse, and if there were any discrepancies with the controlled medications, two nurses could work to resolve any concerns. Pharm 1 stated, that was the standard of practice for handling-controlled medications. Pharm 1 stated the controlled medication count down sheets (CDR) needed to be filed away as a permanent record to ensure controlled medication accountability. Pharm 1 was asked why Pharm 1 signed the blank (not filled in) CDR forms for Residents 34, 71, 97, 148, and 150 during controlled medication disposal when the original quantity was different from the quantity being destroyed for each resident-controlled medication, Pharm 1 stated Pharm 1 just destroyed what was presented to Pharm 1. Pharm 1 stated, I would not know if any medications [were] diverted or lost. Pharm 1 stated I am only documenting the narcotic medication I am disposing of right there. Pharm 1 stated I do not look at any other document to see or reconcile with the unused controlled medication that I am disposing of. Pharm 1 stated Pharm 1 had not provided any training to the facility's staff on medication storage or handling controlled medications. During an interview on 8/8/2024 at 8:50 AM with the DON, the DON stated the facility's practice was not using the CDR sheets during the removal of routine controlled medications since before the DON started working at the facility more than a year and half ago. During a telephone interview on 8/8/2024 at 9 AM with the DON and the facility's dispensing pharmacist (Pharm 2) Pharm 2 stated, Pharm 2 sent a CDR form for each resident's controlled medication to the facility. Pharm 2 stated, CDR forms were used to keep track of what was dispensed and administered to the residents. Pharm 2 stated, it was up to the facility's policy what process for keeping track of controlled medications the facility should follow. Pharm 2 stated it was the responsibility of the facility's Consulting Pharmacist (in general) to help keep the facility compliant with regulations. Pharm 2 stated Consulting Pharmacist needed to follow the facility's policy for handling controlled medications and ensuring the monitoring and accounting of controlled medications. Pharm 2 stated the facility must order controlled medications each time before a resident runs out of their medication by either calling the dispensing pharmacy or sending a faxed refill request. During a concurrent telephone interview with Pharmacist Technician (PhTech) from the facility's dispensing pharmacy, and record review on 8/8/2024 at 11:13 AM, the Controlled Medication Report dated from 1/1/2024 through 8/8/2024 were reviewed, the Controlled Medication Report indicated the facility received the following controlled medications from the dispensing pharmacy for 35 individual residents and the total number of doses for each medication delivered to the facility from 1/1/2024 through 8/8/2024 were as follow: 1. Lorazepam 0.5 mg - 951 tablets 2. Lorazepam 1 mg - 1,861 tablets 3. Clonazepam 0.5 mg - 210 tablets 4. Clonazepam 1 mg - 3,101 tablets 5. Clonazepam 2 mg - 472 tablets 6. Zolpidem 10 mg - 60 tablets 7. Lacosamide 50 mg - 402 tablets 8. Lacosamide 200 mg - 180 tablets During an interview on 8/8/2024 at 3:14 PM with the ADM and the DON, the DON stated Pharm 1 had been to the facility many times and had not identified any concerns with the facility's handling of controlled medications. 2. During a concurrent observation of the controlled medication storage inside the DON's office, and interview with the DON, on 8/7/2024 at 3:03 PM. The cabinet was unlocked. The DON stated the DON placed the controlled medications, awaiting disposal, on top of a box inside of the cabinet. The DON stated the DON did not have a designated or secure location to store controlled medications awaiting disposal. During an interview on 8/7/2024 at 3:27 PM with DON and the DSD inside of the DON's office, the DSD stated, the DSD had the key to the cabinet inside of the DON's office that contained discontinued and expired controlled medications awaiting disposal. The DSD stated the key to the cabinet was hung and stored on a wallboard located inside of the DON's shared office space. The DON stated the cabinet was not kept locked. During an observation of the [NAME] Nursing Station Medication Cart and the East Nursing Station Medication Cart with the DON on 8/7/2024 from 3:44 PM to 4:26 PM, the following resident medications were observed and stored mixed together with noncontrolled medications: West Nursing Station Medication Cart included the following controlled medications for: a. Resident 27 - two medication cards of clonazepam 0.5 mg, half of a tablet in each bubble pack (a card that packages doses of medication within small, clear, or light-resistant, amber-colored plastic bubbles). There were 17 remaining half tablets in one medication card and 15 half tablets in the second medication card. b. Resident 28 - two medication cards of clonazepam 1 mg, one medication card contained 20 tablets and the second medication card contained 21 tablets of clonazepam. c. Resident 20 - two medication cards of lorazepam 1 mg, one medication card contained 6 tablets and the second medication card contained 7 tablets of lorazepam. d. Resident 55 - two medication cards of lorazepam 0.5 mg, one medication card contained 6 tablets and the second medication card was contained 7 tablets of lorazepam. e. Resident 51 - one medication card of lorazepam 0.5 mg, the medication card contained 10 half tablets of lorazepam. East Nursing Station Medication Cart included the following controlled medications for: a. Resident 45 - one medication card of clonazepam 2 mg, the medication card contained 28 tablets of clonazepam. b. Resident 57 - three medication cards of clonazepam 1 mg, one medication card contained 28 tablets, the second medication card had 29 tablets, and the third medication card contained 29 tablets of clonazepam. c. Resident 18 - three medication cards of lorazepam 1 mg, one medication card contained 12 tablets, the second medication card contained 13 tablets, and the third medication card contained 13 tablets of lorazepam. d. Resident 25 - two medication cards of clonazepam 1 mg, one medication card contained 15 tablets and the second medication card was contained 14 tablets of clonazepam. e. Resident 37 - one tablet of lorazepam 0.5 mg, prescribed for single use prior to appointments until 10/30/2024. f. Resident 84 - one tablet of lorazepam 0.5 mg, prescribed for single use prior to appointments until 10/7/2024. During an interview with the DON on 8/7/2024 at 4:18 PM, the DON stated controlled medications were not stored in a double locked drawer in the medication carts. The DON stated routine controlled medications were stored together with regular noncontrolled medications. The DON stated the facility was not following the facility's policy for storage of controlled medications. The DON stated the access key for controlled medications inside of the medications cart was the same key used for noncontrolled medications. The DON stated both nursing stations (West Nursing Station medication carts and the East Nursing Station medication carts) stored controlled routine medications along with noncontrolled medications. During a telephone interview on 8/8/2024 at 8:19 AM with the DON and Pharm 1, Pharm 1 stated Pharm 1 provided pharmacy consultant services to the facility in accordance with federal and state regulations. Pharm 1 stated controlled medications should be stored in a separate locked drawer inside of the medication cart. Pharm 1 stated Pharm 1 did not check the facility's medication storage every month. During an interview on 8/8/2024 at 8:50 AM with the DON, the DON stated the controlled medications that were routinely administered had never been locked or stored separately from the noncontrolled medications since the DON started working at the facility over a year and a half ago. The DON stated, I do not know if any controlled medication has been diverted, loss, or misused. During a concurrent interview with LVN 4 and observation of two medication carts in the [NAME] Nursing Station on 8/8/2024 at 9:50 AM, LVN 4 opened the [NAME] Nursing Station Medication Cart and stated there were currently six residents receiving controlled medications on the [NAME] Nursing Station. LVN 4 pulled the medication cards that were mixed with the noncontrolled medications and stated there were 13 medication cards. LVN 4 left the [NAME] Nursing Station Medication room without locking the two medication carts located inside of the [NAME] Nursing Station Medication Storage Room. During an interview with LVN 4 on 8/8/2024 at 10:23 AM. LVN 4 stated the two medication carts on the [NAME] Nursing Station were unlocked and the medication cart should have been locked before LVN 4 left the medication storage room. 3. During a concurrent observation of two medication carts on the East Nursing Station and interview with LVN 4 on 8/8/2024 at 10:25 AM, LVN 4 unlocked and entered the East Nursing Station, the two East Nursing Station Medication Carts were unlocked, and no licensed nurse or staff were present upon the surveyor's arrival with LVN 4 to the East Nursing Station. LVN 4 stated the two medication carts inside of the East Nursing Station were left unlocked and the East Nursing Station Medication Cart was assigned to LVN 1. LVN 4 stated LVN 4 did not know where LVN 1 was. LVN 4 opened the unlocked medication cart and opened a drawer that contained keys to both medication carts and to the locked narcotic drawer inside of the unlocked medication cart. LVN 4 was able to use the key to unlock the narcotic drawer. LVN 4 used the keys to lock the two medication carts in the East Nursing Station. LVN 4 stated unauthorized staff that worked in the facility had access to the nursing station, which included, certified nurse assistants (CNAs), floor staff, counselors, and housekeeping. LVN 4 stated the unauthorized staff had access to the medications inside of the medication carts including controlled medications because the medication carts were not locked, and the keys were left available to be used by others. During an interview on 8/8/2024 at 11:04 AM with LVN 1, LVN 1 stated LVN 1 left the medication cart on the East Nursing Station unlocked and LVN 1 should have locked the medication cart because there was a lot of medications inside that could be removed while LVN 1 was away from the cart. LVN 1 stated the medication cart was not secured to ensure access was limited to the medications by authorized staff (licensed nurses). During a review of the facility's Policy and Procedures (P&P) titled, Controlled Substance Prescriptions, dated 5/2022, the facility's P&P indicated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and recordkeeping requirements in the facility, in accordance with federal and state laws and regulations. The Director of Nursing and the contracted pharmacist maintain the facility's compliance with federal and state law and regulations in the handling of controlled medications. Only authorized, licensed nursing and pharmacy personnel have access to controlled medication. Controlled substance medications are dispensed by the provider pharmacy in readily accountable quantities and containers designed for easy counting of contents. The pharmacy will provide an individual resident-controlled drug record (count sheet) for each controlled substance medication container dispensed to a resident. Controlled substance medications are stored at the facility under double lock on the medication cart separate from all other medications and counted at each change of custody. The access key to controlled medications is not the same key that allows access to other medications. The medication nurse on duty maintains possession of a key to controlled medications. During a review of the facility's P&P titled, Consultant Pharmacist Services Provider Requirements, dated 5/2022, the facility's P&P indicated, The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility. In collaboration with facility staff, the consultant pharmacist helps to identify, communicate, address, and resolve concerns and issues related to the provision of pharmaceutical (relating to medical drugs, or the preparation use or sale of drugs) services. This includes, but is not limited to .Establishing a system of records for receipt and disposition of all controlled medications to enable an accurate reconciliation, and determining that drug records are in order and that an account of all controlled medications is maintained and periodically reconciled .Checking the medication storage areas at least monthly, and the medication carts at least quarterly, for proper storage and labeling of medications, cleanliness, and removal of expired medications. During a review of the facility's P&P titled, Controlled Substance Disposal, dated 5/2022, the facility's P&P indicated, Disposition is documented on the individual controlled substance accountability record/book .Accountability records for controlled substances that are disposed of or destroyed are maintained with the unused supply until it is destroyed or disposed of and then these records are stored for a period of time outlined per applicable law or regulation or facility policy. During a review of the facility's P&P titled, Storage of Medications, dated 5/2022, the facility's P&P indicated, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (PP) titled, Q:15 (every 15) Minute Monitoring, and provide supervision every 15 minutes per the physician's order to prevent elopement (leaving the facility without notice) from the locked (equipped with secured locks or other functioning security devices) facility for one of four sampled residents (Resident 1) who was assessed as at risk for elopement by failing to: 1. Ensure Certified Nurse Assistant (CNA) 1 and CNA 2 monitored and kept Resident 1 in a clear and direct line of sight (within someone's view) every 15 minutes. 