Every finding on record at Laurel Park Behavioral Health Center

Based on interview and record review, the facility failed to ensure care plans (CP), for two of 20 sampled residents (Resident 6 and Resident 10), were updated and revised quarterly (occurring, done, once every three months, or four times a year) in accordance with the facility's policy and procedure (P&P) titled, Care Plan Comprehensive.These failures had the potential to result in unmet individualized needs for Resident 6 and Resident 10 and the potential to affect the resident's physical and psychosocial well-being.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 paranoid schizophrenia (severe mental health disorder where a person loses touch with reality, experiencing profound paranoia, fixed false beliefs, and hallucinations - most commonly hearing voices).During a review of Resident 6's History & Physical (H&P), dated 1/28/2026, the H&P indicated Resident 6 was alert x 4 (cognitively aware of four specific dimensions: person, place, time, and event).During a review of Resident 6's CP, revision date (updated) 2/9/2026, the CP indicated resident 6 may smoke with supervision per the smoking assessment. The CP did not indicate a quarterly update.During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated 5/7/2026, the MDS indicated Resident 6 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 6 was independent (the resident completes the activity by themselves with no assistance from a helper) with all personal needs.During a review of Resident 10's AR, the AR indicated Resident 10 was admitted to the facility on [DATE], with diagnoses that included schizophrenia [a long term severe mental disorder affecting how a person thinks, feels, and behaves, often causing them to lose touch with reality).During a review of Resident 10's CP, revision date 3/23/2025, the CP indicated Resident 10 may smoke with supervision per the smoking assessment, the CP did not indicate a quarterly update.During a review of Resident 10's H&P, dated 2/11/2026, the H&P indicated Resident 10 was alert x 4.During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 had severe cognitive impairment. The MDS indicated Resident 10 was independent with all personal needs.During an interview on 6/30/2026 at 3:50 pm with the Director of Nursing (DON), the DON stated CPs for Resident 6 and Resident 10 were not updated quarterly and the facility did not follow the P&P.During a review of facility's P&P titled, Care Plan Comprehensive, revised 8/25/2021, the P&P indicated, an individualized comprehensive care plan that includes measurable objectives and timetable to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident. The P&P indicated assessments of residents are ongoing, and care plans are reviewed and revised as information about the resident and the resident's condition change, at least quarterly.

Based on interview and record review, the facility failed to ensure, five of twenty sampled residents (Resident 5, 6, 7, 8, and 9), were evaluated quarterly for smoking in accordance with the facility's policy and procedure (P&P) titled, Smoking.This failure resulted in compromised safety and the potential to result in harm to Resident's 5, 6, 7, 8, and 9.Findings:During a review of Residents 5's admission Record (AR), the AR indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included Paranoid Schizophrenia (severe mental health disorder where a person loses touch with reality, experiencing profound paranoia, fixed false beliefs, and hallucinations - most commonly hearing voices).During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool), dated 4/9/2026, the MDS indicated Resident 5 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 6 was independent (the resident completes the activity by themselves with no assistance from a helper) with all functional abilities (personal needs).During a review of Resident 6's AR, the AR indicated Resident 6 was admitted to the facility on [DATE], with diagnoses including paranoid schizophrenia.During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated 5/7/2026, the MDS indicated Resident 6 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 6 was independent with all personal needs.During a review of Resident 7's AR, the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a long term severe mental disorder affecting how a person thinks, feels, and behaves, often causing them to lose touch with reality).During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 6 had intact cognition. The MDS indicated Resident 7 was independent with personal needs. During a review of Resident 8's AR, the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included schizophrenia.During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 had intact cognition. The MDS indicated Resident 8 was independent with all functional abilities (personal needs). During a review of Resident 9's AR, the AR indicated Resident 9 was admitted to the facility on [DATE] with diagnoses that included schizophrenia.During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 had intact cognition. The MDS indicated Resident 9 was independent with all functional abilities. During a review of the following Smoking Evaluations (SE), the SE indicated,a. Resident 5's latest SE was dated 11/1/2025.b. Resident 6's latest SE was dated 9/15/2025.c. Resident 7's latest SE was dated 1/17/2026.d. Resident 8's latest SE was dated 1/8/2026.e. Resident 9's latest SE was dated 3/26/2026.The SE indicated the following categories were evaluated in the SE: medical (does the resident use oxygen [a colorless gas essential to living organisms]?), cognitive (does the resident have poor memory? Is the resident unable to demonstrate the location of the designated smoking area? Does the resident have dementia?), behavior (unsafe smoking habits, sharing or selling cigarettes or smoking material), observation (Is the resident able to safely hold a cigarette? Does the resident have the ability to light a cigarette? Does the resident properly dispose of ashes or butts? Can the resident smoke safely without use of a smoking apron?).During an interview on 6/29/2026 at 4:15 pm, with Registered Nurse (RN) 1, RN 1 stated smoking evaluations should be completed every three months and as needed when there was a resident change in condition.During an interview on 06/30/2026 at 3:50 pm with the Director of Nursing (DON), the DON stated, SEs for Residents 5, 6, 7, 8, and 9 were past due and the SEs should be completed quarterly per the facility's P&P. The DON stated it was important to complete SEs for the residents to make sure residents who smoked were safe during the activity. The DON stated, the facility did not follow the P&P.During a review of facility's P&P titled, Smoking, revised 08/09/2022, the P&P indicated Purpose to provide a safe environment for residents, staff, and visitors. The P&P's policy indicated to accommodate residents who desire to smoke by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents. The P&P's policy indicated smoking whether it is traditional tobacco or herbs (does not include marijuana or its derivatives) smoked in cigarettes, pipes, cigars, or electronic cigarettes are governed by this policy. The P&P's policy indicated the licensed nurse will evaluate residents who express a desire to smoke, upon admission, quarterly, annually, significant change of condition identification, as needed, and present it to the Interdisciplinary Team for review.

Based on interview and record review, the facility failed to complete and transmit the discharge minimum data set (MDS, a standardized assessment and care-screening tool) assessment in a timely manner for one of one sampled residents (Resident 48) and failed to complete and transmit the annual MDS assessment in a timely manner for two of two sampled residents (Resident 20 and Resident 43) as required by the Centers for Medicare & Medicaid Services (CMS is a federal agency that manages health care programs in the United States) Resident Assessment Instrument (RAI, a tool used by nursing homes to assess the needs, strengths, and preferences of residents) manual.These deficient practices resulted in a late completion and transmission of the MDS assessment to CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system and had the potential to affect the facility's quality monitoring data for residents.a. During a review of Resident 20's admission Record, the admission Record indicated the facility admitted Resident 20 on 10/3/2019, with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thoughts), anemia (a condition where the body does not have enough red blood), and chronic kidney disease. During a review of Resident 20's History and Physical (H&P), dated 1/26/2025, the H&P indicated, Resident 20 was able to make needs known and make decisions. During a review of Resident 20's MDS annual comprehensive assessment, dated 9/17/2025, the MDS indicated Resident 20 had intact cognition (ability to think and understand). The MDS indicated Resident 20 was independent for personal hygiene, dressing, toileting and bathing. During a review of Resident 20's MDS History Report on 10/13/2025, MDS History Report indicated status Export Ready for Annual MDS with date of 9/17/2025. During a review of Resident 43's admission Record, the admission Record indicated the facility admitted Resident 43 on 10/2/2024, with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thoughts), essential hypertension (HTN-a high blood pressure), and hyperlipidemia (high cholesterol, an excess of lipids or fats in the blood). During a review of Resident 43's History and Physical (H&P), dated 1/25/2025, the H&P indicated, Resident 43 could not make own decisions but able to make needs known. During a review of Resident 43's MDS annual comprehensive assessment dated [DATE], the MDS indicated Resident 43 had intact cognition (ability to think and understand). The MDS indicated Resident 43 was independent for toileting, bathing and personal hygiene. During a review of Resident 43's MDS History Report on 10/13/2025, MDS History Report indicated status Export Ready for Annual MDS with date of 10/8/2025. During an interview on 11/13/2025 at 11:10 a.m., with the Assistant Director of Nursing (ADON), the ADON stated the MDS was exported once the Director of Nursing (DON) signed off. The ADON stated she was unsure whether the submission of the MDS was reported in Point Click Care (PCC, an electronic health care system). The ADON stated she needed to consult with their MDS consultant regarding the submission report. After multiple requests for MDS submission confirmation for Resident 20 and Resident 43, no reports were provided by the ADON and the DON. During an interview on 11/13/2025 at 11:33 a.m., with the DON, the DON stated Resident 20's annual comprehensive assessment was submitted late on 11/13/2025 but should have been submitted by 9/17/2025. The DON stated Resident 43's annual comprehensive assessment was missed, and was submitted on 11/13/2025 but should have been submitted on 10/8/2025. The DON stated timely MDS submission (within 14 days) was important to ensure CMS could confirm that Resident 20 and Resident 43 were appropriately assessed and that any changes in their care needs were identified and addressed. During a review of facility's policy and procedure (P&P), titled, Electronic Transmission of the MDS, dated 10/2023, the P&P indicated, All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records are completed and electronically encoded into our facility's MDS information system and transmitted to CMS' Internet Quality Findings: b. During a review of Resident 48's admission Record (AR), the AR indicated Resident 48 was admitted to the facility on [DATE] with diagnosis that included schizoaffective disorder (hallucinations and delusions, and/or depression) and hypertension (elevated blood pressure). During a review of a History and Physical (H&P) dated 10/22/24, the H&P indicated Resident 48 could not make decisions but can make needs known. During a review of Resident 48's Discharge Note (DN), dated 7/5/2025, the DN indicated that Resident 48 was discharged from the facility on 7/5/2025. During a concurrent review of the MDS 3.0 NH Final Validation Report and an interview with the Director of Nursing (DON) on 11/13/2025 at 11:24 am, a copy of the MDS 3.0 NH Final Validation Report indicated Resident 48's MDS was accepted, however, the DON stated, I don't have a copy of that document. During a review of a document titled, Point Click Care – MDS, the document indicated Resident 48's last MDS submission dated 7/4/2025 with the description: Quarterly During an interview and concurrent record review of Resident 48's paper and electronic chart, on 11/13/2025 at 11:10 am with the Assistant Director of Nursing (LVN 1), the MDS indicated Quarterly. LVN 1 stated LVN 1 submitted Resident 48's latest MDS under Quarterly as advised by the facility's consultant, dated 7/4/2025. LVN 1 stated Resident 48 was discharged from the facility on 7/5/2025, not 7/4/2025. During an interview with the DON on 11/13/2025 at 11:33 am, the DON stated it was important to ensure the State had the correct information regarding the residents. The MDS needed to be as accurate as possible – because if the resident status was different, it needed to be addressed and fixed. A review of the MDS RAI Version 3.0 Manual, Chapter 2: Assessment for the RAI dated 10/2024, indicated under Assessment Type/Item Set Discharge Assessment – return not anticipated; under the Assessment Submission Combination indicated May be combined with any OBRA or 5-Day AND must be combined with a Part A PPS Discharge if Medicare Part A.

Based on observation, interview and record review the facility failed to inform six of six sampled residents (Residents 10, Resident 22, Resident 28, Resident 33, Resident 35, and Resident 42) regarding the permanent discontinuation of coffee social during daily community breaks. This deficient practice resulted in limiting residents' ability to exercise choice in the residents' daily routine and ability to participate in preferred social activity which had the potential for psychosocial harm to the residents, and violation of the residents' right to determine their preferred activities. Findings: a. During a review of Resident 10's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 11/18/2024 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), constipation, and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 10's History and Physical (H&P) dated 11/20/2024, the H&P indicated Resident 10 cannot make own decisions but can make needs known. During a review of Resident 10's MDS Minimum Data Set (MDS - a resident assessment tool) dated 8/8/2025, indicated Resident 10's cognitive function was intact (alert, oriented and able to recall information).During an interview on 11/13/2025 at 9:05 a.m. with Resident 10 in the dining room, Resident 10 stated, coffee social relaxes me, I want to have our coffee social back. b. During a review of Resident 22's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 12/22/2005 with diagnoses including schizophrenia, type 2 diabetes mellitus, hypertension (HTN-high blood pressure), and hypothyroidism (thyroid gland doesn't make or release enough thyroid hormones). During a review of Resident 22's H&P dated 7/3/2025, the H&P indicated Resident 22 was alert and deaf but uses sign language (language where people communicate using hands and bodily gestures instead of their mouth). During a review of Resident 22's MDS dated [DATE], indicated Resident 22's cognitive function was intact (alert, oriented and able to recall information). During an interview on 11/13/2025 at 9:05 a.m. with Resident 22 in the dining room, Resident 22 stated, I like to have coffee social back, coffee makes me happy. c. During a review of Resident 28's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 6/26/2005 with diagnoses including schizoaffective disorder (a mental illness that is characterized by disturbances in thought and mood), constipation, and vitamin D deficiency (body lacks sufficient vitamin D). During a review of Resident 28's H&P dated 6/27/2025, the H&P indicated Resident 28 was alert, cooperative, and with appropriate judgement. During a review of Resident 28's MDS, dated [DATE], indicated Resident 28's cognitive function was intact (alert, oriented and able to recall information). During an interview on 11/13/2025 at 9:05 a.m. with Resident 28 in the dining room, Resident 28 stated, I felt sad when we couldn't have any more coffee social, because I like to socialize with others. d. During a review of Resident 33's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 6/7/2024 with diagnoses including schizophrenia, type 2 diabetes mellitus, and hypertension. During a review of Resident 33's H&P dated 10/22/2024, the H&P indicated Resident 33 cannot make own decisions but can make needs known. During a review of Resident 33's MDS, dated [DATE], indicated Resident 33's cognitive function was intact (alert, oriented and able to recall information). During an interview on 11/13/2025 at 9:05 a.m. with Resident 33 in the dining room, Resident 33 stated, coffee also relaxes me, I was mad when they took coffee social away. e. During a review of Resident 35's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 2/28/2025 with diagnoses including schizophrenia, cannabis dependence (marijuana use dependence), and circadian rhythm sleep disorder (sleep disorders that disrupt the body's internal 24-hour clock). During a review of Resident 35's H&P dated 2/28/2025, the H&P indicated Resident 33 cannot make own decisions but can make needs known. During a review of Resident 35's MDS, dated [DATE], indicated Resident 3's cognitive function was intact (alert, oriented and able to recall information). During an interview on 11/13/2025 at 9:05 a.m. with Resident 35 in the dining room, Resident 35 stated, It makes me upset, because I want to have coffee after I smoke. f. During a review of Resident 42's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 2/28/2025 with diagnoses including schizophrenia, deaf non-speaking, irregular menstruation (a condition where a person's menstruation vary significantly in frequency, duration, or flow), and hypothyroidism. During a review of Resident 42's H&P dated 10/22/2024, the H&P indicated Resident 42 cannot make own decisions, but can make own needs known. During a review of Resident 42's MDS, dated [DATE], indicated Resident 42's cognitive function was intact (alert, oriented and able to recall information). During an interview on 11/13/2025 at 9:05 a.m. with Resident 42 in the dining room, Resident 42 stated, I really like coffee, it calms me down, too. During an interview on 11/14/2025 at 8:35 a.m. with Food Service Supervisor (FSS), the FSS stated coffee social was from 9:30 to10:00 a.m. each day. The FSS stated coffee social had been part of the facility since he started at the facility three years ago. The FSS stated coffee social had not been in the regular calendar schedule for two months. The FSS stated residents complained about coffee socials at the resident council meeting. The FSS stated coffee social was removed, because coffee was not part of the residents' regular diet, and because the facility's administrator recommended the stop. The FSS stated residents' rights included having choices and preferences for foods and drinks, which were important for their quality of life and provided the residents' pleasure. During an interview on 11/14/2025 at 9:51 a.m. with the Director of Nursing (DON), the DON stated residents have not been happy about coffee social being taken away. The DON stated she was not aware the residents wanted coffee social back. The DON stated she did not have the authority to reinstate the coffee social. During a concurrent interview and record review on 11/14/2025 4:06 p.m. with Activity Director (AD), AD stated the coffee social was during community break, from 9:30 to10:00 a.m. and not documented as coffee social but well known as coffee social during community break. During a record review of the facility's activity schedule, indicated the daily community break aka coffee social listed as recurring activity at 9:30 to 10:00 a.m. There was no notation of reflecting cancellation, modification, temporary, or permanent suspension of the event. During a record review of the Resident Council Minutes, dated 9/14/25, indicated residents stated their concerns about coffee social. As indicated in the minutes, under Dietary, Resident 35 stated We would like coffee social back in the morning. The facility's response was Coffee social was removed to encouraged residents to attend breakfast. Socials are not required and will not be re-instated at this time. During a review of the facility's Policy and Procedure (P&P), titled Resident Rights, undated, the P&P indicated, .e. self-determination; f. communication with and access to people and services, both inside and outside the facility; g. exercise his or her rights as a resident of the facility.; h. be supported by the facility in exercising his or her rights.p. be informed of, and participate in his or her care planning and treatment. During a review of the facility's P&P, titled Activities and Social Services, undated, the P&P indicated, Residents shall have the right to choose the types of activities and social events in which they wish to participate as long as such activities do not interfere with the rights of other residents in the facility.

During an observation, interview, and record review, the facility failed to treat one of one sampled resident (Resident 1) with dignity and respect during a behavior outburst on 11/14/2025.This deficient practice had the potential to result in escalation of Resident 1's behavior and the potential for 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 8/1/2025, with diagnoses that included paranoid schizophrenia (a type of schizophrenia [mental disorder] associated with feelings of being persecuted or plotted against), depression (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities.During a review of Resident 1's care plan (CP), initiated 8/1/2025, the CP indicate Resident 1 had the potential for verbal outbursts, aggression towards staff and peers as evidenced by threatening staff and yelling at peers. The CP's interventions indicated for staff to approach Resident 1 in a calm and reassuring manner and for staff to prompt Resident 1 for appropriate behavior.During a review of Resident 1's History and Physical (H&P), date of service 8/4/2025, the H&P indicated Resident 1 is a [NAME]-Petris-Short Act (LPS - California law enacted in 1969 that regulates the involuntary commitment of individuals with mental health disorders. An LPS conservatorship is used only when the person needs mental health treatment but cannot or will not accept it voluntarily) conservatee. During an observation on 11/14/2025 at 2:05 PM, Resident 1 was walking down the hallway in front of the dining room and appeared agitated while yelling out. Counselor 1 stated Stop that if you do not want to be restrained. Resident 1 appeared angry and walked through the dining room door toward rooms 12 to 20. Resident 1 stated, Get out of my way or else I will hurt you as Resident 1 walked by the dining room.During an interview on 11/14/2025 at 2:44 PM, the Program Director (PD) stated when a resident (in general) exhibited aggression, staff (in general) needed to redirect the resident by asking the resident the following questions: What is bothering you? How can we help? Do you feel safe? The PD stated PD had to intervene because Resident 1 continued to be agitated. The PD stated after PD talked to Resident 1, the PD found out Resident 1 was bothered by the other residents inside Resident 1's room because they were talking in a different language. The PD stated the staff should not mention restraints during resident behavior outbursts, because that could worsen the residents' agitation. The PD stated the mention of restraints [during this incident] was not treating Resident 1 with dignity and respect. The PD stated Resident 1 needed praise and reassurance to help calm Resident 1.During a review of the facility's Policy and Procedure (P&P) titled Quality of Life - Dignity, dated February 2020, the P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. The P&P indicated residents are treated with dignity and respect at tall times and staff were expected to treat cognitively impaired residents with dignity and sensitivity for example:a. Addressing the underlying motives or root causes for behavior; andb. Not challenging or contradicting the resident's beliefs or statements.

Based on observation, interview, and record review, the facility failed to maintain residents' rooms in a safe, well-kept, and homelike condition when two of three resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) were observed with missing or chipped floor tiles, chipped paint and an accumulation of brown/blackish substance along the walls leading into the restroom. This deficient practice had the potential to exposing residents to an environment that was unclean, and negatively impacting residents' comfort, safety, and quality of life.Findings:During an observation on 11/14/2025 at 2:16 p.m., two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) were observed with chipped, missing floor tile, chipped paint on the wall and dark brown/blackish substance along the wall leading to the restroom. During an interview on 11/14/2025 at 2:21 p.m., with Resident 43, Resident 43 stated the appearance of their room lessened the homelike environment and made him feel uncomfortable.During an interview on 11/14/2025 at 2:31 p.m., with Maintenance Supervisor (MS), the MS stated the importance of maintaining a homelike environment for residents, because the facility served as home for residents. The MS stated resident rooms with missing tiles, chipped paint and dirt accumulation in the residents' rooms were unacceptable.During an interview on 11/14/2025 at 2:33 p.m., with Administrator (ADM), the ADM stated chipped paint and accumulated dirt on resident room was not acceptable and not a homelike environment. The ADM stated the importance of providing residents with a homelike environment that reflects the comforts and conditions of a true home.During a review of facility's policy and procedure (P&P), titled, Homelike Environment, dated 2/2021, the P&P indicated, The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: clean, sanitary and orderly environment .

Based on interview and record review, the facility failed to develop and implement an individualized person-centered care plan for pain for one of one sampled resident (Resident 23) who had a resident-to-resident altercation and experienced pain on 11/12/2025. This failure had the potential for Resident 23 not to receive the necessary care and services for Resident 23's pain and the had the potential to affect the resident's physical and mental well-being.Findings:During a review of Resident 23's admission Record (AR), the AR indicated Resident 23 was admitted to the facility on [DATE] with diagnosis including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and obesity (overweight).During a review of Resident 23's History and Physical (H&P), dated 10/22/2024, the H&P indicated Resident 23 could not make decisions but can make needs known. During a review of Resident 23's Minimum Data Set (MDS, a Resident Assessment) dated 10/15/2025, the MDS indicated Resident 23 was cognitively intact, Resident 23 had clear speech and had the ability to understand and be understood by others. During a review of Resident 23's Situation, Background, Assessment, and Recommendation Communication Form (SBAR), dated 11/6/2025 at 8:00 pm, the SBAR indicated the resident hair was pulled by another resident during an altercation.During a review of Resident 23's SBAR, dated 11/7/2025 at 3:00 pm, the SBAR indicated the resident had scratches on the inner left arm and reported new pain above the left eye and left lower leg. During a review of Resident 23's Medication Administration Record (MAR), for November 2025, the MAR indicated pain medication was administered to Resident 23 on 11/8/2025 and 11/9/2025.During an interview with Resident 23, on 11/12/1025 at 10:48 am, Resident 23 stated, I got into a fight with another resident and got hit in the head and pulling my hair. Resident 23 stated my head and my leg were hurting. Resident 23 stated the resident's head and leg started to hurt and he received medication for the pain.During an interview and concurrent record review with Medical Records Director (MRD), on 11/13/2025 at 3:04 pm, Resident 23's paper and electronic chart were reviewed. There were no care plan for pain on the paper and electronic chart. The MRD stated the MRD could not find nor did Resident 23 have a care plan for pain. During an interview and record review of Resident 23's chart, with the Director of Nursing (DON), on 11/14/2025 at 10:07 am, the DON stated Resident 23 did not have a care plan that addressed Resident 23's pain. The DON stated care plans were important to shape the way we (facility) were to take care of the residents. During a review of the facility's policy titled, Care Plan - Base line, effective 8/25/2021, the policy indicated a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care shall be developed and implemented for each resident .

Based on observation, interview, and record review, Licensed Vocational Nurse 2 (LVN 2) failed to follow instructions for administering Omeprazole (medication to treat certain conditions where there is too much acid in the stomach) before meals as ordered for one of six sampled residents (Resident 12). This deficient practice had the potential to affect the effectiveness of the medication for Resident 12.Findings: During a review of Resident 12's admission Record (AR), the AR indicated the facility admitted Resident 12 on 10/1/2018, with diagnoses that included paranoid schizophrenia (a type of mental disorder associated with feelings of being persecuted or plotted against) and gastroesophageal reflux disease (GERD - stomach acid keeps coming back up into the throat or chest) without esophagitis (inflammation or irritation of the esophagus [the tube that carries food from the mouth to the stomach]). During a review of Resident 12's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/8/2025, the MDS indicated Resident 12 had no cognitive impairment. The MDS indicated Resident 12 was independent with all activities of daily living. During an observation on 11/14/2025 at 8:17 AM, Licensed Vocational Nurse 2 prepared Resident 12's 9:00 AM medications that included Omeprazole 20 milligrams (mg- unit of measurement). The label on the blister pack (a form of tamper-evident packaging where an individual pushes individually sealed tablets through the foil in order to take the medication) indicated to administer Omeprazole 30 - 60 minutes before meals. During an observation on 11/14/2025 at 8:59 AM, Resident 12 approached the nursing station window for Resident 12's medications. LVN 2 administered seven medications to Resident 12 including Omeprazole. During a concurrent record review and interview on 11/14/2025 at 1:35 PM, Resident 12's blister pack and Medication Review Report (MRR) was reviewed with LVN 2. Both the blister pack and the MRR indicated to administer Omeprazole 20 mg, 30 - 60 minutes before meals to Resident 12. LVN 2 stated Omeprazole needed to be administered before meals for the medication to be absorbed and to be more effective. LVN 2 stated the time of administration for Omeprazole needed to be changed before meals. During a review of Resident 12's MRR, active as of November 14, 2025. the MRR indicated an order for Omeprazole capsule Delayed Release, to give 20 mg by mouth, one-time a day 30 to 60 minutes before food. During a review of Resident 12's Medication Administration Record (MAR), the MAR indicated Omeprazole was scheduled to be administered at 9:00 AM. During a review of the facility's Policy and Procedure (P&P) titled Medication Administration - General Guideline dated 10/207, the P&P indicated medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after), except before or after meal orders, which are administered based on mealtimes. The P&P indicated medications are administered in accordance with written orders of the attending physician. During a review of an undated article by National Library of Medicine (NLM -the world's largest biomedical library and a leader in health information research), the article indicated to administer Proton Pump Inhibitors (PPI - e.g. Omeprazole) better under fasting conditions; more effective administration could improve patient outcomes.