2. Ensure CNA 1 and CNA 2 accurately monitored and documented Resident 1's whereabouts every 15 minutes. As a result of these failures, on 5/19/2024 at 10:15 am, Resident 1 entered the facility's unlocked Recreation Room without CNA 1 and CNA 2's supervision. On 5/19/2024 at 10:32 am, Resident 1 eloped from the facility through the patio from the Recreation Room. Resident 1 stacked chairs on top of a table in the patio, climbed onto the facility roof, walked to the southwest corner of the front of the facility building, climbed down using facility fencing, and walked southbound on the street and away from the facility. Resident 1 had not been found. These failures had the potential to put Resident 1 at risk for serious injury, harm, and/or death due to not receiving psychotropic medications (any drug that affected brain activities associated with mental processes and behavior), not having food and shelter, and being exposed to cold weather at night. On 5/21/2024 at 5:10 pm, while onsite at the facility, the surveyor identified an Immediate Jeopardy situation (IJ- a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The surveyor called an IJ in the presence of the Administrator (ADM), Director of Nursing (DON), Quality Assurance Nurse (QAN), Director of Staff Development (DSD), Medical Records Director (MRD), and the facility's [NAME] President (VPL) due to the facility's failure to monitor and supervise Resident 1, under 42 Code of Federal Regulations Section 483.25(d) Accidents, including providing adequate (acceptable in quality or quantity) supervision to prevent accidents to Resident 1 who was at risk for elopement, and was on every 15-minute monitoring by CNA 1 and CNA 2. On 5/22/2024 at 4:54 pm, the facility submitted an acceptable Plan of Action (POA- a list of steps taken to correct the deficient practices). While onsite at the facility, the surveyor verified the facility installed a new lock on the Recreation Room's door, other residents do not have access to the Recreation Room and confirmed the facility's implementations of the POA through observation, interview, and record review. The surveyor determined an IJ situation was no longer present and removed the IJ while onsite at the facility on 5/22/2024 at 5:06 pm, in the presence of the ADM, DON, QAN, DSD, and MRD. The IJ removal plan, dated 5/22/2024 included the following: 1. The facility made every effort to locate Resident 1 in the community by doing the following: a. CNA 2, Mental Health Aide (MHA) 1, and CNA 6 completed a 1-mile parameter search around the facility. b. Licensed Psychiatric Technician (LPT) 1 conducted a search of the roof to determine if Resident 1 had injured himself or was unable to get off roof. c. LPT 1 and LPT 2 contacted Local Police Department and filed a missing person's report. d. The DON called local hospitals daily and asked if Resident 1 had been admitted . e. The QAN and Social Services Designee (SSD) updated County Public Guardian (an individual or entity appointed by the court to make decisions with respect to the personal affairs of an individual) daily and inquired if the County Public Guardian had any new information regarding Resident 1. 2. The facility would provide an environment, safe from hazards and bodily injury to Resident 1 once found. Staff (assigned staff) would supervise Resident 1 every 15 minutes for safety. Staff must visually see Resident 1 upon these checks. The facility ' s updated PP titled, Q:15Minute Monitoring, on 5/22/2024 to reflect the following changes: a. Facility staff (assigned staff) must have a clear line of sight of Resident 1. b. Facility staff must visually identify Resident 1. c. If facility staff exercised the use of a Walkie Talkie device (a small radio held in the hand, used for both sending and receiving messages) to locate Resident 1's whereabout, the staff who visually saw Resident 1 must document Resident 1's location in Resident 1's electronic clinical record under the Plan of Care (POC) portal. d. In documenting Resident 1's location in Resident 1's electronic clinical record, staff were to make an honest and accurate entry that staff visually saw and identified Resident 1. 3. All 95 Residents admitted to the facility would be safe in the environment and safe from hazards and bodily injury. Facility staff would supervise all residents on an hourly basis unless otherwise noted, every 15 minutes for safety. Staff must visually see the residents upon these checks. As per the facility ' s PP titled, Q:15 Minute Monitoring, updated on 05/22/2024, staff assigned to conduct the Q:15-minute checks would do the following: a. Facility staff must have a clear line of sight of the residents. b. Facility staff must visually identify the residents. c. If facility staff exercised the use of a Walkie Talkie device to locate the residents, the staff who visually saw the residents must document the residents' location in the residents' electronic clinical record under the POC portal. d. In documenting the resident's location in the resident's electronic clinical record under the POC portal, staff were to make an honest and accurate entry that staff visually saw and identified the residents. 4. To prevent future incidents of elopement of this likeness, the facility implemented the following: a. On 5/20/2024, the Maintenance Staff (MS) installed a self-locking door hardware on the Recreation Room door. b. On 5/20/2024, facility staff replaced white plastic chairs in the Recreation Room with plastic back and seat. c. ON 5/20/2024, the two staff (CNA 1 and CNA 2) responsible for failing to follow resident care documentation for the Q:15-minute check for Resident 1 were suspended. c1. CNA 1 was terminated on 05/22/2024. Report to the CNA Certification Board to follow. c2. CNA 2 will be terminated on 05/23/2024. Report to the CNA Certification Board to follow. d. On 5/21/2024, the MS had a consultation to have motion sensor cameras installed on the patio to detect any motion. e. On 5/21/2024 and 5/22/2024, all staff (85 staff) were in-serviced on safety and Q:15-minute supervision requirements. f. On 5/22/2024, the MS checked all doors in the facility for self-locking door hardware and replaced any non-self-locking door hardware with self-locking door hardware. This check included the following with the following interventions: f1. On 5/22/2024, the MS replaced the traditional locking doorknob on the roof access with a self-locking doorknob. f2. On 5/22/2024, the MS removed the traditional locking doorknob from the Recreation Room Sliding Door and installed a case lock (a device that kept the door locked and secured). f3. On 5/22/2024, the MS removed the traditional doorknob from the Dining Room and installed a self-locking doorknob. f4. On 5/22/2024, the MS removed the traditional doorknob from the Patio Access Door on [NAME] Unit and installed a self-locking doorknob. g. As of 05/22/2024, all staff would be required to unlock with key to exit onto the patio. h. As of 05/22/2024, all doors in the facility would be required to have a key to unlock for entry. 5. On 5/22/2024, the DSD carried out safety and Q:15-minute supervision in-service training to all staff. The DSD would conduct a safety and Q:15-minute supervision in-service training to all staff annually and upon hire. 6. On 5/22/2024, the Administrator carried out safety and Q:15-minute supervision in-service training to all social services staff (12 staff). Staff that were not able to attend the safety and Q:15-minute supervision in-service training due to being out on leave or being ill, would be in-serviced promptly upon return to work. 7. The QAN to review Q:15-minute documentation for accuracy. The Quality Assessment and Assurance (QAA- a continuous process based on identifying quality problems assessment of data collection and analysis) Committee to review compliance at Quarterly (every 3 months) QAA meeting. Cross Reference F842 Findings: During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1 to the facility on [DATE], with diagnoses that included schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood), anxiety disorder (persistent feeling of dread or panic that can interfere with daily life), and major depressive disorder (common and serious illness that negatively affects how one feels, thinks and acts). During a review of Resident 1's Elopement Risk Assessment (ERA), dated 10/26/2023, the ERA indicated Resident 1 had a history of elopement from previous placements. The ERA indicated Resident 1 believed he did not need treatment for mental illness and shelter as he had been living in the streets. The ERA indicated staff were aware of Resident 1's wander (to move around or go to different places without having a particular purpose or direction) risk. During a review of Resident 1's untitled care plan (CP), initiated on 10/26/2023, the CP indicated Resident 1 had poor impulse control due to absent without official leave (AWOL- also known as elopement) related to schizoaffective disorder. The CP indicated Resident 1 had a history of AWOL from prior facilities. The CP indicated Resident 1 had an attempted AWOL on 1/1/2024 and had one AWOL episode on 1/26/2024. The CP interventions included to assist Resident 1 to identify/discuss feeling associated with impulsive behavior. During a review of Resident 1's Physician Order (PO), dated 1/8/2024, the PO indicated an order for staff to monitor Resident 1 Q:15 minutes, every shift related to safety. During a review of Resident 1's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 4/23/2024, the MDS indicated Resident 1 had moderately impaired cognition (ability to think, remember, and reason). The MDS indicated Resident 1 was independent (no help or staff oversight at any time) with eating, oral hygiene, toileting hygiene, and walking 10 to 150 feet (ft- unit of measurement). The MDS indicated Resident 1 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completed the activity and may be provided throughout the activity or intermittently) with personal hygiene. During a concurrent interview and record review on 5/21/2024 at 10:42 am with the ADM, Resident 1's Location Monitoring Follow Up Question Report (LM Report) dated 5/19/2024 was reviewed. The ADM stated CNA 2 was the primary CNA assigned to monitor Resident 1 every 15 minutes on 5/19/2024. The ADM stated CNA 1 documented on the LM Report that Resident 1 was in Resident 1's room on 5/19/2024 at 10 am. The ADM stated CNA 1 documented on the LM Report that Resident 1 was in the hallway from 10:15 am to 10:30 am. The ADM stated CNA 2 documented on the LM Report that Resident 1 was in the hallway from 11:15 am to 11:45 am. The ADM stated facility staff (CNA 1 and/or CNA 2) did not document Resident 1's whereabouts at 10:45 am and 11 am. The ADM stated per the facility's investigation, Resident 1 entered the facility's Recreation Room at 10:15 am because the Recreation Room door was left unlocked. The ADM stated the Recreation Room's door opened to the patio. The ADM stated residents (all residents) were not allowed to be on the patio without staff supervision. The ADM stated Resident 1 was left unsupervised in