Based on observation, interview, and record review, the facility failed to ensure 16 out of 19 resident rooms (Rooms 3, 4, 5, 6, 7, 8, 9, 10,12, 14, 16, 17, 20, 21, 22, 23) met the minimum requirement of 80 square feet (sq. ft., unit of measurement) per resident in multiple resident rooms. Nine rooms had two beds per room and seven rooms had three beds per room. This deficient practice had the potential to impact on residents' safety and the ability of staff to provide safe nursing care and privacy to the residents Findings: During a review of the facility's Client Accommodation Analysis (CAA), the CAA indicated the following rooms were less than 80 sq. ft. per resident: Room: No. of Beds: Room Size: Floor Area:3 2 137.5 x 159.5. 156 sq. ft.4 2 141 x 159.5 156 sq. ft.5 2 141 x 159.5 156 sq. ft.6 2 137 x 159.5 156 sq. ft.7 3 186.5 x 159.5 221 sq. ft.8 3 158 x 216 234 sq. ft.9 2 159.5 x 130 143 sq. ft.10 3 158 x 203.5 221 sq. ft.12 3 223.5 x 144.5 228 sq. ft.14 3 222.5 x 137.5 222 sq. ft.16 3 151 x 221.5 228 sq. ft.17 3 152.5 x 221.5 235 sq. ft20 2 120.5 x 182.5 150 sq. ft.21 2 121 x 182 150 sq. ft.22 2 119.5 x 182.5 150 sq. ft.23 2 121.5 x 182 150 sq. ft. During a review of the facility's room waiver request letter dated 11/12/2025, the letter indicated there was adequate space for nursing care and the health and safety of residents occupying these rooms were not in jeopardy. The letter indicated the requested rooms were in accordance with the special needs of the residents and did not have any adverse effects on the resident's health and safety or impeded the ability of any residents in the rooms to attain their highest practicable well-being. During an observation on 11/12/2025 to 11/14/2025, Rooms 3, 4, 5, 6, 7, 8, 9, 10, 12, 14, 16, 17, 20, 21, 22, and 23 were uncluttered and residents moved freely in their rooms. There were no residents who expressed any concern about the room sizes during interviews and during the Resident Council Meeting. During an interview on 11/14/2025 at 3:20 PM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated LVN 4 did not have any complaints from the residents regarding the size of the rooms. LVN 4 stated the residents have their own corridors and if they want privacy in their rooms, they have blinds that they can pull to close it. LVN 4 stated the patients also have their own closet in the room to place their clothes.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 1), who was on a [NAME]-Petris-Short (LPS, a California law enacted in 1969 that regulates the involuntary commitment of individuals with mental health disorders) conservatorship (a legal process where a court appoints a person to make certain decisions for an individual who was deemed gravely disabled [unable to provide for basic needs] due to a mental health disorder), did not elope (the act of leaving a facility unsupervised and without prior authorization) from a secure facility (a building, institution, or location designed and operated with features that physically restrict unauthorized access or the movement of individuals to prevent people from leaving or others from entering) on 7/28/2025 at 9:27 PM by failing to ensure,1. Certified Nursing Assistant (CNA) 1 reported to Licensed Vocational Nurse (LVN) 1 (charge nurse), CNA 1 found Resident 1, unsupervised, past a locked gate and in the facility's parking lot on 7/28/2025 at 9 PM (the parking lot was an unauthorized area to residents at 9 PM) as indicated in the facility's protocol titled, Supervision Level Protocol and Guidelines.2. Adequate supervision was provided to Resident 1 and failing to ensure Resident was placed on one-to-one supervision (1-1 supervision, one staff supervises one resident) on 7/28/2025 at 9 PM, after Resident 1 was found in the parking lot as indicated in the facility's protocol titled, Supervision Level Protocol and Guidelines, the facility's Policy and Procedures (P&P) titled, Elopements, and Safety of Residents.These failures resulted in Resident 1's elopement on 7/28/2025 at 9:27 PM, Resident 1 was not found until 7/29/2025 at 11 PM. Resident 1 was transferred to the General Acute Care Hospital (GACH) on 7/30/2025 at 10:27 AM for an evaluation. Resident 1 tested positive for amphetamines (a class of powerful and addictive stimulant drugs that speed up the central nervous system [the body's processing center: brain and spinal cord], can significantly affect safety by impairing judgement and physical coordination) at the GACH. Resident 1 was at risk for serious harm and injury when Resident 1 tested positive for amphetamines and did not receive regularly scheduled psychotropic, (prescription drugs that affect brain activity and are used to treat mental health conditions) anticonvulsant (prescription drugs used to prevent or treat seizures [sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness]and mood disorders), and anticholinergic (prescription drugs used to treat and regulate bodily functions) medications.On 8/12/2025 at 4:35 PM, while onsite at the facility, the California Department of Public Health (CDPH, 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) situation. The IJ was called in the presence of the Administrator (ADM), the Director of Nursing (DON), and the Program Director (PD) due to the facility's failure to ensure Resident 1 did not elope from the facility on 7/28/2025.On 8/13/2025 at 3:30 PM, the ADM provided an acceptable IJ Removal Plan (IJRP, a detailed plan that includes interventions to immediately correct the deficient practices in the IJ). While onsite at the facility, the surveyor verified and confirmed the facility's full implementation of the IJRP through observations, interviews, and record review, and determined the IJ situation regarding Resident 1's elopement was no longer present. The surveyor removed the IJ on 8/13/2025 at 6 PM in the presence of the ADM, the DON, the PD, the [NAME] President of Operations (VPO), the Behavioral Health Consultant (BHC), the Medical Director for Behavioral Health Services (MD), and the Clinical Resource Nurse.The acceptable IJRP included the following summarized actions:A. Immediate Corrective Action:1. On 7/28/2025 @ 10:15 PM, LVN 1 noticed resident 1 missing and immediately initiated the Elopement protocol (procedures implemented in the healthcare setting to prevent and manage resident elopement) by conducting a resident headcount and alerted all staff to search for Resident 1 inside and outside the facility. Resident 1 was not located inside the facility and staff started driving around the area.2. On 7/28/2025 @ 10:25 PM, LVN 1 called the police department (PD) to make a missing persons' report. The PD came to the facility, met with the ADM who provided a description of Resident 1, Resident 1's face sheet, medical history, current medication regimen, a picture, and camera footage of Resident 1 [to the PD]. 3. On 7/28/2025 at 11:30 PM, the ADM and LVN 2 contacted Resident 1's family member (FM) 1 regarding Resident 1's elopement. The ADM gave the next of kin the ADM's cellphone number and requested FM 1 to contact the ADM if Resident 1 got in touch with FM 1 or if Resident 1 showed up at FM 1's house.4. On 7/29/2025 the ADM suspended CNA 1 pending the investigation of the incident regarding CNA 1 failing to report to LVN 1 that Resident 1 was in the parking lot unsupervised [no adequate staff supervision, can lead to potential harm, injury, or exposure to danger].5. On 7/29/2025 at 10 PM, LVN 3 searched for the area, at a local gas station, LVN 3 spoke to the gas station attendant and the attendant stated he had seen Resident 1 at a homeless encampment [located] across the street from the gas station. LVN 3 recognized Resident 1 and when called Resident 1's name, Resident 1 ran away from LVN 3 but LVN 3 provided crisis communication [structured process for managing high-stress situations involving patients, their families, and staff by delivering clear, empathetic, and timely messages to de-escalate emotions and facilitate problem-solving]. Resident 1 complied with LVN 3's verbal redirection and voluntarily returned to the facility.6. On 7/29/2025 at 11 PM, LVN 3 placed Resident 1 in a safe and appropriate environment by putting Resident 1 on 1-1 supervision for personal safety. Resident 1 was assessed, and no injuries were found. Resident 1 was provided with food, shower, and clean clothing. LVN 3 initiated a Change of Condition (COC, a sudden clinically important deviation in the resident's health or functioning that requires further assessments and interventions). 7. On 7/30/2025 LVN 3 contacted the physician (Medical Doctor [MD] 2) who ordered Resident 1 to be transferred to the GACH to obtain medical clearance.8. On 7/30/2025, 3 staff accompanied Resident 1 to the emergency room for evaluation. Resident 1 returned to the facility on 7/29/2025 at [11] PM.9. On 07/30/2025 at 3:07 PM an Interdisciplinary Team (IDT, a team of health care professionals who work together to establish plans of care for residents) was conducted to discuss appropriate interventions and plan of care for Resident 1. The IDT determined Resident 1 required a more secure environment and contacted LA County DMH (Department of Mental Health) liaison to request a transfer to a more secure [place].10. On 8/12/2025, the Clinical Resource Nurse, [NAME] President of Operations, the DON, and the ADM developed the Protocol for Supervision of Residents at Risk for Elopement. The Protocol provides guidelines to staff for increased supervision and support of residents at risk for Elopement.B. Identification of other residents potentially affected:1.On 8/12/2025, the DON conducted a re-evaluation of all 43 residents in the facility to determine the Risk of Elopement. 43 residents had the potential to be affected by the alleged deficient practice. 1 of 43 residents (Resident 2) was identified as being at risk for elopement, the protocol for residents with high-risk for elopement was initiated for Resident 2. Resident 2's Care Plan (CP) for AWOL [absent without leave or permission]/ /Elopement was revised and resolved as appropriate.C. Measures put in place to sustain compliance: 1. On 8/12/2025 the Director of Staff Development (DSD) initiated in-service to facility staff (Registered Nurses [RNs], LVNs, CNAs, Program counselors, Behavioral specialists, and the SSD) on the P&Ps titled, Increased Level of Supervision, Elopement, Protocol for Supervision of Residents at Risk for Elopement, and Head Count of Residents. The following [staff] completed the in-services: LVN - 13, CNA - 15, RN - 3, Primary Counselor - 7, Behavior Specialist - 3.2. On 8/12/2025, the DSD began to validate the competency/posttest of facility staff with the facility's P&Ps Increased Level of Supervision, Elopement, and Head Count of Residents, through a post-test to 5 random facility staff weekly for 3 months or until substantial compliance is achieved. Starting 8/12/25, the DSD is expected to report the monthly findings at the Quality Assessment and Assurance Meeting (QAA, a committee that meets quarterly to develop and implement appropriate plans of action to correct identified quality deficiencies). The following staff have received the in-services and completed post- tests: 12 of 19 LVNs, 16 of 22 CNAs, 4 of 7 RNs, 6 of 8 Primary Counselors, and 3 of 4 Behavior Specialist.3. The facility staff who have not been in-serviced due to leave of absence or on vacation have been scheduled to be in-serviced prior to the start of their next scheduled shift.4. On 8/12/2025 at approximately 8 PM, the DSD was informed by the ADM that all new staff are required to take the competency skills posttest on Elopement, Head Count, and Increased level Supervision. The DSD/designee was informed by the ADM that all newly hired facility staff should receive the skills competency on P&P on Elopement, Head Count, and Increased Level of Supervision as part of the orientation process.5. On 8/12/2025 at 9 PM, the DSD/designee was informed by the ADM to audit the competency skills/posttests starting 08/13/25 will audit once weekly for 4 weeks, once monthly for two months until 11/10/25 and then quarterly.6. On 8/13/2025 at 11 AM, a camera was installed in the administration building that will provide surveillance over the parking lot area. A sensor flood light was also installed on the west side of the garage building that turns on when motion is detected along with a loud alarm to alert any movement in the area.7. On 8/13/2025 the assigned CNA floater will be responsible for watching/looking over the front patio area to ensure residents are not near the exit gates or near the wall barrier. CNA is instructed to alert additional staff if needed.D. Monitoring Performance:1. Starting 8/12/2025, the DON/designee is expected to report findings related to results from the elopement assessment to the QAA committee for further recommendations monthly for 3 months or until substantial compliance is achieved.2. Starting 8/12/2025, the DSD is expected to report findings based on the P&P on Elopement, Head Count, and Increased Level of Supervision, post-test from the facility staff to the QAA committee for further recommendations monthly for 3 months or until substantial compliance is achieved.3. Starting 8/12/2025, the DSD/designee is expected to report findings of new hire completion of the in-service on the P&Ps on Elopement, Head Count, and Increased Level of Supervision, and the skills competency/posttest to the QAA committee for further recommendations monthly for 3 months or until substantial compliance is achieved.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/7/2024 with diagnoses including paranoid schizophrenia (a mental illness characterized by hallucinations [false perception of objects or events involving the senses] and delusions, leading to a distorted perception of reality) and diseases of the musculoskeletal system and connective tissue (illnesses that affect the parts of the body that aid in movement and support). The AR indicated Resident 1's Responsible Party (RP) was a conservator (a public official appointed by the court to care for an individual who was deemed unable to care for his/herself).During a review of Resident 1's History and Physical (H&P), dated 11/8/2024, the H&P indicated Resident 1 did not have the capacity to make decisions.During a review of Resident 1's CP, initiated 11/7/2024, the CP indicated, Resident [1] is at risk for elopement related to being in an open placement setting. The CP's goal indicated, [Resident 1] will maintain 0 [zero] AWOL gestures (actions or behaviors that indicate someone is absent without permission) by [the] next review.During a review of Resident 1's Physician Progress Note (PN) dated 7/24/2025, the progress note indicated Resident 1 was an LPS conservatee (a person deemed incapable of managing his/her own affairs by a court and placed under the care of a conservator).During a review of Resident 1's PN, dated 7/24/2025, timed at 10:20 PM, the PN indicated, at approximately 7:10 p.m., on 7/24.2025, [Resident 1] was seen by staff jumping [the] exterior wall near [the] gate [ an unauthorized area]. The PN indicated [Resident 1] appeared to be moving towards [the] facility trailer and facility staff (unidentified) were able to redirect [Resident 1] and brought [Resident 1] back to [a] secure area of facility. The PN indicated [Resident 1] was placed on [every]15 [minute] monitoring.During a review of Resident 1's PN- Interdisciplinary Team Meeting (IDT, a team of health care professions who work together to establish plans of care for residents) notes, dated 7/29/2025, timed at 3:09 PM, the notes indicated, On 7/28/2025.at [9 pm] [Resident 1] took [Resident 1's] last medication for the day, then [CNA 1] was walking to the parking lot and noticed [Resident 1] was in an unauthorized area. At [10:15 PM LVN 1] was not able to account for [Resident 1] while [LVN 1] was doing rounds. At [10:26 PM] via video footage, [Resident 1] was seen leaving [the] facility.During a review of Resident 1's PN- Change of Condition (COC, a sudden clinically important deviation in the resident's health or functioning that requires further assessments and interventions), dated 7/30/2025, timed at 1:52 AM, the PN-COC indicated, [Resident 1] was returned to the facility by [LVN 2] post AWOL.[Resident 1] had redness on bilateral eyes and states to [LVN 2] that [Resident 1] smoked something earlier but [Resident 1] was fine now.During a review of Resident 1's Physician Order (PO), dated 7/30/2025, timed at 9:11 AM, the PO indicated, May send [Resident 1] to [GACH] for further evaluation and treatment [related to] safety one time only for 1 day [manifested by] AWOL.During a review of Resident 1's GACH records, titled Emergency Trauma Documentation, dated 7/30/2025, the GACH record indicated, .The patient does confess to methamphetamine (a highly addictive lab-made stimulant that affects the central nervous, users are at high risk for psychosis [a state of detachment from reality that is a major safety hazard]) and alcohol use. The caregivers (facility staff who accompanied Resident 1 to the GACH) stated that the patient [Resident 1] jumped a large wall to elope from the facility. highly suspicious of schizophrenia and methamphetamine abuse given history of taking and clinical exam findings. The record indicated Resident 1's toxicology (a test that analyzes urine or blood to determine the presence of drugs, alcohol, or other substances) notable for amphetamines.During a review of Resident 1's GACH Toxicology report, dated 7/30/2025, the report indicated amphetamines were detected in Resident 1's urine.During a review of Resident 1's Order Summary Report (OSR), dated active as of 8/13/2025, the OSR indicated Resident 1 had the following physician orders:1. Valproic acid (medication used to treat certain types of seizures or used as a mood stabilizer) 750 milligrams (mg, unit of measurement) administered by mouth at bedtime for irritable affect (a state of being easily annoyed, frustrated, or provoked to anger) related to paranoid schizophrenia, start date of 11/11/2024.2. Zyprexa (medication used to treat certain mental disorders including paranoid schizophrenia) 15 mg administered by mouth two times a day for withdrawn behavior related to paranoid schizophrenia, start date of 11/11/2024.3. Haloperidol (medication used to treat certain mental disorders including paranoid schizophrenia) 15 mg administered by mouth in the morning and at bedtime manifested by responding to internal stimuli (RTIS-reacting to changes or signals originating within the body) related to paranoid schizophrenia, start date of 12/12/2024.4. Lexapro (medication used to treat anxiety [excessive and persistent worry, fear, and nervousness] and depression [a mental health disorder characterized by sadness, loss of interest, and other symptoms that impact daily life]) 5 mg administered by mouth one time a day for feelings of sadness and withdrawn behavior (a behavior characterized by isolating oneself and avoiding social interactions) related to paranoid schizophrenia, start date of 4/12/2025.5. Benztropine Mesylate (medication used to manage extrapyramidal symptoms [involuntary movements, tremors, and muscle stiffness] caused by antipsychotic medications) one mg administered by mouth at bedtime for tremors and stiffness of muscles, start date of 7/25/2025.The active orders did not indicate an order for 1-1 supervision for Resident 1.During a review of Resident 1's Medication Administration Record (MAR), dated July 2025, the MAR indicated:1. Resident 1 did not receive the 9 PM dose of Benztropine Mesylate 1 mg on 7/29/2025.2. Resident 1 did not receive the 11 AM and 9 PM dose of Haloperidol 15 mg on 7/29/2025.3. Resident 1 did not receive the 7 AM dose of Lexapro 5 mg on 7/29/2025.4. Resident 1 did not receive the 9 PM dose of Valproic Acid 750 mg on 7/29/2025.5. Resident 1 did not receive the 12 PM and 9 PM dose of Zyprexa 15 mg on 7/29/2025.During a review of Resident 1's rounding report (a visual confirmation of Resident 1's location) titled General Resident Supervision Rounds and Area Safety/Security Inspection Rounds, dated 7/28/2025, the rounding report indicated Resident 1 was observed hourly on 7/28/2025 from 12 AM to 10 PM.During a concurrent observation of the facility's surveillance video and interview on 8/12/2025 at 11:10 AM, with the ADM, the facility's surveillance video indicated that on 7/28/2025 at 9:27 PM Resident 1 moved and wheeled a trash can to the facility's locked gate. The video indicated Resident 1 climbed onto the wheeled trash can, climbed over the locked gate, and eloped from the facility. The ADM stated Resident 1 climbed over the locked gate and eloped from the facility. The ADM stated Resident 1 was found at a homeless encampment on 7/29/2025 by LVN 2. The ADM stated Resident 1 was returned to the facility around 11 PM on 7/29/2025.During a telephone interview on 8/12/2025 at 12:30 PM with CNA 1, CNA 1 stated CNA 1 saw Resident 1 in the parking lot around 9 PM on 7/28/2025. CNA 1 stated residents (in general) were not allowed in the parking lot area without staff supervision. CNA 1 stated Resident 1 went through a locked gate to get into the parking lot. CNA 1 stated Resident 1 tried to hide from CNA 1 under a tree and CNA 1 stated CNA 1 asked Resident 1 how Resident 1 had made it to the parking lot past the locked gate. CNA 1 stated Resident 1 refused to answer. CNA 1 stated CNA 1 returned Resident 1 to Resident 1's room but did not report Resident 1 was found in an unauthorized area [parking lot] to other staff members including the assigned charge nurse (LVN 1).During an interview on 8/12/2025 at 4:44 PM with LVN 1, LVN 1 stated Resident 1 was on hourly supervision on 7/28/2025. LVN 1 stated LVN 1 was doing rounds (structured regular visits by staff to resident rooms to check on the resident's well-being, comfort, needs, and safety) on 7/28/2025 at 10:15 PM and LVN 1 couldn't find Resident 1. LVN 1 stated LVN 1 was unaware Resident 1 was found unsupervised in the parking lot earlier that evening [on 7/28/2015 at 9 PM].During an interview on 8/13/2025 at 5:45 PM with the ADM, the ADM stated the facility's parking lot area was an unauthorized area to all residents [due to the facility being a secure facility]. The ADM stated when Resident 1 was found in the parking lot on 7/28/2025 at 9 PM and Resident 1's behavior of being in an unauthorized area, CNA 1 needed to report the incident to the charge nurse because Resident 1's behavior indicated Resident 1 had a desire to elope from the facility. The ADM stated Resident 1 should have been placed on 1-1 supervision, on 7/28/2025, per the facility's increased level of supervision protocol.During a review of the facility's P&P titled, Safety of Residents, effective 6/27/2022, the P&P's purpose indicated, To provide a safe environment for residents.Upon admission, residents will be monitored for behavioral triggers including, but not limited to:.Increased pacing or wandering.Response to unsafe behavior: If a resident's behavior becomes.unmanageable in a way that compromises his or her safety. the Charge Nurse and the [Director of Nursing Services] DNS are notified immediately. The Charge Nurse will: .Maintain 1-1 supervision of the resident until the behavior has subsided.During a review of the facility's P&P titled, Elopements, revised 2/21/2025, the P&P indicated, The residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit), or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization . and/or any necessary supervision to do so.The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary.The effectiveness of interventions will be evaluated, and changes will be made as needed.During a review of the facility's undated Protocol titled, Supervision Level Protocol and Guidelines, the protocol indicated, When residents are under general supervision, they are expected to stay in the building except when following standard policies for leaving (e.g. therapeutic pass (authorized outing), outings, appointments, and hospital stays). A staff member entering/exiting a secured resident area is responsible for detecting any resident who attempts to leave without permission. The staff member should verbally redirect the resident away from the area and alert other staff members for assistance so they can intervene to keep the residents safe. The protocol indicated, Increased supervision is provided to.residents whose .behavior .indicated an increased level of risk. The protocol indicated residents required 1-1 supervision when residents were actively seeking to elope or required constant observation. The protocol indicated 1-1 supervision is an emergency intervention that may be implemented by charge nurses or RNs with a doctor's order. The protocol indicated that a resident on 1-1 supervision will have dedicated staff assigned to have visual contact with the resident at all times, the assigned staff will have no other duties besides the 1 to 1 observation of the resident. The protocol's guidelines indicated a resident will be placed 1 to 1 supervision per doctor's orders for a maximum of 72 hours. The protocol indicated the IDT will reevaluate the necessity of continuing this level of supervision.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) was free from physical abuse when on 6/14/2025 Resident 2 shoved Resident 1. This failure resulted in physical abuse to Resident 1 and had the potential to result in psychosocial harm and injury to Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/7/2024 with a diagnosis that included paranoid schizophrenia (a mental illness characterized by hallucinations [false perception of objects or events involving the senses] and delusions, leading to a distorted perception of reality). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/15/2025, the MDS indicated Resident1's cognitive (the ability to think and process information) skills for daily decision making were intact. The MDS indicated Resident 1 was independent (the resident completes the activity by themselves with no assistance from a helper) with self-care (activities including eating, hygiene, and dressing) and mobility (walking, lying, and standing). During a review of Resident 1's Interdisciplinary Care Conference Note, dated 6/17/2025, the note indicated Resident 1 reported to staff Resident 1 was shoved by a male peer [Resident 2] in the hallway on 6/14/2025. The note indicated there was a history of boundary issues between Resident 1 and Resident 2. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 4/6/2023 with diagnosis including schizophrenia (a mental illness characterized by disturbances in thought) and generalized anxiety disorder (a mental illness characterized by excessive, persistent, and irrational worry or fear that can interfere with daily life). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making were intact. The MDS indicated Resident 2 was independent with self-care and mobility. During a review of Resident 2's Care Plan (CP), the CP indicated Resident 2 exhibited inappropriate physical boundaries with male peer [Resident 1] engaging in play fighting, dated 6/14/2025, the CP indicated, Staff will support resident with identifying and implementing appropriate physical boundaries with peers . During an interview on 6/17/2025 at 12:20 pm with Behavioral Health Counselor (BHC) 1, BHC 1 stated, on 6/14/2025 in the morning (no time recall), Resident 1 approached BHC 1 and made the BHC 1 aware Resident 2 pushed Resident 1 in the hallway. BHC 1 stated BHC 1 approached Resident 2 and asked Resident 2 about the incident. BHC 1 stated Resident 2 told BHC 1 Resident 1 made inappropriate comments and entered Resident 2's room without permission. BHC 1 stated Resident 1 and Resident 2 had a history of giving each other a hard time. BHC 1 stated it was the policy of the facility to report this type of [physical] abuse immediately. During an interview on 6/17/2025 at 12:56 pm with Resident 1, Resident 1 stated the morning of 6/14/2025 Resident 1 and Resident 2 were talking about arcade games in the hallway when Resident 2 shoved Resident 1. Resident 1 stated Resident 2 placed Resident 2's palms on Resident 1's chest and shoved Resident 1. Resident 1 stated, He almost knocked me to the ground, but I didn't fall. Resident 1 stated Resident 1 didn't know why Resident 2 pushed Resident 1 but Resident 1 was upset after being shoved by Resident 2. During an interview on 6/17/2025 at 1:15 pm with Resident 2, Resident 2 stated during the morning of 6/14/2025 Resident 2 and Resident 1 were horseplaying (play that is physically rough) in the hallway. Resident 2 stated Resident 2 shoved Resident 1 in the chest after Resident 2 became upset with Resident 1 because Resident 1 didn't know how to play well. During an interview on 6/17/2025 at 1:30 pm, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 6/14/2025, BHC 1 told LVN 1 Resident 2 shoved Resident 1. LVN 1 stated Resident 2 admitted to shoving Resident 1 on the chest. LVN 1 stated physical abuse could result in bodily harm or may cause Resident 1 to become withdrawn (a condition where an individual tends to distance themselves from social interactions, both physically and emotionally). During an interview on 6/17/2025 at 2:45 pm with the Administration (ADM), the ADM stated the ADM is the abuse coordinator for the facility. The ADM stated it is the policy of the facility to prevent physical abuse [to residents]. The ADM stated that when a resident shoved another resident it was physical abuse. During a review of the facility's Policy and Procedure (P&P) titled, Abuse Prohibition, dated 2/23/2021, the P&P indicated, Healthcare Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Physical abuse includes hitting, slapping, pinching, kicking, etc