the Recreation Room and on the patio (on 5/19/2024) from 10:15 am to 10:32 am. The ADM stated Resident 1 climbed onto the facility's roof from the patio and eloped from the facility. The ADM stated facility staff (CNA 1 and CNA 2) did not realize Resident 1 was missing until after lunch (1 pm), even though CNA 1 and CNA 2 were documenting Resident 1's whereabouts between 10:15 am to 11:45 pm. During a concurrent review of the facility's video surveillance and interview on 5/21/2024 at 11:57 am with the Program Director of Special Treatment Program (PD), the surveyor reviewed the facility's video surveillance, dated 5/19/2024 with the PD. The PD stated, the facility's video surveillance dated 5/19/2024, at 10:10:00 am, Resident 1 was in the hallway, standing adjacent to the facility's Beauty Parlor. The PD stated there were no staff visible in the (video surveillance's) frame. The PD stated at 10:15:22 am, Resident 1 was standing in the hallway across from the Recreation Room. The PD stated no staff were visible in the frame. The PD stated at 10:15:56 am, Resident 1 entered the Recreation Room. The PD stated at 10:30:32 am, Resident 1 climbed onto the roof from the patio using 5 stacked plastic chairs and plastic folding table that Resident 1 obtained from the Recreation Room and placed on the patio. The PD stated at 10:32:36 am, the video surveillance showed Resident 1 was outside of the facility fencing, walking south bound on the street and away from the facility. The PD stated no staff were visible in the frame. The PD stated there were no staff present to monitor and supervise Resident 1 while Resident 1 was in the Recreation Room and the patio. The PD stated the Recreation Room was supposed to remain locked for residents' safety. During a telephone interview on 5/21/2024 at 1:28 pm with CNA 1, CNA 1 stated (in general) when a resident was on Q 15-minute monitoring, CNA 1 was supposed to supervise a resident by checking on him/her. CNA 1 stated (on 5/19/2024) CNA 1 went on break from 10:20 am to 10:30 am. CNA 1 stated CNA 1 documented Resident 1's whereabouts (at 10 am, 10:15 am and 10:30 am) without knowing Resident 1's accurate location because no other staff had documented in Resident 1's record. CNA 1 stated CNA 1 documented the whereabouts of Resident 1 because CNA 1 wanted to ensure the charting (medical record) was complete. CNA 1 stated CNA 1 changed the documentation to indicate Resident 1 was AWOL once facility staff realized Resident 1 was missing after lunch time. CNA 1 stated it was important to know Resident 1's whereabouts and accurate location for Resident 1's safety. CNA 1 stated when CNA 1 documented she knew Resident 1's location even though she did not, Resident 1 could get hurt. During a telephone interview on 5/21/2024 at 1:37 pm with CNA 2, CNA 2 stated CNA 2 was the primary CNA assigned to Resident 1 on 5/19/2024. CNA 2 stated Resident 1 was supposed to be monitored every 15 minutes to ensure Resident 1's safety. CNA 2 stated CNA 2 documented Resident 1's whereabouts as being in the hallway at 11:15 am, 11:30 am, and 11:45 am on 5/19/2024 even though CNA 2 did not know Resident 1's accurate location. CNA 2 stated because CNA 2 did not monitor Resident 1's accurate whereabouts as directed; Resident 1 was able to elope from the facility. CNA 2 stated Resident 1 could get really hurt and have an accident being out on the streets. During an interview on 5/21/2024 at 4 pm with the DSD, the DSD stated staff (CNA 1 and CNA 2) completing the Q 15-minute monitoring of Resident 1 must locate and visualize Resident 1's actual whereabouts every 15 minutes for Resident 1's safety. The DSD stated staff blindly documenting Resident 1's whereabouts when Resident 1's actual whereabouts were not visualized put Resident 1 at risk for elopement and serious injury, or even death. The DSD stated Resident 1 should not be out in the community unsupervised because Resident 1 had moderately impaired cognition and Resident 1 was a danger to himself and others. During a concurrent interview and record review on 5/21/2024 at 4:29 pm with the DON, Resident 1's Elopement Risk Assessment (ERA) dated 10/26/2023 was reviewed. The DON stated Resident 1 was at risk for elopement. The DON stated Resident 1 was on monitoring for poor impulse control and for AWOL/elopement risk because Resident 1 had attempted to leave the facility in the past (1/1/2024 and 1/26/2024). The DON stated the facility's protocol for Q 15-minute monitoring was to check a resident's (Resident 1's) location every 15 minutes. The DON stated that (Q 15-minute monitoring) meant staff needed to visualize Resident 1 every 15 minutes and document Resident 1's accurate location. The DON stated the staff (CNA 1 or CNA 2) who visualized Resident 1 was supposed to document Resident 1's location to ensure Resident 1's location was accurate, and that Resident 1 was being appropriately monitored and supervised. The DON stated (in general) when a resident was not appropriately monitored or supervised like Resident 1, then like Resident 1, that resident could also leave the facility without staff knowing. The DON stated because Resident 1 eloped from the facility, Resident 1 was a danger to himself and others. The DON stated CNA 1 and CNA 2 falsified Resident 1's Q 15-minute monitoring report by documenting they monitored/supervised and knew Resident 1's whereabouts even though they did not visually see Resident 1's whereabouts. The DON stated this (falsification of record) prevented staff from knowing Resident 1's accurate location and intervening the moment Resident 1 was missing. The DON stated the consequence of CNA 1 and CNA 2 not monitoring Resident 1's whereabouts accurately was that Resident 1 may not be found. The DON stated Resident 1 could become seriously injured or even die. During a review of the facility's PP titled, Q:15 Minute Monitoring, dated 4/2024, the PP indicated the facility provided an atmosphere that was safe and secure for all residents and staff. The PP indicated a tool to assist in providing a safe and secure environment was Q:15-minute checks. The PP indicated the CNA assigned to the resident placed on Q:15-minute checks sought, found, and documented location and condition of the resident every 15 minutes during their shift and must be done in a timely manner. The PP indicated staff who implemented the Q:15-minute checks must maintain a clear and direct line of sight at time of documentation of Q:15-minute checks and document their location.

Based on observation, interview, and record review the facility failed to ensure one of two sampled Residents (Resident 1) was free from sexual abuse (non-consensual sexual contact of any type with a resident). On 6/16/2021 at 5:45 pm, Licensed Vocational Nurse 1 (LVN 1) and Certified Nursing Assistant 1 (CNA 1) found Resident 1 and Resident 2 partially naked inside Resident 1's room having sex. The facility did not protect Resident 1 from further abuse by failing to conduct a thorough investigation to identify whether it was consensual, and report the incident to the police, the Department of Public Health, and the Ombudsman (an official appointed to investigate individuals' complaints against maladministration). On 6/21/2021 at 4:25 pm the facility reported to the Department that Resident 1 alleged Resident 2 went inside Resident 1's room several times (unidentified times) between 6/19/2021 and 6/20/2021, and had unwanted sexual contact (kissing, sexual intercourse, hickeys [a dark red or purple mark on the skin caused by intense suction]) with Resident 2. This deficient practice resulted in Resident 1 experiencing sexual abuse and feeling afraid. On 6/29/2021 at 2:35 pm, the Department called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirement of participation has caused or is likely to cause serious injury, impairment or death to a resident) situation in the presence of the Director of Nursing (DON) and the Program Director (PD). The DON and PD were informed of the facility's failure to have systems in place to ensure Resident 1 was protected from sexual abuse. On 7/1/2021 at 4:08 pm, during an onsite visit, the Department verified and confirmed the IJ was removed after the facility presented an acceptable plan of action. The plan of action included: a. The facility developed written policies that provided guidelines for Prevention of Sexual Abuse, Unwanted Pregnancy, and Care plan for Unwanted Physical Sexual Contact and Consensual Physical Sexual Contact. b. The facility placed Resident 2 on a one to one monitoring (under constant observation by an assigned staff) on all shifts. c. The Facility protected Resident 1 from Resident 2. d. Resident abuse in-service included how to deal with allegations of abuse, neglect, exploitation or mistreatment, and instructions on when and how the newly implemented investigation format would be utilized. e. The facility's Staff Developer (DSD) conducted in-service training for new policies and procedure, which began on 6/30/2021 and all staff have been sent a text message regarding this incident of alleged sexual abuse and signs of possible sexual abuse, training on interview of residents denying or confirming that the sexual act was consensual, and documenting this in the residents' records on 7/1/2021. f. The facility was responsible for reporting within two- hour to the State Department of Public Health, Ombudsman, local Police Department, resident's responsible party, attending physician, and medical director, concerning any abuse of a resident. The report included resident name, room number, type of abuse, persons involved, and action taken by the facility. g. The facility planned in case of future incident to put the alleged abuser on one to one supervision every shift for the safety of all residents until it is deemed safe for the alleged abuser to mix independently with other residents. The alleged abuser will have one on one counseling to discuss the emotional affects and alternatives to abusive behavior and if necessary, the alleged abuser will be referred to higher level of care. Cross Reference F607 and F609 Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 9/13/2019 with diagnoses of schizoaffective disorder (chronic mental health condition characterized primarily such as hallucinations [experience involving the apparent perception of something not present], delusions [A belief or altered reality that is persistently held despite evidence or agreement to the contrary], depressed [state of general unhappiness] episodes and periods of high energy). A review of Resident 1's Minimum Data Set (MDS, an assessment and care screening tool), dated 6/8/2021, indicated Resident 1 had intact cognitive skills (ability to think, understand, and reason), no mobility impairment, and needed supervision for personal hygiene (practices performed to maintain cleanliness and preserve health). A review of Resident 1's Progress Notes (PN), dated 6/16/2021, and timed at 5:45 pm, indicated LVN 1 and CNA 1 found Resident 1 and Resident 2 partially naked and having sex together, in Resident 1's room. The PN indicated LVN 1 verbally prompted the residents to stop what they were doing and separated the residents. A review of Resident 1's medical record from 6/16/2021 to 6/20/2021 indicated no documented evidence the facility investigated regarding Resident 1 and Resident 2's sexual activity that was witnessed by LVN 1 and CNA 1. In addition, there was no evidence the sexual activity was reported to the Department in accordance with the facility's policy and procedure. A review of Resident 1's PN, dated 6/21/2021, and timed at 4:05 pm, indicated Resident 1 told Social Worker (SW) she would like to move to a different unit because Resident 2 went into her room. The PN indicated SW reminded the resident to call for staff (unidentified), pull the call light (a device used by a resident to signal his or her need for assistance), or to leave the room if Resident 2 entered her room. A review of Resident 1's PN, dated 6/21/2021, and timed at 4:40 pm, indicated the Program Director (PD) notified LVN 1 that Resident 1 requested for a room change because she was concerned about Resident 2 trying to be sexually assaultive with her and getting into her room without her permission. A review of Resident 1's PN, dated 6/21/2021, and timed at 5:27 pm, indicated Resident 1 stated Resident 2 sexually assaulted her on 6/16/2021 and the incident was not consensual. The PN notes indicated Resident 1 was moved to a different unit on 6/21/2021. A review of Resident 1's PN, dated 6/21/2021, and timed at 10:34 pm, indicated Resident 1 told LVN 3 that she (Resident 1) did not report the sexual assault during the weekend (6/19/2021 and 6/20/2021)with Resident 2 because Resident 1 was afraid of making Resident 2 angry. The PN indicated LVN 3 and CNA 1 did a complete body check on Resident 1 and noted 6 hickeys (a temporary bruise on the skin) on her neck and jaw areas. A review of the facility's Confidential Report dated 6/21/2021 and timed at 4:25 pm, indicated Resident 1 alleged Resident 2 went inside Resident 1's room several times (unidentified times) on 6/19/2021 and on 6/20/2021(unidentified times) and had unwanted sexual contact (kissing, sexual intercourse, hickeys), with Resident 2. During an observation and interview on 6/22/2021, at 12:56 pm, inside the facility's treatment room, Resident 1 was awake and had five light, reddish purple discolorations on her neck. Resident 1 stated Resident 2 went inside her room on 6/19/2021 and on 6/20/2021(unidentified times) and asked to have sex with her. Resident 1 stated she refused and told Resident 2 to leave her room but Resident 2 did not listen and forced herself on Resident 1. Resident 1 stated she did not report the incident to the staff. Resident 1 stated she did not want to describe exactly what happened but stated she told Resident 2 no. During a telephone interview on 6/23/2021 at 12:15 pm, LVN 2 stated she saw Resident 1 with hickeys on her neck on 6/20/2021 during the morning shift and stated she did not report to the Administrator (ADM). During an interview on 6/28/21, at 10:45 am, PD stated, the facility did not do a care plan for and did not have a policy for consensual sexual activities. PD also stated the Assistant Program Director (APD) told him on 6/21/2021 that Resident 1 wanted a room change because Resident 2 kept going inside Resident 1's room and she (Resident 1) felt unsafe. A review of Resident 2's Admission Record indicated the facility admitted the resident on 5/27/2021 with diagnoses of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and herpes viral infection (a virus causing contagious sores, most often around the mouth or on the genitals). A review of Resident 2's Care Plan (CP) initiated on 5/27/2021, indicated Resident 2 was preoccupied with sexual urges and behaviors and the goal was for Resident 2 to have zero episodes in a month. A review of Resident 2's Minimum Data Set (MDS, an assessment and care screening tool), dated 6/9/2021, indicated Resident 2 had intact cognitive skills, no mobility impairment, and needed supervision for personal hygiene. A review of Resident 2's Order Summary Report dated 5/27/2021 indicated a physician order to monitor and record every shift Monday through Friday, episode of poor impulse control - ambulating naked and socially inappropriate behavior - sexually preoccupied, starting on 5/27/2021. A review of Resident 2's untimed Documentation Record (DR), dated 6/1/2021 to 6/21/2021, indicated Resident 2 had twelve episodes of ambulating naked: six episodes on 6/7/2021 and six episodes on 6/12/2021. DR indicated Resident 2 had four episodes of sexually preoccupied behaviors (unidentified), and one episode on 6/16/2021. During an observation of Resident 2 on 6/22/2021 at 12:26 pm, inside Resident 2's room, an attempt to interview the resident, Resident 2 made eye contact when greeted, but stopped and moved further away when asked about the alleged incident. Resident 2 declined to be interviewed and did not want to discuss the alleged incident. During an interview on 6/22/2021, at 12:27 pm, CNA 2 stated he intervened and redirected Resident 2 away from Resident 1 when he saw Resident 2 rubbing Resident 1's shoulder on 6/18/2021 (unidentified times). CNA 2 stated he saw Resident 1 moved away from Resident 2's touch. A review of Resident 1 and Resident 2's medical records from 6/18/2021 to 6/20/2021 indicated there was no documented evidence regarding the incident on 6/18/2021 or that it was reported to the ADM to ensure the safety of Resident 1. During an interview on 6/22/2021, at 3:58 pm, the DON stated the facility did not have a policy for consensual sexual activity. DON stated that if she noticed residents engaged in a sexual activity, she would separate them because the facility did not allow consensual sex. During interview with Medical Records (MR) on 6/22/2021 at 4:22 pm, MR stated there was no nurse's notes that on 6/20/2021 regarding Resident 1's hickeys on her neck nor any documentation if it was further assessed and if it was reported to the Administrator (ADM). During an interview on 6/23/2021, at 12:15 pm, LVN 2 stated she noticed skin discolorations on Resident 1's neck on 6/20/2021 (one day before Resident 1 reported the sexual abuse and requested room change) but did not investigate, document, or report her observation to the facility's abuse coordinator. LVN 2 stated she received abuse in-service about a month ago. During a telephone interview on 6/29/2021, at 10:43 am, the ADM stated the facility did not condone residents having sexual activities in the facility. ADM stated she was aware that Resident 1 and Resident 2 had sex on 6/16/2021 but no investigation was done to identify whether or not it was consensual. The ADM stated the facility attempted to develop a policy for consensual sex over several years but was unable to complete it. ADM stated the facility did not have a policy for consensual sex. During an interview with DON on 6/30/2021 at 2:27 pm and review of the facility's Management of Abuse Reporting Policy revised 12/2020, DON stated the policy indicated for an alleged or suspected abuse, timely reporting of incidents with or without injury must be done within two hours to the state licensing, ombudsman and the police department. DON stated the policy should have been followed on the day LVN 1 and CNA 1 found Resident 1 and Resident 2 having sex and when LVN 2 noted the hickeys on Resident 1's neck area but no report was done. DON stated it was important to report abuse according to the facility's policy, to ensure Resident 1's safety and to protect all other residents in the facility. A review of the Facility Management Abuse policy with a revised date of December 2020, indicated it was the responsibility of the facility's employees to report promptly within two hours any incident that involved resident abuse, sexual abuse, to the Department, police and the local Ombudsman. The policy indicated upon receiving reports of sexual abuse residents must be sent to general acute care hospital 1 (GACH 1), and the ADM and any legal entities would conduct an internal investigation which would determine if any other resident s could have been harassed or abuse (sexually) by the perpetrator. The policy was not specific on investigation and protection.

Based on observation, interview, and record review, the facility failed to implement and develop a policy on sexual abuse (is non-consensual sexual contact of any type with a resident) for one of two sampled residents (Resident 1) by failing to: 1. Report and investigate the sexual act between Resident 1 and Resident 2 that was witnessed by Licensed Vocational Nurse 1 (LVN1) and Certified Nursing Assistant 1 (CNA 1) on 6/16/2021 at 5:45 pm. 2. Protect Resident 1 from further sexual abuse that led Resident 1 to request to have a room change to a different unit in the facility. 3. Prevent Resident 1 from being sexually abused and afraid of Resident 2. 4. Develop a policy and procedure for consensual sex between residents and ensuring a safe environment to prevent sexual abuse. On 6/16/2021 at 5:45 pm, Licensed Vocational Nurse 1 (LVN 1) and Certified Nursing Assistant 1 (CNA 1) found Resident 1 and Resident 2 partially naked inside Resident 1's room having sex and the facility did not conduct an investigation, did not report the incident to the police, the Department and the Ombudsman (an official appointed to investigate individuals' complaints against maladministration) and did not protect Resident 1 from further abuse. On 6/21/2021 at 4:25 pm the facility reported to the Department that Resident 1 alleged Resident 2 went inside her room several times (unidentified times) on 6/19/2021 and on 6/20/2021 and had unwanted sexual contact (kissing, sexual intercourse, hickeys [a dark red or purple mark on the skin caused by intense suction]) with Resident 2. These deficient practices resulted in late reporting and for Resident 1 to experience sexual abuse and feeling afraid. On 6/29/2021 at 2:35 pm, the Department informed the Director of Nursing (DON) and the Program Director (PD) about the Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirement of participation has caused or is likely to cause serious injury, impairment or death to a resident) at the skilled nursing facility due to the facility's failure to prevent the resident to resident sexual abuse, and not having a specific policy on consensual sex amongst the residents. On 7/1/2021 at 4:08 pm, during an onsite visit, the Department verified and confirmed the IJ was removed after the facility presented an acceptable plan of action. The plan of action included: a. The facility developed written policies that provided guidelines for Prevention of Sexual Abuse, Unwanted Pregnancy, and Care plan for Unwanted Physical Sexual Contact and Consensual Physical Sexual Contact. b. The facility placed Resident 2 on a one to one monitoring (under constant observation by an assigned staff) on all shifts. c. The Facility protected Resident 1 from Resident 2. d. Resident abuse in-service included how to deal with allegations of abuse, neglect, exploitation or mistreatment, and instructions on when and how the newly implemented investigation format would be utilized. e. The facility's Staff Developer (DSD) conducted in-service training for new policies and procedure, which began on 6/30/2021 and all staff have been sent a text message regarding this incident of alleged sexual abuse and signs of possible sexual abuse, training on interview of residents denying or confirming that the sexual act was consensual, and documenting this in the residents' records on 7/1/2021. Cross Reference F600 and F609 Findings: A review of Resident 1's Progress Notes (PN), dated 6/16/2021, and timed at 5:45 pm, indicated LVN 1 and CNA 1 found Resident 1 and Resident 2 partially naked and having sex together, in Resident 1's room. The PN indicated LVN 1 verbally prompted the residents to stop what they were doing and separated the residents. The PN indicated both residents told LVN 1 that they had consented to the sexual activity. A review of Resident 1's medical record from 6/16/2021 to 6/20/2021 indicated no documented evidence the facility investigated regarding Resident 1 and Resident 2's sexual activity that was witnessed by LVN 1 and CNA 1. A review of Resident 1's Admission Record indicated the facility admitted the resident on 9/13/2019 with diagnoses of schizoaffective disorder (mental illness that can affect your thoughts, mood and behavior), borderline personality disorder (a mental disorder characterized by unstable moods, behavior, and relationships), and unspecified intellectual disabilities (below-average intelligence). A review of Resident 1's Minimum Data Set (MDS, an assessment and care screening tool), dated 6/8/2021, indicated Resident 1 had intact cognitive skills (ability to think, understand, and reason), no mobility impairment, and needed supervision for personal hygiene (practices performed to maintain cleanliness and preserve health). A review of Resident 1's PN, dated 6/21/2021, and timed at 4:05 pm, indicated Resident 1 told Social Worker (SW) she would like to move to a different unit because Resident 2 went into her room (unspecified date and time). The PN indicated SW reminded the resident to call for staff (unidentified), pull the call light (a device used by a resident to signal his or her need for assistance), or to leave the room if Resident 2 entered her room. A review of Resident 1's PN, dated 6/21/2021, and timed at 4:40 pm, indicated the Program Director (PD) notified LVN 1 that Resident 1 requested for a room change because she was concerned about Resident 2 trying to be sexually assaultive with her and getting into her room without her permission. A review of Resident 1's PN, dated 6/21/2021, and timed at 10:34 pm, indicated Resident 1 told LVN 3 that she (Resident 1) did not report the sexual assault during the weekend (6/19/2021 and 6/20/2021) with Resident 2 because Resident 1 was afraid of making Resident 