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received treatment and care in accordance with the physician's order for orthostatic blood pressure monitoring (involves measuring blood pressure while sitting, standing, and lying down to assess changes) by failing to ensure Resident 1 was monitored for orthostatic hypotension (condition in which the blood pressure quickly drops upon standing up after sitting or lying down) with three blood pressure (BP) readings on 1/15/25 and observed for adverse side effects. This deficient practice had the potential to result in hypotension (very low blood pressure) with dizziness and fainting and can lead to falls and injuries for Resident 1. 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 that included schizophrenia (a mental illness characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and general anxiety (worrying constantly and inability to control it). During a review of Resident 1's History and Physical (H&P) dated 10/22/24, the H&P indicated Resident 1 does not have the capacity to make own decisions but can make needs known. During a review of Resident's 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 1/17/25, the MDS indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 was independent with eating, oral hygiene, toileting hygiene, shower/bathing self, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 1's Medication Administration (MAR) for the month of January 2025, the MAR indicated Resident 1 was prescribed two antipsychotic medications (medications to treat psychosis [severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality]) and for staff to monitor side effects related to hypotension. During a review of Resident 1's Medication Review Report for active physician orders, the report indicated the following: 1. Monitor orthostatic B/P while (lying/sitting/standing) one time a day starting on the 15th and ending on the 15th every month BP (Lying). 2. Monitor orthostatic B/P while (lying/sitting/standing) one time a day starting on the 15th and ending on the 15th every month BP (Sitting). 3. Monitor orthostatic B/P while (lying/sitting/standing) one time a day starting on the 15th and ending on the 15th every month BP (Standing). During a review of Resident 1's Weights and Vitals Summary for 12/27/24 to 1/30/25, the summary did not indicate a standing position orthostatic blood pressure (BP) reading was taken within minutes of the lying and sitting BP orthostatic readings. The lying and sitting orthostatic BP readings were taken out of sequence. The sitting position BP was taken at 10:30 a.m. followed by the lying position BP taken at 10:33 a.m. The BP readings on 1/15/25 were as follows: 1/15/25 at 9:00 a.m., 130/82 mmHg (Sitting, left arm) 1/15/25 at 10:30 a.m., 127/85 mmHg (Sitting, right arm) 1/15/25 at 10:33 a.m., 124/80 mmHg (Lying, right arm) 1/15/25 at 8:49 p.m., 123/84 mmHg (Standing, left arm) During a concurrent interview and record review on 1/30/25 at 3:18 p.m. with Licensed Vocational Nurse 3 (LVN 3), the Medication Administration Record (MAR) dated January 2025, Medication Review Report - Order Summary, and Weights and Vitals Summary for 12/27/24 to 1/30/25, for Resident 1 were reviewed. LVN 3 stated there were only two orthostatic BP readings taken on 1/15/25, and both readings (10:30 a.m. sitting and 10:33 a.m. lying) were taken in the wrong sequence. LVN 3 stated three BPs needed to be taken to check for hypotension and should be done three to five minutes apart. LVN 3 stated it was important to take all three readings as ordered by the physician because a drop in blood pressure could affect Resident 1 to faint or fall and sustain an injury. During a concurrent interview and record review on 1/30/25 at 4:30 p.m. with the facility's Director of Nursing (DON), the Medication Administration Record (MAR), dated January 2025, Medication Review Report - Order Summary, and Weights and Vitals Summary for 12/27/24 to 1/30/25, for Resident 1 were reviewed. The DON stated Resident 1 was not monitored for orthostatic hypotension in accordance with the physician's order. During a review of the facility's Policy and Procedure (P&P) titled, Physician Orders, dated 3/22/22, the P&P indicated, . To ensure that all physician orders are complete and accurate. The P&P further indicated, Treatment orders will include the following: 1) A description of the treatment, including the treatment site, if applicable; 2) The frequency of treatment and duration of order (when appropriate); and 3) The condition/diagnosis for which the treatment is ordered. Medication/treatment orders will be transcribed onto the appropriate resident administration record. Documentation pertaining to physician orders will be maintained in the resident's medical record. Current month's administration records will be maintained in the MAR/TAR binders. During a review of the facility's P&P titled, Psychotropic Medication Use, dated 6/2021, the P&P indicated, The Facility should comply with the State Operations Manual, and all other Applicable Law relating to the use of psychoactive medications, including gradual dose reductions. The P&P further indicated, All medications use to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All residents receiving medications used to treat behaviors should be monitored for harm or adverse consequences.