2 angry. The PN indicated LVN 3 and CNA 1 did a complete body check on Resident 1 and noted six hickeys on her neck and jaw areas. A review of the facility's Confidential Report dated 6/21/2021 and timed at 4:25 pm, indicated Resident 1 alleged Resident 2 went inside Resident 1's room several times (unidentified times) on 6/19/2021 and on 6/20/2021(unidentified times) and had unwanted sexual contact (kissing, sexual intercourse, hickeys), with Resident 2. During an observation and interview on 6/22/2021, at 12:56 pm, inside the facility's treatment room, Resident 1 was awake and had five light, reddish purple discolorations on her neck. Resident 1 stated Resident 2 went inside her room on 6/19/2021 and on 6/20/2021 (unidentified times) and asked to have sex with her. Resident 1 stated she refused and told Resident 2 to leave her room but Resident 2 did not listen and forced herself on Resident 1. Resident 1 stated she did not report the incident to the staff. Resident 1 stated she did not want to describe exactly what happened but stated she told Resident 2 no. A review of Resident 2's Admission Record indicated the facility admitted the resident on 5/27/2021 with diagnoses of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and herpes viral infection (a virus causing contagious sores, most often around the mouth or on the genitals). A review of Resident 2's Minimum Data Set (MDS, an assessment and care screening tool), dated 6/9/2021, indicated Resident 2 had intact cognitive skills, no mobility impairment, and needed supervision for personal hygiene. A review of Resident 2's Order Summary Report indicated a physician order to monitor and record every shift episode of poor impulse control - ambulating naked and socially inappropriate behavior - sexually preoccupied, starting on 5/27/2021. A review of Resident 2's untimed Documentation Record (DR), dated 6/1/2021 to 6/21/2021, indicated Resident 2 had twelve episodes of ambulating naked: six episodes on 6/7/2021 and six episodes on 6/12/2021. DR indicated Resident 2 had four episodes of sexually preoccupied behaviors (unidentified) one episode on 6/16/2021 and three episodes on 6/20/2021. A review of the facility's Confidential Report dated 6/21/2021 and timed at 4:25 pm, indicated Resident 1 alleged Resident 2 went inside Resident 1's room several times (unidentified times) on 6/19/2021 and on 6/20/2021(unidentified times) and had unwanted sexual contact (kissing, sexual intercourse, hickeys), with Resident 2. During an observation of Resident 2 on 6/22/2021 at 12:26 pm an attempt to interview the resident, Resident 2 made eye contact when greeted, but stopped and moved further away when asked about the alleged incident between Resident 1 and Resident 2. Resident 2 declined to be interviewed and did not want to discuss the alleged sexual incident. During an interview on 6/22/2021, at 12:27 pm, CNA 2 stated on 6/18/2021 (unidentified time), he saw Resident 2 rubbing Resident 1's shoulder and intervened and redirected Resident 2 away from Resident 1. CNA 2 stated he saw Resident 1 moved away from Resident 2's touch. A review of Resident 1 and Resident 2's medical records from 6/18/2021 to 6/20/2021 there was no documented evidence regarding the incident on 6/18/2021 or that it was reported to ensure the safety of Resident 1. During an interview on 6/22/2021, at 3:58 pm, the DON stated the facility did not have a policy for consensual sexual activity. DON stated that if she noticed residents engaged in sexual activity, she would separate them because the facility did not allow consensual sex. During interview with Medical Records (MR) on 6/22/2021 at 4:22 pm, MR stated there was no nurse's notes that on 6/20/2021 regarding Resident 1's hickeys on her neck nor any documentation if it was further assessed and if it was reported to the Administrator (ADM). During an interview on 6/23/2021, at 12:15 pm, LVN 2 stated she noticed skin discolorations on Resident 1's neck on 6/20/2021 (one day before Resident 1 reported the sexual abuse and requested room change) but did not investigate, document, or report her observation to the facility's abuse coordinator (Administrator). During an interview with PD on 6/28/2021, at 10:45 am, PD stated, the facility did not develop a care plan for residents or a policy for consensual sexual activities. PD also stated Assistant Program Director (APD) told him on 6/21/2021 (unknown time) that Resident 1 felt afraid of Resident 2 and wanted a room change. During a telephone interview on 6/29/2021, at 10:43 am, the Administrator (ADM) stated the facility did not condone sexual activity. ADM stated she was aware that Resident 1 and Resident 2 had consensual sex on 6/16/2021 but no investigation was done. The ADM stated the facility attempted to develop a policy for consensual sex over several years but was unable to complete it. ADM stated the facility did not have a policy on consensual sex. A review of the Facility Management Abuse policy with a revised date of December 2020, indicated it was the responsibility of the facility's employees to report promptly within two hours any incident that involved resident abuse, sexual abuse, to the Department, police and the local Ombudsman. The policy indicated upon receiving reports of sexual abuse residents must be sent to general acute care hospital 1 (GACH 1). The policy was not specific on investigation and protection.

Based on observation, interview, and record review the facility failed to report a sexual abuse (non-consensual sexual contact of any type with a resident) allegation for one of two sampled residents (Resident 1) to the California Department of Public Health (CDPH) within a two hour time frame as indicated in their Abuse Prevention Policy. On 6/16/2021 at 5:45 pm, Licensed Vocational Nurse 1 (LVN 1) and Certified Nursing Assistant 1 (CNA 1) found Resident 1 and Resident 2 partially naked inside Resident 1's room having sex and the facility did not conduct an investigation, did not report the incident to the police, the Department and the Ombudsman (an official appointed to investigate individuals' complaints against maladministration) and did not protect Resident 1 from further abuse. On 6/21/2021 at 4:25 pm the facility reported to the Department of Public Health that Resident 1 alleged Resident 2 went inside Resident 1's room several times (unidentified times) on 6/19/2021 and on 6/20/2021(unidentified times) and had unwanted sexual contact (kissing, sexual intercourse, hickeys, [a dark red or purple mark on the skin caused by intense suction]) with Resident 2. The report was made to the Department over 24 hours after the alleged incident occurred. This deficient practice resulted in late reporting and for Resident 1 to experience sexual abuse and feeling afraid. On 6/29/2021 at 2:35 pm, the Department of Public Health called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirement of participation has caused or is likely to cause serious injury, impairment or death to a resident) situation in the presence of the Director of Nursing (DON) and the Program Director (PD). The DON and PD were informed of the facility's failure to have systems in place to ensure Resident 1 was protected from sexual abuse. On 7/1/2021 at 4:08 pm, during an onsite visit, the Department verified and confirmed the IJ was removed after the facility presented an acceptable plan of action. The plan of action included: a. The facility developed written policies that provided guidelines for Prevention of Sexual Abuse, Care plan for Unwanted Physical Sexual Contact and Consensual Physical Sexual Contact. b. The facility placed Resident 2 on a one to one monitoring (under constant observation by an assigned staff), on all shifts. c. The Facility protected Resident 1 from Resident 2. d. Resident abuse in-service included how to deal with allegations of abuse, neglect, exploitation or mistreatment, and instructions on when and how the newly implemented investigation format would be utilized. e. The facility's Staff Developer (DSD) conducted in-service training for new policies and procedure, which began on 6/30/2021 and all staff have been sent a text message regarding this incident of alleged sexual abuse and signs of possible sexual abuse, training on interview of residents denying or confirming that the sexual act was consensual, and documenting this in the residents' records on 7/1/2021. f. The facility was responsible for reporting within two- hour to the State Department of Public Health, Ombudsman, local Police Department, resident's responsible party, attending physician, and medical director, concerning any abuse of a resident. The report included resident name, room number, type of abuse, persons involved, and action taken by the facility. g. The facility planned in case of future incident to put the alleged abuser on one to one supervision every shift for the safety of all residents until it is deemed safe for the alleged abuser to mix independently with other residents. The alleged abuser will have one on one counseling to discuss the emotional affects and alternatives to abusive behavior and if necessary, the alleged abuser will be referred to higher level of care. Cross Reference F600 and F607 Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 9/13/2019 with diagnoses of schizoaffective disorder (chronic mental health condition characterized primarily such as hallucinations [experience involving the apparent perception of something not present], delusions [A belief or altered reality that is persistently held despite evidence or agreement to the contrary], depressed [state of general unhappiness] episodes and periods of high energy). A review of Resident 1's Minimum Data Set (MDS, an assessment and care screening tool), dated 6/8/2021, indicated Resident 1 had intact cognitive skills (ability to think, understand, and reason), no mobility impairment, and needed supervision for personal hygiene (practices performed to maintain cleanliness and preserve health). A review of Resident 1's Progress Notes (PN), dated 6/16/2021, and timed at 5:45 pm, indicated LVN 1 and CNA 1 found Resident 1 and Resident 2 partially naked and having sex together, in Resident 1's room. The PN indicated LVN 1 verbally prompted the residents to stop what they were doing and separated the residents. A review of Resident 1's PN, dated 6/21/2021, and timed at 4:05 pm, indicated Resident 1 told Social Worker (SW) she would like to move to a different unit because Resident 2 went into her room (unspecified date and time). The PN indicated SW reminded the resident to call for staff (unidentified), pull the call light (a device used by a resident to signal his or her need for assistance), or to leave the room if Resident 2 entered her room. A review of Resident 1's PN, dated 6/21/2021, and timed at 4:40 pm, indicated the Program Director (PD) notified LVN 1 that Resident 1 requested for a room change because she was concerned about Resident 2 trying to be sexually assaultive with her and getting into her room without her permission. A review of Resident 1's PN, dated 6/21/2021, and timed at 5:27 pm, indicated Resident 1 stated Resident 2 sexually assaulted her on 6/16/2021 and the incident was not consensual. The PN notes indicated Resident 1 was moved to a different unit. A review of Resident 1's PN, dated 6/21/2021, and timed at 10:34 pm, indicated Resident 1 told LVN 3 that she (Resident 1) did not report the sexual assault during the weekend with Resident 2 because Resident 1 was afraid, of making Resident 2 angry. The PN indicated LVN 3 and CNA 1 did a complete body check on Resident 1 and noted six hickeys, on her neck and jaw areas. A review of the facility's Confidential Report dated 6/21/2021 and timed at 4:25 pm, indicated Resident 1 alleged Resident 2 went inside Resident 1's room several times (unidentified times) on 6/19/2021 and on 6/20/2021(unidentified times) and had unwanted sexual contact (kissing, sexual intercourse, hickeys), with Resident 2. During an observation and interview on 6/22/2021, at 12:56 pm, inside the facility's treatment room, Resident 1 was awake and had five light, reddish purple discolorations on her neck. Resident 1 stated Resident 2 went inside her room on 6/19/2021 and on 6/20/2020 (unidentified times) and asked to have sex with her. Resident 1 stated she refused and told Resident 2 to leave her room but Resident 2 did not listen and forced herself on Resident 1. Resident 1 stated she did not report the incident to the staff. Resident 1 stated she did not want to describe exactly what happened but stated she told Resident 2 no. During a telephone interview on 6/23/2021 at 12:15 pm, LVN 2 stated she saw Resident 1 with hickeys, on her neck on 6/20/2021 during the morning shift and stated she did not report to the ADM. During an interview on 6/28/21, at 10:45 am, PD stated, the facility did not do a care plan for consensual sexual activities and did not have a policy for consensual sexual activities. PD also stated the Assistant Program Director (APD) told him on 6/21/2021 that Resident 1 wanted a room change because Resident 2 kept going inside Resident 1's room (unidentified date and time), and she (Resident 1) felt unsafe. A review of Resident 2's Admission Record indicated the facility admitted the resident on 5/27/2021 with diagnoses of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and herpes viral infection (a virus causing contagious sores, most often around the mouth or on the genitals). A review of Resident 2's Care Plan (CP) initiated on 5/27/2021, indicated Resident 2 was preoccupied with sexual urges and behaviors and the goal was for Resident 2 to have zero episodes in a month. A review of Resident 2's Order Summary Report indicated a physician order to monitor and record every shift episode of poor impulse control - ambulating naked and socially inappropriate behavior - sexually preoccupied, starting on 5/27/2021. A review of Resident 2's Minimum Data Set (MDS, an assessment and care screening tool), dated 6/9/2021, indicated Resident 2 had intact cognitive skills, no mobility impairment, and needed supervision for personal hygiene. A review of Resident 2's untimed Documentation Record (DR), dated from 6/1/2021 to 6/21/2021, indicated Resident 2 had twelve episodes of ambulating naked: six episodes on 6/7/2021 and six episodes on 6/12/2021. DR indicated Resident 2 had four episodes of sexually preoccupied behaviors (unidentified), and one episode on 6/16/2021. During an observation of Resident 2 on 6/22/2021 at 12:26 pm, inside Resident 2's room, an attempt to interview the resident, Resident 2 made eye contact when greeted, but stopped and moved further away when asked about the alleged incident. Resident 2 declined to be interviewed and did not want to discuss the alleged incident. During an interview on 6/22/2021, at 12:27 pm, CNA 2 stated he intervened and redirected Resident 2 away from Resident 1 when he saw Resident 2 rubbing Resident 1's shoulder on 6/18/2021 (unidentified time). CNA 2 stated he saw Resident 1 moved away from Resident 2's touch. A review of Resident 1 and Resident 2's medical records from 6/18/2021 to 6/20/2021 indicated there was no documented evidence regarding the incident on 6/18/2021 or that it was reported to the ADM to ensure the safety of Resident 1. During an interview on 6/22/2021, at 3:58 pm, the DON stated she was not sure if the facility had a policy for consensual sexual activity. DON stated that if she noticed residents engaged in sexual activity, she would separate them because the facility did not allow consensual sex. During an interview on 6/22/2021, at 4:19 pm, DON stated the facility did not have a policy for consensual sex. During an interview on 6/23/2021, at 12:15 pm, LVN 2 stated she noticed skin discolorations on Resident 1's neck on 6/20/2021 (one day before Resident 1 reported the sexual abuse and requested room change) but did not investigate, document, or report her observation to the facility's Administrator (ADM). During a telephone interview on 6/29/2021, at 10:43 am, the ADM stated the facility did not condone residents having sexual activities in the facility. ADM stated she was aware that Resident 1 and Resident 2 had sex on 6/16/2021 but no investigation was done to identify whether or not it was consensual. The ADM stated the facility attempted to develop a policy for consensual sex over several years but was unable to complete it. ADM stated the facility did not have a policy for consensual sex between residents. During an interview with DON on 6/30/2021 at 2:27 pm and review of the facility's Management of Abuse Reporting Policy revised 12/2020, DON stated the policy indicated for an alleged or suspected abuse, timely reporting of incidents with or without injury must be done within two hours to the state licensing, ombudsman, and to the police department. DON stated the policy should have been followed on the day LVN 1 and CNA 1 found Resident 1 and Resident 2 having sex and when LVN 2 noted the hickeys on Resident 1's neck area but no report was done. DON stated it was important to report abuse according to the facility's policy, to ensure Resident 1's safety and to protect all other residents in the facility. A review of the Facility Management Abuse policy with a revised date of December 2020, indicated it was the responsibility of the facility's employees to report promptly within two hours any incident that involved resident abuse, sexual abuse, to the Department, police, and the local Ombudsman. The policy indicated upon receiving reports of sexual abuse residents must be sent to general acute care hospital 1 (GACH 1). The policy was not specific on investigation and protection.

Based on interview, record review, and video surveillance review, the facility failed to protect a resident from non-consensual sexual activity (any sexual intercourse, with any part of the body or object, by a person upon another person, that is without consent and/or by force) for one of two sampled residents (Resident 1). 1. Certified Nursing Assistant (CNA) 1 left the Zone CNA 1 was assigned to supervise, which included Resident 1's room, at a locked behavioral unit, on 8/31/20, during the 11 p.m. to 7:30 a.m. shift. CNA 2, who was seen during the facility's video surveillance review, was sitting 35 steps away and facing Resident 1's room, did not move from his sitting position as Resident 2 followed Resident 1 inside her room. 2. Resident 2, who was known to CNA 2, Residents 4, 5, and 6 the behavior of following female residents inside their rooms did not have documented facility behavioral assessments and interventions in the resident's records to protect other female residents from possible sexual abuse. CNA 2 wrote Resident 2's behavior on the facility's communication board to communicate Resident 2's behavior to the Specialized Treatment Program staff, a month before Resident 2 left the facility. Residents 5 and 6 reported to LVN 2, Resident 2's behavior of going inside their room and bothers Resident 5. 3. The administrator did not include interviews of other residents that could have been possible victims of sexual abuse in the facility. The administrator stated she only talked to the residents and staff that were directly involved in Resident 1's sexual abuse allegation to Resident 2. This deficient practice resulted in Resident 1 being sexually abused by Resident 2. Resident 1, then feared Resident 2's sexual behavior. Resident 1 sustained vaginal tearing (injury to the tissue in the vaginal wall, which is an indicator of sexual abuse) with a potential to cause permanent psychological harm, and exposure to [MEDICAL CONDITION] including but not limited to chlamydia (infection of the reproductive system), gonorrhea (infection of the cervix), and Human Immunodeficiency Virus (HIV; [MEDICAL CONDITION] transmitted via blood or sexual intercourse that causes infection and attacks the body's ability to fight off other infection). An immediate jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called on 12/2/20, at 2:55 p.m. with the facility's administrator (ADM). The facility administrator was informed of the facility's failure to protect Resident 1 from non-consensual sexual activity against Resident 2. This deficient practice resulted in Resident 1 being sexually abused by Resident 2, causing vaginal tearing. This deficient practice resulted serious actual harm to Resident 1 and potential serious harm to other female residents (Residents 4 and 5) that threatened the health and safety of all 33 female residents in the facility. On 12/5/20 at 10:30 a.m., the facility submitted an acceptable plan of action (POA), and the surveyor verified the implementation of the POA by observations, interviews, and record review and confirmed the removal of the immediate jeopardy on 12/5/20, at 11:19 a.m. in the presence of the administrator. The administrator provided an acceptable plan of action as follows: a. Resident 1 was transferred to the acute general hospital (GACH) on 8/31/20 for a sexual assault examination. b. Residents 1 and 5 would be counseled and evaluated by the facility psychiatrist on issues of sexual abuse, harassment, feelings of safety, and other issues related to the situation for appropriate treatment recommendations. c. All staff with a focus on night shift facility staff to supervise facility surroundings and pay attention to resident activities for the entire shift while on duty. d. All staff would be required to make rounds to common areas of the facility every 15 minutes. e. Hourly in-room inspections would be done in teams of two with one staff standing by the doorway to supervise the facility hallway and witness other staff entrance to resident's rooms for visual inspection. f. The facility software (Point click care) would be utilized as means of communication for all facility staff to report verbal, physical, and sexual harassment, in addition to verbal communication. g. Facility to consult with a trauma professional to provide extended training to both staff and residents. h. Inservice education would begin for all facility staff on 12/3/20, 12/4/20, and will continue through 12/8/2020 in order to connect with all staff and shifts. i. During a sexual assault investigation, the facility would identify others who could have been abused. j. Attending psychiatrist, psychologist, or licensed social worker would discuss the abuse and give recommendations for treatment. k. All changes in the facility abuse investigation process will be noted in the facility Abuse Policy on 12/3/20. l. The facility's treatment team will meet to discuss the abuse policy revision changes on 12/3/30 that included but not limited to the administrator, director of nursing, program director, quality assurance nurse, social service director, assistant program director, and nursing supervisor. Findings: 1. A review of Resident 1's Face Sheet dated 8/31/20, indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Admitting Psychiatric History signed and dated by the psychiatrist on 9/19/19 indicated the resident had flat affect (no facial expression), motor [MEDICAL CONDITION] (resident moves slowly, speech and thoughts are slowed with minimal motor responses), limited insight (insight (ability to understand or recognize one's own condition)), and fairly poor judgement (judgement (ability to critically evaluate a situation and make good decisions about a course of action)). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning screening tool) dated 6/9/20, indicated the resident's cognition (mental process of acquiring knowledge and understanding) was intact (fully able to understand and express thoughts). The MDS indicated Resident 1 was independent in walking and all self-care needs. A review of Resident 1's Interdisciplinary Progress Notes, dated 8/31/20 at 8:10 a.m., Resident 1 stated she was raped on 8/31/20 at around 4:22 a.m. A review of Resident 1's Interdisciplinary Progress Notes, dated 8/31/20 at 4:40 p.m., indicated Resident 1 left the facility to the general acute care hospital (GACH) accompanied by a facility staff. The note indicated a sexual assault response nurse (a registered nurse who have completed specialized education and clinical preparation in the medical forensic care of the patient who has experienced sexual assault or abuse) would meet the resident at the GACH. A review of the Forensic Medical Report: Acute (actual incident transpired less than 120 hours) Adult/Adolescent Sexual Assault Examination dated 8/31/20, indicated Resident 1 was evaluated by a forensic nurse specialist (a registered nurse that treat assault victims and/or investigate crime scenes). The report indicated the assailant was a known friend (Resident 2), pushed and verbally threatened Resident 1 and stated He (Resident 2) was gonna have sex with me whether I am ready or not. The report indicated Resident 2 restrained Resident 1 by holding both her wrists and covered her mouth. The anogenital (the area from the anus to the vaginal area) examination indicated Resident 1 had 2-4 areas of linear (regular in shape) lacerations (tear-like wounds caused by some [MEDICATION NAME] trauma) to the midline perineum (the region between the thighs, and by the opening of the vagina and the anus in females) measuring 1-2 centimeters (cm; unit of measurement) in size. The rectum indicated one area of bruising described as irregular in shape, red in color, and 1-2 cm in size. The narrative report indicated that according to the police officer, Resident 1 reported that Resident 2 raped her vaginally and anally for 10 minutes each. The attached Treatment Recommendations to the Forensic Medical Report indicated antibiotics treatment was recommended to be prescribed to Resident 1 such as [MEDICATION NAME] 1 gram (gm; unit of measurement)y mouth once to be taken that day, and [MEDICATION NAME] 250 mg intramuscularly (injection via the muscle) once to be taken that day. [MEDICAL CONDITION] was also recommended if needed. A review of Resident 1's Trauma informed care plan dated 6/13/20, indicated the resident shared history of sexual abuse by a family member. An additional issue was added in the same care plan, dated 9/14/20, indicated the resident expressing nightmares of a family member attempting to rape her. The interventions included one is to one trauma centered counseling sessions. 