Based on observation, interview, and record review, the facility failed to obtain informed consents from the resident or the resident's responsible party for two of six sampled residents (Resident 7 and Resident 18) by failing to: A. Ensure the frequency (how many times per day and how often a medication is to be administered) of Clozapine (an antipsychotic medication [a drug used to treat serious mental health conditions]) was indicated in Resident 7's informed consent. B. Ensure an informed consent was obtained before increasing the dose of Olanzapine (an antipsychotic [main class of drugs used to treat people that have mental disorders like schizophrenia [mental disorder characterized by loss of contact with the environment]) medication, ordered for schizophrenia manifested by responding to internal stimuli (when someone exhibits behaviors that suggest they are perceiving or reacting to things that are not present in the external environment, often due to hallucinations [false perception of objects or events involving the senses] or delusions[a belief or altered reality that is persistently held despite evidence or agreement to the contrary]) for Resident 18. This deficient practice violated the resident's right to be fully informed and consent to receive psychoactive (mind altering drug that affects how the brain works, used to treat symptoms of psychosis [a collection of symptoms that affect the mind, where there has been some loss of contact with reality]) medications. Findings A. During a review of Resident 7's Admission Record (AR), the AR indicated the facility admitted Resident 7 on 12/28/2022 and readmitted the resident on 6/9/2024, with diagnosis including, schizophrenia, hypertension (HTN-high blood pressure), and type 2 diabetes mellitus (T2DM-a long term condition in which the body has trouble controlling blood sugar and using it for energy, can lead to poor wound healing). During a review of Resident 7's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/17/2024, the MDS indicated Resident 7's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 7 was independent (resident completes the activity by self with no assistance from a 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 7's Medication Review Report, date range: 12/1/2024 to 12/31/2024, the report indicated a physician's order for Clozapine (medication used to treat schizophrenia) 150 mg (milligrams, unit of measurement) by mouth two times a day m/b [manifested by] responding to internal stimuli related to paranoid schizophrenia. During an interview and a concurrent record review on 12/19/2024 at 10:19 AM, with Licensed Psychiatric Technician (LPT) 1, Resident 7's Medication Administration Record (MAR) for the months of October 2024 through December 2024 were reviewed, the MARs indicated the following: - Resident 7 was administered Clozapine 150 mg PO [administered by mouth] twice daily starting on 10/24/2024 at 5 PM. LPT 1 stated the physician's order was active, and Resident 7 was taking Clozapine 150 mg as ordered. During an interview and a concurrent record review on 12/19/2024 at 10:19 AM, with LPT 1, Resident 7's Psychotropic Medication Administration Informed Consents were reviewed. The informed consent indicated the physician ordered Clozapine 150 mg PO for Schizophrenia manifested by responding to internal stimuli. LPT 1 stated informed consents must include medication, dosage, frequency, diagnosis, and manifestation as indicated on the form. LPT 1 stated the frequency of Clozapine was not included on the informed consent and Resident 7's informed consent was not accurately verified by LPT 1 and Registered Nurse (RN) 1. LPT 1 stated that informed consents ensured the person agreeing to a treatment was given all the information available including the risks, benefits, reasonable alternatives, and the consequences of not having the treatment. LPT 1 stated the form should be filled out accurately because it was a legal document and should include all the required information that's indicated on the form. During an interview and a concurrent record review on 12/19/2024 at 10:58 AM, with RN 1, Resident 7's Psychotropic Medication Administration Informed Consent was reviewed with RN 1. RN 1 stated that RN 1 recalled completing the informed consent form after the physician had obtained verbal consent from Resident 7's conservator (a person legally appointed by a court to manage the financial affairs and personal well-being of another person who is unable to do so themselves due to age, mental incapacity, or other reasons) for the use of the Clozapine. RN 1 stated RN 1 did not include the frequency for Clozapine and should have been included in the informed consent. RN 1 stated the informed consent was a legal document allowing the resident or conservator to make an informed decision about their treatment and protected the provider from potential legal issues by documenting the patient's awareness of the information provided. B. During a review of Resident 18's AR, the AR indicated the facility admitted Resident 18 on 4/6/2023, with diagnosis including, schizophrenia, hypertension, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 18's MDS, dated [DATE], the MDS indicated Resident 18's cognition was intact. The MDS indicated Resident 18 was independent with activities of daily living and was independent with mobility. During a review of Resident 18's Order Recap (summary) Report, date range: 10/1/2024 to 10/31/2024, the report included a physician order dated, 10/23/2024, for Olanzapine 30 mg PO at bedtime related to schizophrenia. During a review of Resident 18's Order Summary Report, dated active as of 10/3/2024, the report indicated a physician's order dated 10/3/2023 for Olanzapine 25 mg PO [administered] at bedtime related to schizophrenia. During a review of Resident 18's MAR, dated 10/2024, the MAR indicated Resident 28 was administered Olanzapine 30 mg PO at bedtime related to schizophrenia starting on 10/24/2024. During an interview on 12/19/2024 at 10:19 AM, with LPT 1, LPT 1 stated that inform consents ensure that a person agreeing to treatment is given all the information available about risks, benefits, reasonable alternatives, and the consequences of not having the treatment. LPT 1 stated all residents taking psychotropic medications should have informed consents obtained by the physician prior to the administration of the mediation. During an interview and a concurrent record review on 12/19/2024 at 10:58 AM, with RN 1, Resident 18's informed consents since admission were reviewed with RN 1. RN 1 stated RN 1 was unable to find the informed consent indicating a dose increase of Olanzapine to 30mg for Resident 18. RN 1 stated the Resident 18's physician should have obtained an inform consent from the conservator when Olanzapine was increased from 25 mg to 30 mg. RN 1 stated the licensed nurses should verify that inform consents have been obtained prior to the administration of psychotropic medications. RN 1 stated informed consents were legal documents and allowed the resident (in general) or conservator to make informed decisions about their treatments while also protecting the provider from potential legal issues by documenting the patient's awareness of the information provided. During an interview on 12/19/2024 at 4:09 PM, with the Health Information Manager (HIM), the HIM stated the HIM was unable to obtain and provide the informed consent for the latest Olanzapine order that indicated the increase to 30 mg. The HIM stated it was more likely that it was not done. During a review of the facility's P&P titled, Guidelines for Charting and Documentation, dated 4/2012, the P&P indicated: A. The general rules for charting and documentation are to be concise, accurate, and complete and use objective terms. Avoid brief, monotonous, and meaningless entries. B. Content of Orders: specify the type, route, dosage, frequency, and strength of the medication ordered (i.e., Dilantin 100 mg PO TID). During a review of the facility's P&P titled, Antipsychotic/Psychotropic Medication Use, dated 6/2021, the P&P indicated: a. Prior to the administration of antipsychotic/psychotropic medication the prescribing practitioner shall obtain informed consent and will be verified by a licensed nurse. b. facility shall verify informed consent prior to the administration of a psychotropic medication for a resident.