2. A review of Resident 2's Face Sheet dated 8/31/20, indicated Resident 2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 2's MDS dated [DATE], indicated the resident's cognition was intact. The MDS indicated Resident 2 was independent in walking and all self-care needs. A review of Resident 2's Interdisciplinary Notes, dated 8/31/20 at 4:40 p.m., indicated a local police officer arrived at the facility and arrested Resident 2. The police officer took Resident 2 to the Police Station for further investigation at 4:40 p.m. on 8/31/20. A review of the facility's investigation report addressed to the Department dated 9/4/2020, indicated that Certified Nursing Assistant (CNA) 1 assigned to supervise the zone that included Resident 1's room was on an unannounced break and unauthorized time-off the floor. The report indicated that CNA 2 who was an additional staff assigned to supervise another zone on the same floor did not see Resident 2 enter Resident 1's room even though CNA 2 was present a few rooms down. The report indicated that CNA 1's employment from the facility was terminated and CNA 2' employment was suspended for three days for the lack of awareness what was happening around him. The report indicated that the facility's video footage indicated Resident 1 and 2 was seen playing cards earlier that evening. The report indicated that Resident 2 was observed entering Resident 1's room from the video footage and stayed for 10 minutes. Resident 2 informed the facility that both residents made a decision to go to resident 2's room and have sexual relations. The report indicated Resident 1 stated she was raped by Resident 2. A review of a facility document signed by CNA 2 dated 9/1/20, indicated CNA 2's interview statement. The document stated CNA 2 stated that on 8/31/20, at around 4:05 a.m., Resident 2 approached him for a toothbrush. CNA 2 informed Resident 2 to wait until 5 a.m. CNA 2 stated he (CNA 2) was sitting in front of another resident's room by the edge of the door. CNA 2 stated Resident 2 walked past by him and CNA 2 informed Resident 2 not to go to any other residents' rooms. CNA 2 stated he thought Resident 2 would just sit by the laundry room. During an interview, on 9/1/20 at 9:47 a.m., the facility's administrator stated that on 8/31/20, Resident 1 went to the GACH for a sexual assault examination and returned to the facility on the same day. The administrator stated CNA 1 worked at the facility from 11 p.m. to 7:30 a.m. (on 8/31/20). The administrator stated CNA 1 was assigned to monitor Zone 3 (a total of seven rooms in the facility's hallway) where Resident 1 was residing. The administrator stated the video surveillance recording on the day of the incident (8/31/20) was reviewed. The administrator stated that on 8/31/20, at 4:26 a.m. Resident 2 entered Resident 1's room and at 4:36 a.m., Resident 2 was observed leaving Resident 1's room. The administrator stated CNA 1 was not where he should be (Zone 3) at the time the sexual assault occurred. The administrator stated CNA 1 did not inform CNA 2 that CNA 1 would leave his post. The administrator stated CNA 2 was assigned to Zone 2 which was located on the same facility hallway adjacent to Zone 3 (CNA 1's assigned hallway). During the same interview on 9/1/20 at 9:47 a.m., the administrator stated CNA 2 did not witness Resident 2 entering Resident 1's room. The Administrator stated CNA1 was terminated from the facility on 9/1/20 for not following the facility's zoning policy (to monitor their assigned zones in order to ensure residents are free from distress). The administrator stated CNA 2 was suspended (temporary removal of an employee from performing his/her work duties and from receiving pay, as a disciplinary measure) from work. During an interview, on 9/1/20 at 10:30 a.m., Resident 1 was interviewed regarding the incident with Resident 2. Resident 1 stated at 4:20 a.m. on 8/31/20, Resident 1 went to get water and went back inside her room. Resident 1 stated when she laid down, Resident 1 heard a voice (Resident 2) on top of her. Resident 1 stated she pushed and shoved off Resident 2. Resident 1 stated when her back hit the bed, Resident 1 just closed her eyes in fear that Resident 2 would hit her. Resident 1 stated she was informed by the GACH staff that she had vaginal tearing. Resident 1 stated she was concerned because Resident 2 did not use a condom (a thin rubber sheath worn on a man's penis during sexual intercourse as a contraceptive or as a protection against infection). A review of the video surveillance on the day in question (8/31/20), the video camera angle showed Zones 2 and 3 with Resident 1's room at the bottom right of the screen. The video surveillance review indicated the exact time stamps showing on the screen. During the review, the following chain of events were reviewed: -At 4:19:07 a.m., Resident 2 and CNA 2 were sitting by the hallway in Zone 2. CNA 2 was sitting in the middle of another resident room's doorway facing Zone 3, that was a few rooms down to Resident 1's room. Resident 2 was sitting at the corner end of the hallway. -At 4:19:35 a.m., Resident 1 exited her room and walked around the hallway towards Resident 2. -From 4:22:25 a.m. to 4:24:31 a.m., Resident 2 got up and walked around and talked to CNA 2. -At 4:25:52 a.m., Resident 1 appeared back in the video surveillance from the other hallway, stopped by and appeared talking to Resident 2 who was sitting by the corner end of the hallway. -At 4:26:31 a.m., Resident 1 started to walk away from Resident 2. -At 4:26:42 a.m., Resident 1 was observed walking (manner of walking showed slow, small steps and appeared to be dragging her feet) past CNA 2 in the facility hallway. CNA 2 was sitting approximately 35 steps away from Resident 1's room location. -At 4:26:47 a.m., Resident 2 got up and started to walk (manner of walking was two times faster compared to Resident 1) following Resident 1 as she walked down the hallway leading to her room. -At 4:27:06 a.m., Resident 1 walked in her room. -At 4:27:10 a.m., (4 to 5 seconds interval) Resident 2 walked in Resident 1's room and immediately stuck his head out of the doorway looking at the right side of the facility hallway where CNA 2 was sitting. CNA 2 did not move from the same location where he was sitting. -At 4:36:20 a.m., (approximately 9 minutes from the time Resident 2 walked in Resident 1's room) Resident 2 exited Resident 1's room and walked 28 steps toward CNA 2 and stopped to talk to CNA 2. -At 4:37:09 a.m., Resident 2 left CNA 2's location and walked back at the end of the hallway and sat back at the corner end of the hallway. During an interview, on 9/1/20 at 11:15 a.m., the director of nursing (DON) stated CNA 1 should have stayed and monitored his assigned hallway which included Resident 1's room. The DON stated CNA 2 should have caught Resident 2 entering Resident 1's room. During an interview, on 9/1/20 at 11:20 a.m., Resident 4 (Resident 1's roommate) stated Resident 1 woke her up on 8/31/20 at around 5 a.m., and informed her that Resident 2 walked into their room and stated, Hey you wanna f_,_,_? Resident 4 stated that Resident 1 said No to Resident 2. Resident 4 stated Resident 2 made Resident 1 take-off Resident 1's clothes. Resident 4 stated that it was the first time she learned of Resident 2 behaving like that. Resident 4 stated that Resident 2 followed her (Resident 4) around before to have sexual relations. However, Resident 4 stated Resident 2 would listen when Resident 4 would say no. During a telephone interview, on 11/14/20 at 11:15 p.m., CNA 2 stated he was working on 8/31/20 at the 11 p.m. to 7 a.m. shift. CNA 2 stated he was sitting that night because he was assigned to supervise Zone 2. CNA 2 stated he remembered informing Resident 2 that night not to go to any other residents' rooms. CNA 2 stated Resident 2 used to do that before- go to other female residents' rooms. CNA 2 stated Resident 2 used to follow and go to Resident 5's room, a month ago before Resident 2 left the facility. CNA 2 stated that he knew because he wrote Resident 2's behavior in the facility's communication board. CNA 2 stated the white board located in the facility's conference room was used to communicate resident behaviors that needed to be endorsed to the STP (Specialized Treatment Program; the group that specializes in the resident's psychiatric rehabilitation) staff. CNA 2 stated that this how he knew Resident 2 had a previous behavior of going to other female resident's room. CNA 2 stated he thought that the behavior was already resolved. During the same telephone interview, CNA 2 stated that the facility's Zoning policy required each CNA assigned rooms to monitor. CNA 2 stated that during that day and time in question, CNA 1 was on break from 3:30 a.m. to 4 a.m. However, CNA 1 did not come back at 4 a.m. CNA 2 stated that he was supposed to watch over CNA 1's assigned zone while he was out on break. CNA 2 stated that from the location where he was sitting, he was supposed to cover for CNA 1. CNA 2 stated he did not check where Resident 2 was going when he saw Resident 2 walking back and forth the facility hallway. CNA 2 stated he did not know why he did not notice Resident 2 followed Resident 1 inside her room. During a telephone interview, on 11/16/20 at 4 p.m., the DON stated she could not find documented evidence of Resident 2's previous behavior of going into other female residents' rooms. The DON stated the Nursing Department communicates resident behaviors and changes of condition through 24-hour communication log. The DON stated the facility's STP staff uses the communication board to indicate resident behaviors or changes that needed to be endorsed or monitored. The DON stated the STP director would communicate directly with the Nursing Department if there were any needed behaviors to be monitored as indicated in the STP communication board. During an observation, on 12/2/20 at 6:11 a.m., there was a white board found in the facility's conference room. During a concurrent interview with the Licensed Vocational Nurse (LVN) 1 who works for the night shift (11 p.m. to 7 a.m.) stated the white board is used mostly by night shift (staff) to leave communications for the (STP) counselors of important things that they need to know about the residents, in case something happened at night before they come in. During an interview, on 12/2/20 at 6:55 a.m., the administrator stated that the facility makes every attempt to keep the residents out of each other's room but it's hard with this resident population . It's ongoing with our population, it is an ongoing issue people want to try on each other's clothing, play cards with each other it's hard to keep them out of one another's room and we are constantly working on it. During an interview, on 12/2/20 at 7:49 a.m., Resident 1 stated that after what happened to her and since Resident 2 left the facility (on 8/31/20), Resident 1 had not seen anybody sleeping and staff had been awake and alert. Resident 1 stated she had observed the facility staff walking around and stand in the middle of the hallway. During an interview, 12/2/20 at 8:10 a.m., the STP Program Director (PD) stated that the facility's main form of communication between the STP staff and nurses was More verbal . Communication is done through the communication board . It could be any 11 p.m. to 7 a.m. shift staff writing on the board. The STP PD stated that if there was anything new about a resident written on the communication board, the facility staff would develop a care plan. During an attempt to interview Resident 5, on 12/2/20 at 8:55 a.m., Resident 5 refused to be interviewed. During an interview, on 12/2/20 at 9:28 a.m., Resident 6 stated she used to be Resident 5's roommate when Resident 2 was still residing at the facility. Resident 6 stated Resident 2 used to come inside their room and would say bad things to Resident 5 in Spanish about her behind. Resident 2 would sometimes call her a b---h and Resident 5 did not like it. Resident 6 stated Resident 2 would tell Resident 5 that Resident 2 would marry Resident 5, a month before Resident 2 left the facility. Resident 5 told Resident 6 that she spoke to the STP counselor that Resident 2 had been bothering her. Resident 6 stated they both (Resident 5 and 6) told a charge nurse (LVN 2) about Resident 2's behavior before Resident 2 left the facility. During a follow up interview with the administrator on 12/2/20 at 2:20 pm, the administrator stated that during her investigation of Resident 1's sexual abuse allegation, the administrator did not include interviews of other residents that could have been possible victims of sexual abuse in the facility. The administrator stated she only talked to the residents and staff that she knew were directly involved in the sexual abuse allegation. During a telephone interview, on 12/2/20 at 2:35 p.m., LVN 2 stated she could not recall any residents notifying her Resident 2's behavior of going into other female resident's room or bothering any female residents. A review of a facility document, titled Unsatisfactory Behavior/Incident Information, signed and dated by CNA 1 on 9/1/20, indicated CNA 1 was to return from lunch (sic) at 4 a.m. The incident occurred at 4:26 a.m., where a male resident entered a female resident's room and was later accused of rape . This incident could have been avoided if CNA 1 was at his post redirecting the male resident back to his room or out of the female resident's room. A review of the facility's policy and procedure, titled Zoning Policy updated on 7/23/20, indicated each CNA is assigned to a section of the unit to monitor in order to ensure residents are free from distress. The policy indicated if leaving their assigned zone, the CNA had to notify their charge nurse and co-workers. The policy indicated CNAs had to position themselves in a way that allowed them to view the entire zone. The policy indicated CNAs were not to leave their zone until their relief arrived. A review of the facility's CNA job description, (undated) indicated the CNAs position responsibilities included: understanding the responsibilities of zoning and following facility safety rules and procedures while on assignment. A review of the facility's policy on abuse identification titled Policy: Recognizing signs and symptoms of abuse/neglect, (undated) indicated the facility will not condone (disregard) any form of resident abuse or neglect. A review of the facility's policy titled, Sexual Abuse, (undated) defined sexual abuse as, but not limited to sexual harassment (the making of unwelcomed and inappropriate sexual remarks or physical advances), sexual coercion (forcing, threatening or intimidating someone to perform sexual acts), or sexual assault.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from sexual abuse by failing to: 1. Adequately supervise and monitor Resident 1 (female) and Resident 2 (male) who was placed on a one to one observation on 10/23/17 due to inappropriate sexual behavior towards other female residents in the facility). On 12/3/17 at 4:29.33 p.m., Resident 1 entered Resident 2's room and exited Resident 2's room at 4:43.05 p.m., (remained in Resident 2's room for 14 minutes), and Resident 1 alleged that Resident 2 sexually assaulted her inside Resident 2's room. 2. Adequately implement the one to one observation and supervision for Resident 2 as indicated in the facility's policy. Resident 2 was not closely supervised by Certified Nursing Aassistant 1 (CNA 1) for 14 minutes while he was inside his room. The facility's video footage dated 12/3/17, and timed from 4:29.50 p.m., to 4:43.03 p.m., showed CNA 1 sitting on a chair outside Resident 2's room (14 minutes) without physically going inside Resident 2's room to observe and supervise Resident 2. 3. Conduct a thorough and accurate final investigation of Resident 1's allegation of sexual assault. The facility's Administrator (ADM) did not complete an investigation within five days after Resident 1's allegation of sexual assault. ADM concluded the investigation on 2/20/18 (61 days). These deficient practices resulted in Resident 1 was sexually assaulted (she did not feel safe around Resident 2), and had the potential to place other residents at risk for sexual abuse. Findings: 1. During an observation on 12/5/17 at 10:36 a.m., Resident 1 was awake and stated that on 12/3/17 (couldn't remember the time), Resident 2 told her that he wanted to pray for her family and that she went inside Resident 2's room. Resident 1 stated that Resident 2 entered the same room a few seconds after she entered Resident 2's room. Resident 1 stated that Resident 2 touched her breasts and took his pants off and that Resident 2 held her down on his bed and bit the left side of her neck. Resident 1 stated that she told Resident 2 to stop and that Resident 2 did not stop until she was able to free herself. Resident 1 stated that CNA 1 or other staff did not go inside the room to help her. During a concurrent interview, Resident 1 stated that she entered Resident 2's room because she thought that Resident 2 wanted to pray. Resident 1 stated that she did not feel safe around Resident 2. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE], and was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set ((MDS), a standardized assessment and care-screening tool), dated 9/12/17, indicated that the resident was cognitively intact (ability to think and reason) for daily decision making (ability to think and reason) and was independent for walking, dressing and required supervision for personal hygiene. A review of Resident 1's Interdisciplinary Progress Notes, dated 12/3/17, and timed at 4:45 p.m., indicated that Resident 1 reported Resident 2 of unwanted sexual actions. The Interdisciplinary Progress Notes indicated that Resident 1 alleged that Resident 2 threw Resident 1 on the bed, got on top of her, bit her neck, attempted to remove her upper clothing, masturbated in front of her, and Resident 1 was screaming stop. The Interdisciplinary Progress Notes indicated that Resident 1 had a slight dark reddish-brown discoloration in shape of two half circles to her left side of neck. A review of Resident 1's Incident Report dated 12/3/17, and timed at 4:45 p.m., indicated that the temporary measure initiated to prevent reoccurrence was to perhaps CNAs doing 1:1 monitoring should check whole room. A review of Resident 1's Incident Report dated 12/3/17, and timed 4:45 p.m., indicated that Resident 1 approached CNA 4 and alleged that Resident 2 was causing problems, and that CNA 4 told Resident 1 to tell CNA 1 yourself. 2. During an interview on 12/5/17 at 11:28 a.m., Resident 2 stated in Spanish that the holy death, told him to do bad things. A review of Resident 2's Admission Record, indicated resident was admitted to the facility on [DATE], and was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's Order Summary Report dated 10/24/17, indicated for Resident 2 to be on a one to one monitoring for safety precautions. A review of Resident 2's Order Summary Report dated 4/19/17, indicated to monitor resident and record episodes of assaultive behavior every shift. A review of Resident 2' Order Summary Report dated 6/23/17, indicated to monitor resident and record episodes of socially inappropriate behavior touching. A review of Resident 2's MDS dated [DATE] indicated that resident was cognitively intact for daily decision-making (ability to think and reason) and was independent for walking, dressing and required supervision for personal hygiene. The same MDS indicated that Resident 2 had physical behavioral symptoms directed toward others such as (hitting, kicking, pushing, scratching, abusing other sexually). A review of Resident 2's Socially Inappropriate Behavior dated 1/19/18, indicated that Resident 2 was placed on a one to one monitoring on 10/23/17 due to inappropriate sexual behaviors against other female residents at the facility. A review of Resident 2's Interdisciplinary Progress Notes dated 12/3/17 and timed at 9:40 p.m. indicated that Resident 2 told a police officer that Resident 1 was sitting down on his bed. During a telephone interview on 2/20/18 at 12:37 p.m., CNA 1 stated that on 12/3/17 during the 3-11 p.m., shift, she (CNA 1) was assigned to Resident 2 on a one to one supervision because Resident 2 had history of inappropriate sexual behaviors. CNA 1 stated that she (CNA 1) did not physically go inside Resident 2's room to physically check on Resident 2 and that she (CNA 1) was supposed to check inside Resident 2's room to ensure that Resident 2 was still alive, and to make sure he was ok. CNA 1 stated that it was her responsibility if something happened. CNA 1 stated that Resident 1 came out of Resident 2's room and that she (CNA 1) told Resident 1 that she could not be inside Resident 2's room. During an observation on 12/5/17 at 11:05 a.m., of the facility's video footage dated 12/3/17, the day of the incident, with the program manager. The following was observed and verified with the program manager as the events occurred: a. At 4:29.32 p.m., Resident 1 went inside a room. The program manager stated that Resident 1 went inside Resident 2's room. b. At 4:29.37 p.m., Resident 2 went inside his room (5 seconds after Resident 1). c. At 4:29 39 p.m., CNA 1 (identified by the program manager) following Resident 2. d. At 4:43.03 p.m., CNA 1 was sitting on the chair and was moving her arms up and Resident 1 was observed walking out of Resident 2's room. e. From 4:29.50 p.m., to 4:43.11 p.m., CNA 1 was sitting on a chair outside Resident 2's door. The program manager stated that CNA 1 was not observed physically going inside Resident 2's room. During an interview on 12/5/17 at 12:35 p.m., the Director of Staff Development (DSD) stated that CNA 1 was supposed to check inside Resident 2's room to monitor what Resident 2 was doing because Resident 2 was on a one to one monitoring. The DSD stated that a one to one monitoring required staff to know resident's locations at all times and what residents were doing for safety reasons. During an interview on 12/5/17 at 10:29 a.m., the facility's administrator (ADM) stated that Resident 2 had other episodes of inappropriate sexual behavior with other female residents in the facility and that Resident 2 required one to one monitoring twenty-four hours a day. 3. During a telephone interview on 2/20/18 at 2:40 p.m., the ADM stated that she failed to conclude the investigation regarding Resident 1's allegation of sexual assault and that she was supposed to finish the investigation within five days after the incident on 12/3/17 between Resident 1 and Resident 2. During a telephone interview, on 2/23/18, at 8:13 a.m., the ADM stated that she did not have an explanation for the inaccuracy in documentation in Resident 2's Document Location on 12/3/17 at 4:30 p.m. The ADM stated that the documentation did not reflect Resident 2's actual location on 12/3/17 at 4:30 p.m., because according to the facility's video footage, on 12/3/17 at 4:30 p.m., Resident 2 was inside his room not in the day room. A review of the facility's undated policy and procedure titled One to One Observation, indicated that the facility would provide an atmosphere that was safe and secure for residents. The policy indicated the assigned staff member to conduct the one to one supervision was required not to leave resident alone and that resident to be by the staff's side, no further than an arms distance at all times. A review of the facility's undated policy titled Staff Responsible for Coordinating Abuse Prevention Program Policies and Procedure, indicated that the administrator assumed the responsibility for the overall coordination and implementation of the facility's abuse prevention program policies and procedures.