Based on observation, interview, and record review, the facility failed to develop and implement an individualized person-centered plan of care (care plan, CP) that included measurable objectives, timeframes, and interventions that met resident needs for two of two sampled residents (Resident 17 and Resident 24) by failing to: A. Develop a CP for Resident 17 in a timely manner to address Resident 17's refusal of the front wheel walker (FWW, a mobility device with two wheels in the front and two glide caps in the back that's used to help people with limited mobility walk and transfer) after several falls. B. Implement goals and care interventions in a timely manner to address Resident 24's need for supervision during smoking breaks. These deficient practices had the potential to result in unmet individualized needs for Resident 24 and the potential to affect the resident's physical and psychosocial well-being and negatively affect Residents 17 and 24. Findings A. During a review of Resident 17's Admission Record (AR), the AR indicated the facility admitted Resident 17 on 10/3/2019, with diagnosis including, schizophrenia (a mental illness that is characterized by disturbances in thought), anemia (a condition where the body does not have enough healthy red blood cells), and pain in the leg. During a review of Resident 17's Change in Condition Evaluation, dated 7/8/2024, timed at 9 AM, the evaluation indicated Resident 17 had a fall on 7/8/2024 and the fall was associated with no or minor injury. During a review of Resident 17's CP, revision date 7/10/2024, the CP indicated Resident 17 was as risk for falls. The CP indicated Resident 17's latest fall was on 7/8/2024 without injury. The latest intervention of the CP was initiated on 7/17/2024 and indicated Resident 17 may always use a walker for ambulation (walking). During a review of Resident 17's Physical Therapy Evaluation, dated 7/16/2024, indicated Resident 17's treatment plan was the need of a FWW as a fall prevention measure. During a review of Resident 17's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/19/2024, the MDS indicated Resident 17 cognition (the ability to think and process information) was intact. The MDS indicated Resident 17 was independent (resident completes the activity by themself with no assistance from a 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 17's Medication review Report, active orders with date range 12/1/2024 to 12/31/2024, the report indicated a physician's order dated 7/8/2024 for approval of physical therapy (PT) evaluation for Resident 17 to assess the potential benefit of a walker to help prevent further falls. During an observation and a concurrent interview on 12/18/2024 at 10:31 AM, Resident 17 was observed in the patio taking short steps, swaying side to side during occasional steps, and was not using a FWW. Resident 17 stated Resident 17 refused to use the walker because it made Resident 17 feel old. Resident 17 stated Resident 17 understood that Resident 17 should be using the walker to prevent from falling. During an interview and a concurrent record review on 12/19/2024 at 09:47 AM, with Licensed Psychiatric Technician (LPT) 1, Resident 17's CPs were reviewed. LPT 1 stated Resident 17 did not have a CP that addressed Resident 17's refusal of the FWW. LPT 1 stated Resident 17 had a history of falls without major injuries. LPT 1 stated Resident 17 also had the tendency of placing herself on the floor and hadn't had a fall since 7/8/2024. LPT 1 stated the physician ordered a PT evaluation after Resident 17's last fall to evaluate for the need and benefit of a walker. LPT 1 stated PT recommended the use of the walker and educated Resident 17 on how to use the walker. LPT 1 stated Resident 17 had a physician's order for the walker, however, Resident 17 often refused to use it. LPT 1 stated the facility didn't CP the refusal of the walker and should have care planned it. LPT 1 stated care planning the refusal helped the facility develop different strategies to address the concern of the falls for Resident 17 and could potentially improve Resident 17's outcome. During an interview on 12/20/2024 at 10:30 AM, with Registered Nurse (RN) 1, RN 1 stated the facility should have care planned Resident 17's refusal of the FWW because it was the treatment plan to prevent falls. RN 1 stated care planning the refusal of the FWW helped focus on understanding the reasons behind Resident 17's refusal and provided alternative goals and interventions to address the fall risk concern while respecting the resident's autonomy. B. During a review of Resident 24's Admission Record (AR), the AR indicated the facility admitted Resident 24 on 3/1/2023, with diagnosis including, schizophrenia, hypertension (HTN-high blood pressure), and Gastroesophageal Reflux Disease (GERD- a condition where stomach contents leak back into the esophagus, or food pipe, irritating the lining of the esophagus). During a review of Resident 24's Smoking Evaluation, dated 3/9/2024, the evaluation indicated Resident 24 required smoking supervision per the facility's policy and did not have the ability to light a cigarette. During a review of Resident 24's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/11/2024, the MDS indicated Resident 24's cognition was moderately impaired. The MDS indicated Resident 24 was independent (resident completes the activity by themself with no assistance from a 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 24's medical record on 12/17/2024 at 3:49 PM, there was no smoking CP in the medical record. During an interview and a concurrent record review on 12/18/2024 at 1:02 PM, with Registered Nurse (RN) 2, Resident 24's CPs were reviewed with RN 2. RN 2 stated Resident 24's CPs did not include a smoking CP. RN 2 stated all residents who smoked at the facility should have a smoking CP. RN 2 stated smoking CPs ensured interventions for the resident's safety were in place, such as the proper handling of cigarettes, smoking expectations, compliance with the smoking policy, and smoking cessation education. RN 2 stated monitoring smoking interventions helped the staff determine if the smoking CP needed modification or an adjustment based on the resident's compliance and safety. During an interview on 12/20/2024 at 3:17 PM, with RN 3, RN 3 stated nursing CPs were patient-centered, and they promoted collaboration, compliance, and continuity of care. RN 3 stated all residents who smoked should have a CP, this ensured resident safety, smoking compliance to facility's policy, and education on smoking cessation. RN 3 stated that CPs ensured staff provided quality care and ensured interventions were being executed. During a review of the facility's P&P titled, Smoking, dated 8/9/2022, the P&P indicated that the Interdisciplinary Team (IDT) will develop and individualized plan for safe storage, use of smoking materials, assistance and required supervision, if necessary, for residents who smoke. This is documented on the Resident Smoking Evaluation, the residents Plan of Care, and discussed with the resident and Responsible Party at resident care conference meetings. During a review of the facility's P&P titled, Care Plan Comprehensive, effective date 8/25/2021, the P&P indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental, and psychosocial needs shall be developed for each resident. The P&P indicated assessments of residents are ongoing and care plans are reviewed and revised as information about the resident and the resident's condition change. The P&P indicated each resident's comprehensive care plan is designed to: 1. Build on Resident's individualized needs, strengths, and preferences. 2. Reflect the resident's expressed wishes regarding care and treatment goals.

Based on interview and record review, the facility failed treatments and services were provided for two of two sampled residents (Resident 24 and Resident 39) as indicated in the facility policy and procedure (P&P) titled, Physician Order, and Medication Ordering and Receiving from Pharmacy, when, A. The facility failed to follow a physician's order from 2/2024 to 12/2024 for Resident 24, that indicated orthostatic blood pressure ([OBP], the measurement of BP taken when a person stands up from a lying or sitting position. The person lies down for at least five minutes, the BP and pulse are measured while lying or sitting, then the person stands up and the measurement is repeated after one and three minutes. The purpose is to compare the BPs taken in both positions and look for a significant drop in BP upon standing which would indicate orthostatic hypotension [low BP]) was to be taken . B. The facility failed to re-order Resident 39's Propranolol (medication used to treat severe restlessness, and agitation) and Resident 39 missed five doses of the medication. These deficient practices resulted in an incorrect treatment due to no measurements of OBPs for Resident 24 and had the potential to result in physical declines to Residents 24 and 39. Findings: A. During a review of Resident 24's Admission Record (AR), the AR indicated the facility admitted Resident 24 on 3/1/2023, with diagnosis including, schizophrenia (a mental illness that is characterized by disturbances in thought), hypertension (HTN-high blood pressure), and Gastroesophageal Reflux Disease (GERD- a condition where stomach contents leak back into the esophagus, or food pipe, irritating the lining of the esophagus). During a review of Resident 24's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/11/2024, the MDS indicated Resident 24's cognition (the ability to think and process information) was moderately impaired. The MDS indicated Resident 24 was independent (resident completes the activity by themself with no assistance from a 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 24's Medication Review Report, dated active as of 12/18/2024, the report included a physician's order, dated 3/1/2023, the order indicated to monitor orthostatic BP while lying/sitting/standing, one time a day starting on the 15th and ending on the 15th of every month. During a review of Resident 24's Weights and Vitals Summary (VSS, the basic measurements of your body's functions, like your temperature, heart rate (pulse), breathing rate, and blood pressure), dated 2/2024 to 12/2024, the VSS did not indicate OBPs were taken for Resident 24 from 2/2024 to 12/2024. During an interview and a concurrent record review on 12/17/2024 at 2:31 PM, with Registered Nurse (RN) 1, Resident 24's VSS was reviewed with RN 1. RN 1 stated OBPs were not carried out as the physician order indicated. RN1 stated RN 1 could not identify any records indicating OBPs for Resident 24 were performed. RN 1 stated if OBPs were not documented, they were not performed. RN 1 stated physician orders must be followed, if not followed, it could impact the patient's safety. RN 1 stated carrying out physician orders ensured the correct treatment plan was followed and failure to do so could lead to potential complications for the resident. During an interview on 12/20/2024 at 3:17 PM, with RN 3, RN 3 stated maintaining patient safety relied significantly on clear and carefully reviewed physician orders by the nurses, which could prevent errors. RN 3 stated carrying out physician orders was the standard of care and was essential for delivering the correct treatment plan, which ultimately impacts the patient's well-being. RN 3 stated not following the physician orders led to potential harm and problems for the residents. During a review of the facility's P&P titled, Physician Order, dated 8/9/2022, the P&P indicated: 1.The purpose of the policy was to ensure that all physician orders are complete and accurate. 2.The Medical Records Department would verify that physician orders were complete, accurate and clarified as necessary. 3.Documentation pertaining to physician orders will be maintained in the resident's medical record. 48729 B. During a review of Resident 39's AR, the AR indicated Resident 39 was admitted to the facility on [DATE] with multiple diagnoses including schizophrenia and drug induced akathisia (a feeling of restlessness and distress that can be caused by various medications) During a review of Resident 39's MDS, dated [DATE], indicated Resident 39 had intact cognition and was independent for eating, toileting, and hygiene. During a review of Resident 39's Medication Administration Record (MAR) dated 12/1/2024 to 12/31/2024, the MAR indicated to give Propranolol 20 milligrams (mg, unit of weight) by mouth three times a day with start date 10/2/2024. The MAR indicated NN on the following days and times: 1. 12/13/2024 at 4:30 PM 2. 12/16/2024 at 6:30 AM and 4:30 PM 3. 12/17/2024 at 6:30 AM and 11:30 AM The MAR indicated NN = No/ See Nurse Notes. During a review of Resident 39's Progress Notes (PN) dated 12/13/2024 at 4:23 PM, 12/16/2024 at 6:22 AM, 12/16/2024 at 4:11 PM, 12/17/2024 at 7:35 AM, and 12/17/2024 at 12:54 PM, the PNs indicated Propranolol was not available. During an interview on 12/18/2024 at 2:35 PM with Licensed Psychiatric Tech (LPT) 1, LPT 1 stated some medications were automatically ordered on cycles while others had to be manually re-ordered from the pharmacy. LPT 1 stated staff usually re-ordered medications when the amount equaled a five-day supply. During an interview on 12/19/2024 at 2:40 PM with RN 1, RN 1 stated Resident 39's Propranolol should have been re-ordered on 12/13/2024 when it was first identified that the medication was unavailable. RN 1 stated Resident 39 was taking the medication for drug induced akathisia which could cause abnormal movements. RN 1 stated without the medication, Resident 39 might not be able to relax Resident 39's body and the resident could potentially become anxious, and it could be detrimental to Resident 39's mental health. During an interview on 12/20/2024 at 9:58 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated LVN 1 could not find documentation indicating when Resident 39's Propranolol was re-ordered, or which nurse re-ordered the medication. LVN 1 stated if the medication was re-ordered, this would be found in the progress notes but there was no note indicating when the medication was ordered. LVN 1 stated it was important to document when a medication was re-ordered to have good communication with staff and to be able to follow up with the pharmacy if there was a delay. LVN 1 stated it was also important to re-order and document so that staff could monitor the resident for behaviors as needed if the medication was not able to be filled in time. During a telephone interview on 12/20/2024 at 11:14 AM with Pharmacy Technician (PT), the PT stated pharmacy records showed the facility requested a refill for Resident 39's Propranolol on 12/17/2024 and it was delivered the same day. During a review of the facility's P&P titled, Medication Ordering and Receiving from Pharmacy, dated 2/2022, the P&P indicated, to reorder medication five days in advance of need to assure an adequate supply was on hand.

Based on observation, interview, and record review, the facility failed to ensure proper disposal (discarding of medications) of drugs (medications), for three of three sampled residents (Residents 7, 8, and 13), as indicated in the facility's Policy and Procedure (P&P) titled, Disposal of Medications and Medication-Related Supplies, when, 1. On 12/18/2024, three blister packs (a tamper-evident packaging where individually sealed tablets are pushed through foil to dispense the medication) of expired antibiotic (medications that fight bacterial infections) medications were found in the medication cart. This deficient practice had the potential to result in the accidental use of ineffective antibiotic medications and the potential to result in bacterial growth and physical declines to Residents 7, 8, and 13. Findings: On 12/18/2024 at 8:37 AM, during a Medication Cart inspection in Nursing Station 1 with Registered Nurse 2 (RN 2) and Licensed Psychiatric Technician 1 (LPT 1), there were three blister packs of antibiotic medications. The packs indicated the following antibiotic medications and expiration dates, - For Resident 7, Sulfamethoxazole 800 mg (milligram, unit of measurement)-Trimethoprim 160 mg tablet (combination of two antibiotics, used to treat a wide variety of bacterial infections), expiration date: 12/2/2024. - For Resident 8, Amoxicillin 500 mg capsules (used to treat bacterial infections, such as chest infections [including pneumonia] and dental abscesses [pocket of pus]), expiration date: 12/16/2024. - For Resident 13, Amoxicillin 500 mg capsules with expiration date: 12/16/2024. During a review of the facility's record titled, Medication Disposition Record/Pass Log, on 12/18/2024, the log indicated and confirmed the following antibiotic medications were expired for Residents 7, 8, and 13: 1. Resident 7 - Sulfamethoxazole 800 mg-Trimethoprim 160 mg tablet; fill date: 6/5/24; quantity filled: 20; quantity disposed: 13; method of disposition, waste management; expiration date: 12/2/24; disposition (discarding of medications) date: 12/18/24. The log indicated two signatures from RN 2 and LPT 1. 1. Resident 8 - Amoxicillin 500 mg capsule, fill date: 6/19/24; quantity filled: 21; quantity disposed: 1; method of disposition: waste management; expiration date: 12/16/24; disposition date: 12/18/24; 2 signatures: 2 signatures: RN 2 and LPT 1. 2. Resident 13 - Amoxicillin 500 mg capsule; fill date: 6/19/24; quantity filled: 21; quantity disposed: 1; method of disposition: waste management; expiration date: 12/16/24; disposition date: 12/18/24; 2 signatures: RN 2 and LPT 1. During a concurrent interview and review of the facility's medication disposal log with RN 2 and LPT 1 on 12/18/2024 at 8:46 AM, RN 2 and LPT 1 stated they [the facility] used a log located in a white binder to record expired medications. RN 2 and LPT 1 stated their signatures were on the log and indicated expired medications for Residents 7, 8, and 13. The expired medications were disposed on 12/18/24. During a concurrent interview and review of the facility's medication disposal log with RN 2 on 12/19/2024 at 11:03 AM, RN 2 stated disposal of expired medications were placed in a locked bin. RN 2 stated no blister packs with expired medications were to be kept with current medications (not expired) in the medication cart. RN 2 stated all expired medications should be removed from the blister packs and individually disposed of and placed in the locked bin. During a review of the facility's P&P titled, Disposal of Medications and Medication-Related Supplies, dated October 2017, the P&P indicated, Discontinued medications and medications left in the facility after a resident's discharge, which do not quality for return to the pharmacy for credit, are destroyed. The P&P indicated the medication is destroyed within 90 days from the date the medication [is] discontinued.

Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 2 and Resident 15) were free from physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) as indicated in the facility's policy and procedure (P&P) titled, Abuse Prohibition Policy and Procedure, when on 12/11/2024 Resident 2 punched Resident 15 on the chest and Resident 15 pushed Resident 2 to the ground. This deficient practice resulted in physical abuse and had the potential to result in injury and harm to Resident 15 and Resident 2. Findings: During a review of Resident 2's Admission Record (AR), the AR indicated the facility admitted Resident 2 on 4/8/2011, and readmitted the resident on 5/28/2014, with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), moderate intellectual disabilities, and chronic (long standing) obstructive pulmonary disease (COPD-a common lung disease causing restricted airflow and breathing problems). During a review of Resident 2's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 11/7/2024, the MDS indicated Resident 2's ability to hear was adequate and Resident 2 had clear speech. The MDS indicated Resident 2's cognition (the ability to think and process information) was moderately intact, made self-understood, and was able to understand others. The MDS indicated Resident 2 was independent (resident completes the activity by themself with no assistance from a 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 15's AR, the AR indicated the facility admitted Resident 15 on 2/11/2020, with diagnoses including schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior), hypertension (HTN-high blood pressure), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 15's MDS, dated [DATE], the MDS indicated Resident 15's cognition was moderately intact. The MDS indicated Resident 15 was independent with ADLs and was independent with mobility. During a review of Resident 2's Progress Notes, dated 12/11/2024 timed at 11:50 AM, the progress notes indicated Resident 15 was in an altercation with another male peer [Resident 2] and Resident 15 called Resident 2 a boy, so Resident 2 punched Resident 15 in the chest and Resident 15 punched Resident 2 back in the chest and Resident 2 then fell to the ground. During a review of Resident 2's Confidential Adverse Incident Initial Reporting (CAR) Form, dated 12/15/2024, the CAR indicated the date of the incident was 12/11/2024. The CAR indicated Resident 2 reported Resident 2 hit Resident 15 because Resident 15 called Resident 2 a name. During a review of Resident 2's Interdisciplinary Care Conference form, dated 12/16/2024 timed at 9:23 AM, the IDT Care Conference notes indicated it was alleged that Resident 2 punched Resident 15 in the chest, then Resident 2 was pushed by Resident 15 and observed to fall to the ground. During an interview on 12/17/2024 at 09:07 AM, Resident 15 was unable to give a clear statement regarding the altercation with Resident 2. Resident 15 had disorganized and incoherent thoughts and stated, My shoes have wings, and they want me to fly to the moon, but [NAME] is trying to stop me. During an interview on 12/17/2024 at 10:27 AM, Resident 2 stated Resident 2 got upset and angry with Resident 15 for calling him a boy. Resident 2 stated Resident 2 punched Resident 15 on the chest and Resident 15 then pushed Resident 2 to the ground. Resident 2 pointed with his finger at the corridor next to the dining facility where the incident occurred. Resident 2 was unable to state when the incident occurred. During an interview on 12/17/2024 at 10:44 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated that CNA 1 was working at the facility on 12/11/2024 the day of the altercation between Resident 2 and Resident 15. CNA 1 stated CNA 1 was inside the [NAME] unit looking for a resident at that time. CNA 1 stated the [NAME] unit was located near the corridor where the altercation occurred. CNA 1 stated Resident 15 and Resident 2 didn't show any signs of aggressiveness, anger, or impulsive behaviors the morning of 12/11/2024. CNA 1 stated Resident 2 was generally calm and tended to keep to himself. CNA 1 stated Resident 15 tended to get restless when too many people were around or got agitated when Resident 15 didn't get what Resident 15 wanted. CNA 1 stated CNA 1 didn't see what led to the altercation and only caught the tail end (the last part of something) of the incident. CNA 1 stated CNA 1 saw Resident 2 on the ground and Resident 15 fleeing the scene in a fast pace. CNA 1 stated Resident 2 reported Resident 15 called Resident 2 a boy and that made Resident 2 upset and angry causing Resident 2 to punch Resident 15 in the chest, which then led Resident 15 to push Resident 2 to the ground. CNA 1 stated Resident 8 witnessed the incident and told CNA 1 Resident 2 threw a punch at Resident 15 and Resident 15 pushed Resident 2 to the ground. CNA 1 stated residents (in general) in the facility should be monitored consistently for their safety, well-being, and progress in treatment. During an interview on 12/17/2024 at 1:48 PM, with the Administrator (ADM), the ADM stated the ADM conducted the 5-day follow-up report investigation. The ADM stated the ADM had two witnesses CNA 1 and Resident 8. The ADM stated CNA 1 witnessed Resident 2 on the ground and did not witness what started the altercation. The ADM stated Resident 8 stated, a black guy pushed a white guy and then he gave the middle finger and walked away. The ADM stated when CNA 1 asked Resident 2 what happened Resident 2 walked away, then Resident 2 reported Resident 2 hit Resident 15 because Resident 15 called him a name. The ADM stated Resident 15 never gave his statement, denied doing anything. During an interview on 12/19/2024 at 9:47 AM, with Licensed Psychiatric Technician (LPT) 1, LPT 1 stated LPT 1 was working on 12/11/2024 the day of the altercation between Resident 2 and Resident 15. LPT 1 stated the altercation was around noon during medication administration time. LPT 1 stated LPT 1 was in the nursing station administering residents' medication. LPT 1 stated Resident 2 came up to the nursing station for his medication and LPT 1 did not notice any signs of aggressiveness, agitation, irritable or delusional (a belief or altered reality that is persistently held despite evidence or agreement to the contrary) behavior. LPT 1 stated LPT 1 didn't notice any signs of aggressiveness, agitation, anxious or delusional behavior with Resident 15. LPT 1 stated LPT 1 did not witness the altercation until staff members notified LPT 1. LPT 1 stated staff were occupied around noon because of medication administration and prepping for lunch distribution. LPT 1 stated continuous monitoring was the cornerstone of effective care in behavioral facilities, ensured residents received the support they needed to recover and thrive in a safe and structured environment. During an interview on 12/20/2024 at 10:12 AM, with Registered Nurse (RN) 1, RN 1 stated that she wasn't working on 12/11/2024 the day of the altercation between Resident 2 and Resident 15. RN 1 stated that Resident 15 typically wasn't aggressive or angry and stated Resident 15 was respectful, responded to commands, and was easily redirectable. RN 1 stated Resident 2 typically wasn't aggressive or angry and was respectful too. RN 1 stated Resident 2 got angry at times when Resident 2 was anxious. RN 1 stated Resident 2 responded better to staff Resident 2 was familiar with but Resident 2 opened up once Resident 2 got to know the staff. RN 1 stated careful supervision of residents ensured safety, timely intervention, created a safe environment, and encouraged healthy behaviors which ultimately enhanced resident outcomes. During a review of the facility's P&P titled, Abuse Prohibition Policy and Procedure, review date 2/23/2021, the P&P indicated: Healthcare Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment. To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown source, and misappropriation of property for all patients. The Center will provide adequate supervision when the risk of resident-to-resident altercation is suspected.

Based on interview and record review, the facility failed to ensure the assessment entry in the general (refers to the initial observation of the patient's overall appearance, including their level of comfort, posture, hygiene, skin color, and any noticeable physical characteristics) section on a physical and history (H&P) exam was accurately documented to reflect the Resident's ability to hear and verbalize with others for one of one sampled resident (Resident 2). This deficient practice had the potential to negatively affect Resident 2's plan of care and delivery of necessary care and services. Findings: During a review of Resident 2's Admission Record (AR), the AR indicated the facility admitted Resident 2 on 4/28/2011 and readmitted the resident on 5/28/2014 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), moderate intellectual disabilities, and chronic (long standing) obstructive pulmonary disease (COPD-a common lung disease causing restricted airflow and breathing problems). During a review of Resident 2's History and Physical (H&P), dated 10/22/2024, the H&P indicated Resident 2 was nonverbal, deaf, and used sign language. The H&P indicated Resident 2 could not make own decisions but could make needs known. The H&P indicated Nurse Practitioner 1 (NP 1) spoke with Resident 2 and Resident 2 verbally agreed to receive chronic care management services. During a review of Resident 2's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 11/7/2024, the MDS indicated Resident 2's ability to hear was adequate and Resident 2 had clear speech. The MDS indicated Resident 2's cognition (the ability to think and process information) was moderately intact. The MDS indicated Resident 2 was independent (resident completes the activity by themself with no assistance from a helper) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and was independent with mobility. During an observation and concurrent interview on 12/18/2024 at 12:34 PM, with Resident 2, Resident 2 was observed verbally communicating with other residents in the patio during lunch time. Resident 2 stated Resident 2 was able verbally respond without any difficulty and denied having hearing problems. During a phone interview and concurrent record review on 12/20/2024 at 12:56 PM, with NP 1, Resident 2's H&P was reviewed. The NP 1 stated NP 1 the information regarding Resident 2 documented on the H&P [nonverbal, deaf, and used sign language] in error and NP 1 mixed up Resident 2 with another resident. The NP 1 stated NP 1 saw many residents on 10/22/2024 and documented Resident 2 was nonverbal, deaf, and used sign language in error. The NP 1 stated the H&P should be accurately completed because it provided the foundation for proper diagnosis and treatment, gave healthcare providers a comprehensive understanding of a patient's health condition, and allowed them to tailor care plans, identify potential risks, and make informed decisions to achieve the best possible patient outcomes. During an interview on 12/20/2024 at 1:07 PM, with Registered Nurse (RN) 2, RN 2 stated inaccurate assessments could lead to misdiagnoses, inappropriate treatments, and potentially harmful consequences for the patient. RN 2 stated clinicians should ensure H&P exams were accurate because they provided critical information about a person's general physical health, possible diseases, and progress toward recovery. During a review of the facility's P&P titled Guidelines for Charting and Documentation, revision dated 4/2012, the P&P indicated the general rule for charting and documentation was to be concise, accurate, and complete and use objective terms. the P&P indicated to avoid brief, monotonous, and meaningless entries. During a review of the facility's P&P titled, Resident Assessments, revision dated 10/2023, the P&P indicated assessments are completed by staff members who have these skills and qualifications to assess relevant care areas and who are knowledgeable about the resident's strengths and areas of decline.

Based on interview, and record review, the facility failed to update a care plan (CP) and include new interventions, for one of two sampled residents (Resident 36), after Resident 36 sustained a fall on10/30/2024 and as indicated in the facility's policy and procedure titled, Care Plan Comprehensive, and Fall Management. This deficient practice had the potential to result in unmet individualized needs for Resident 36 and the potential to affect the resident's physical and psychosocial well-being. Findings: During a review of Resident 36's Admission Record (AR), the AR indicated the facility admitted Resident 36 on 3/26/2024, with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and psychoactive (altering the mind or consciousness) substance abuse. During a review of Resident 36's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/1/2024, the MDS indicated Resident 36's cognition (the ability to think and process information) was moderately intact. The MDS indicated Resident 36 was independent (resident completes the activity by themself with no assistance from a 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 36's At Risk for Falls CP, initiated 5/3/2024, the interventions in the CP indicated the facility would obtain and evaluate orthostatic blood pressure (the measurement of blood pressure taken when a person stands up from a lying or sitting position) and provide verbal cues for safety and sequencing when needed. During a review of Resident 36's Interdisciplinary Care Conference report dated 10/31/2024, the report indicated Resident 36 had a fall on 10/15/2024 at 7:40 AM. During a review of Resident 36's Interdisciplinary Care Conference report dated 10/30/2024, the report indicated that Resident 36 had a fall on 10/30/2024 at 7:40 AM. During an interview on 12/17/2024 at 9:45 AM, with Resident 36, Resident 36 stated Resident 36 had two recent falls at the facility but Resident 36 could not recall exactly when the falls occurred. During an interview and concurrent record review on 12/19/2024 at 9:47 AM, with Licensed Psychiatric Technician (LPT) 1, the At Risk for Falls CP dated 5/3/2024, was reviewed with LPT 1. The interventions in the CP indicated the facility would monitor for headaches, vomiting, or worsening symptoms and monitor Resident 36 for any changes and continue with q15 (a safety check occurring every 15 minutes) monitoring. LPT 1 stated Resident 36's At Risk for Falls CP was initiated on 5/3/2024. LPT 1 stated the CP for At Risk for Falls was not updated to include new interventions after Resident 36 had a fall 10/30/2024. LPT 1 stated At Risk for Falls CPs should be updated to include new interventions after each fall to prevent further falls that could potentially lead to injury. LPT 1 stated interventions should be added to At Risk for Falls CPs whenever there was a change in the resident's condition, behavior, environment, or risk factors, to ensure the CPs remained effective in preventing falls and addressed the specific needs of the residents (in general). During an interview on 12/20/2024 at 9:57 AM, with Registered Nurse (RN) 1, RN 1 stated staff should always update At Risk for Falls CPs after a fall occurred [to include new interventions]. RN 1 stated a fall was a significant change in a resident's condition and updating the CP with new interventions allowed the facility to identify the causes of the fall, implement new interventions to address those specific risk factors, and minimized the chances of future falls by tailoring the plan to the individual's unique needs based on the incident. RN 1 stated updating the CP promptly and effectively helped reduce the risk of future falls and ensured resident safety and well-being. During a review of the facility's P&P titled, Care Plan Comprehensive, revision dated 8/25/2021, the P&P indicated: A. Assessments of residents are ongoing and care plans are reviewed and revised as information about the resident and the resident's condition changes. B. The Interdisciplinary Team (IDT) is responsible for evaluation and updating of care plans: 1.When there has been a significant change in resident's condition. 2.When the desired outcome is not met. 3.When the resident has been readmitted to the facility from a hospital stay; and 4.At least quarterly. During a review of the facility's P&P titled, Fall Management, dated 5/26/2021, the P&P indicated if patient falls update care plan to reflect new interventions.

Based on interview and record review the facility failed to evaluate and ensure one of four Certified Nursing Assistants (CNA 3) had completed annual skills training. This failure had the potential to result in unsafe resident care. Findings: During a concurrent interview and record review on 12/20/2024 at 12:25 PM with Director of Staff Development (DSD), CNA 3's employee file and Employee Orientation IMD Checklist, (EOIC) dated 5/2/2023 was reviewed. The EOIC indicated CNA 3 was hired on 5/2/2023 and CNA 3 completed trainings on 5/2/2023, 5/3/2023 and 5/5/2023. The DSD stated skills training needed to be updated annually to ensure staff was update for any changes and ensure safety and care were done correctly. The DSD stated the DSD did not see any documentation indicating skills training was completed by CNA 3 in 2024. The DSD stated CNA 3 should not have cared for residents until CNA 3's skills trainings were up to date. During a review CNA 3's Timecard, (TC) dated from 11/01/2024 to 12/16/2024, the TC indicated CNA 3's most recent days of work were 12/7/2024 11:12 PM through 12/8/2024 7:12 AM and on 12/8/2024 11:20 AM through 12/9/2024 7:07 AM. During a review of the facility's assignment sheet titled, L.P. Assignments - Nursing Direct Care NOC, (LPA) dated 12/7/2024 and 12/8/2024, the LPA indicated CNA 3 had direct patient care on these days. During a review of the facility's policy and procedure (P&P) titled, In-service Training, All Staff, dated 8/2022, the P&P indicated all staff must participate in initial orientation and annual in-service training.

Based on interview and record review, the facility failed to report allegations of exploitation (taking advantage of a resident for personal gain, using manipulation, intimidation, threats, or pressure) within 24 hours for three of three sampled residents (Residents 1, 2, and 3) to the California Department of Public Health (CDPH) in accordance with the facility's policy and procedure (P&P). On 2/18/2022, at 5:50 pm, Resident 2 told SSD that she and Resident 1 purchased marijuana (a green, brown, or gray mix of dried, crumbled parts from the marijuana plant which contains chemicals which act on your brain and can change your mood or consciousness) from Primary Counselor (PC) who was employed by the facility (unidentified date and time). On 2/21/2022, at approximately 9:15 am, Resident 3 Reported to SSD he purchased marijuana from PC. The Administrator (ADM) reported the allegations of exploitation to CDPH on 2/22/2022 (four days after the allegations were made). These deficient practices had the potential to result in further exploitation and misuse of residents' personal funds. On 2/23/2022, at 7:01 pm, the State Agency (SA) declared an Immediate Jeopardy (IJ) situation (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Vice President of Operations (VPO). On 2/25/2022, the facility provided an acceptable IJ Removal Plan (Removal Plan, interventions to remove the immediacy and correct the deficient practices). While onsite, the surveyors confirmed implementation of the immediate corrective actions through observation, interview, and record review. On 2/25/2022, at 2:55 pm, the IJ was removed in the presence of the ADM, VPO, Director of Nursing (DON) and Clinical Resource Nurse (CRN). The acceptable IJ Removal Plan included the following: 1. On 2/23/22, the facility's Director of Staff Development (DSD) and CRN provided training to staff regarding abuse prohibition with special focus on exploitation, financial abuse, and reporting. 2. On 2/23/22, VPO provided training to ADM regarding protecting residents by timely reporting to CDPH of unusual occurrences and abuse allegations within 24 hours. 3. On 2/24/22, a new system was put into place in the stand-up meeting to ensure timely report of abuse. The system included notation of if any abuse was identified and if it was reported to CDPH, Ombudsman (an official appointed to investigate individuals' complaints against maladministration) and police within two hours. 4. On 2/24/22, VPO provided training to the ADM and DON (Director of Nursing) regarding the new system. Cross Reference F689 Findings: A review of the facility's Unusual Occurrence Report, (UOR), dated 2/22/2022, indicated on 2/18/2022, at 5:50 pm, Resident 2 told SSD, that PC gave and sold marijuana to residents (residents unidentified). SSD reported the interview with Resident 2 to the ADM and as to other residents having knowledge of the situation. On 2/18/22, at 7 pm, SSD interviewed Resident 1 who admitted PC had sometimes given and sold him marijuana and It should be noted that following the 2/15/22 incident. The UOR indicated on 2/21/2022, at around 9:15 am, Resident 3 asked SSD if PC was at the facility. SSD asked Resident 3 if there was anything Resident 3 needed which led to an interview during which Resident 3 admitted to purchasing marijuana from the PC. A review of Resident's 1 Admission Record indicated Resident 1 was admitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 2/2/2022, indicated Resident 1 was cognitively intact for daily decision making and independent with activities of daily living. A review of Resident 1's Progress Notes, dated 2/15/2022, timed at 1:12 pm, indicated a safety check (room search) was conducted in the resident's room and had a strong odor for which Resident 1 admitted to smoking marijuana in his room with his two peers (unidentified) and handed two lighters. SSD found marijuana inside Resident 1's room. A review of Resident 2's Admission Record indicated, Resident 2 was admitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's MDS dated [DATE], indicated Resident 2 was cognitively intact for daily decision making and independent with activities of daily living. A review of Resident 2's Progress Notes, dated 2/15/2021, timed at 11:56 am, indicated, ADM notified Resident 2's responsible party about facility staff finding Resident 2 with marijuana. The notes indicated the resident's responsible party agreed to not give Resident 2 so much money (unidentified amount) since Resident 2 did not need a lot of money at the facility. A review of Resident 3's Admission Record indicated Resident 3 was admitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's MDS, dated [DATE], indicated Resident 3 was cognitively intact for daily decision making and independent with activities of daily living. During an interview on 2/23/2022, at 12:58 pm, Resident 1 stated he was smoking marijuana and got caught like a week ago, when the Activity Director (AD) and SSD found a pipe (is used to inhale the smoke of a burning substance) in his backpack. Resident 1 could not remember the exact date and time he was caught. Resident 1 stated he obtained marijuana from PC who would roll the marijuana up and dropped it in the morning by the tree or curb in the parking lot and would tell Resident 1 where he dropped the marijuana and Resident 1 would find it, put it away and save it for the night. Resident 1 stated, he started off getting the marijuana for free then the PC started asking him to pay. The most he paid PC was $20.00 for two years. During an interview on 2/23/2022, at 1:35 pm, Resident 2 stated PC gave her a joint, (another term for marijuana) last summer (unidentified time). Resident 2 did not answer when asked how much she paid PC for the marijuana. During an interview on 2/23/2022, at 1:46 pm, Resident 3 stated she obtained marijuana from Resident 1 who bought it from PC. Resident 3 stated she paid $5.00 (five dollars) for a joint. Resident 3 stated Resident 2 and another resident (unidentified) who was no longer at the facility told her PC gave them joints, edibles brownies or cookies with weed (another term for marijuana) in it. During an interview on 2/23/2022, at 3:20 pm, ADM stated Resident 1 was found to have marijuana in his room on 2/15/22 during a room search (the facility's weekly process of checking resident rooms for unauthorized items including contrabands [goods that have been imported or exported illegally] along with tidying up the room). ADM stated marijuana was considered a contraband and was not allowed in the facility. During an interview on 2/24/2022, at 11 am, ADM stated, the incident on 2/15/2022 was not reported to CDPH since the facility did not know who gave the marijuana to Residents 1, 2, and 3, until facility started their investigation on 2/18/2022. ADM stated she failed to report the incident to CDPH within twenty-four hours. ADM also stated PC was terminated from employment. During an interview on 2/28/22, at 10:28 am, SSD stated Resident 1, and Resident 2 were observed on 2/15/22, (time unidentified), by a Certified Nursing Assistant (unidentified) smoking cigarettes in the back patio during a non-smoking schedule. A room search was conducted by SSD and AD on the same day after the residents were interviewed. More cigarette lighters, a pipe to smoke marijuana according to Resident 1 and what appeared to be a rolled joint that looks like a white paper rolled, just a little bit of some green stuff in it, were found in Resident 1's room who stated it was marijuana. SSD bagged the marijuana and threw it in the locked dumpster outside of the building. No marijuana or contraband was found in Resident 2's room. SSD stated the incident was reported to ADM on the same day, time undetermined. A review of the facility's P&P titled, Abuse Prohibition, revised 4/9/2021, under section, Process, No. 7.4, indicated, Report allegations involving neglect, exploitation or mistreatment (including injuries of unknow source), suspected criminal activity, and misappropriation of patient property within 24 hours if the event does not result in serious bodily injury. A review of the facility's fax receipt confirmation, dated 2/22/22, timed at 5:41 p.m., indicated, UOR was sent to CDPH.

Based on interview and record review, the facility failed to supervise and ensure three of three sampled residents (Residents 1, 2, and 3) did not use and did not purchase marijuana (a green, brown, or gray mix of dried, crumbled parts from the marijuana plant which contains chemicals which act on your brain and can change your mood or consciousness), from the facility's Primary Counselor (PC). On 2/15/2022, at 1:12 pm, the facility's Social Services Director (SSD) found marijuana (a green, brown, or gray mix of dried, crumbled parts from the marijuana plant which contains chemicals which act on your brain and can change your mood or consciousness) inside Resident 1's room. On 2/18/2022, at 5:50 pm, Resident 2 allegedly told SSD that she and Resident 1 purchased marijuana from PC who was employed by the facility (unidentified date and time). On 2/21/2022, at approximately 9:15 am, Resident 3 Reported to SSD he purchased marijuana from PC. The ADM reported the allegations of exploitation to CDPH on 2/22/2022 (four days after the allegations were made). These deficient practices had the potential to result in drug overdose (an excessive and dangerous dose of a drug) and chemical imbalances (occurs when the substances that help the body function the way it should become out of balance) and can lead to mental effects such as hallucinations (wander mentally), delusions (false beliefs that contradict reality) or [CONDITION(S)] (a term used to describe when a person interprets or perceives reality in a different way to those around them) and/or physical effects such as impaired body movements, breathing problems, increased heart rate, and/or intense nausea and vomiting resulting in hospitalization . (https://[NAME].nih.gov/publications/drugfacts/marijuana). On 2/23/2022, at 7:01 pm, the State Agency (SA) declared an Immediate Jeopardy (IJ) situation (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Vice President of Operations (VPO). On 2/25/2022, the facility provided an acceptable IJ Removal Plan (Removal Plan, interventions to remove the immediacy and correct the deficient practices. While onsite, the surveyors confirmed implementation of the immediate corrective actions through observation, interview, and record review. On 2/25/2022, at 2:55 pm, the IJ was removed in the presence of the ADM, VPO, Director of Nursing (DON) and Clinical Resource Nurse (CRN). The acceptable IJ Removal Plan included the following: 1. On 2/23/22, the facility's Director of Staff Development (DSD) and CRN provided training to staff regarding abuse prohibition with special focus on exploitation, financial abuse, and reporting. 2. On 2/23/22, VPO provided training to ADM regarding protecting residents by timely reporting to DPH of unusual occurrences and abuse allegations within 24 hours. 3. On 2/24/22, a new system was put into place in the stand-up meeting to ensure timely report of abuse. The system included notation of if any abuse was identified and if it was reported to CDPH, Ombudsman (an official appointed to investigate individuals' complaints against maladministration) and police within two hours. 4. On 2/24/22, VPO provided training to the ADM and DON (Director of Nursing) regarding the new system. Cross Reference F609 Findings: A review of the facility's Unusual Occurrence Report, (UOR), dated 2/22/2022, indicated on 2/18/2022, at 5:50 pm, Resident 2 told SSD, that PC gave and sold marijuana to residents (residents unidentified). SSD reported the interview with Resident 2 to the ADM and as to other residents having knowledge of the situation. On 2/18/22, at 7 pm, SSD interviewed Resident 1 who admitted PC had sometimes given and sold him marijuana and It should be noted that following the 2/15/22 incident. The UOR indicated on 2/21/2022, at around 9:15 am, Resident 3 asked SSD if PC was at the facility. SSD asked Resident 3 if there was anything Resident 3 needed which led to an interview during which Resident 3 admitted to purchasing marijuana from the PC. A review of Resident's 1 Admission Record indicated Resident 1 was admitted on [DATE] with multiple diagnoses including [CONDITION(S)] disorder (a serious mental illness that affects the way a person thinks, feels, acts, expresses emotions, perceives reality, and behave clearly), [CONDITION(S)] (a condition in which your [CONDITION(S)] doesn't produce enough of certain crucial hormones) and [CONDITION(S)] (a sleep disorder in which you have trouble falling and/or staying asleep). A review of Resident 1's Medication Review Report (physician orders), with an order date of 8/18/2021, indicated for the resident to receive [MEDICATION(S)] (medication used to treat psychotic disorders [conditions that cause difficulty telling the difference between things or ideas that are real and things or ideas that are not real]), 10 milligrams (mg, a unit of measurement) by mouth at bedtime related to [CONDITION(S)] disorder. A review of Resident 1's Medication Review Report (physician orders), with an order date of 11/19/2021, indicated for the resident to receive [MEDICATION(S)] (an antipsychotic medication that is used to treat severe [CONDITION(S)] symptoms in people who have not responded to other medications) 500 mg at bedtime. A review of Resident 1's Medication Administration dated 2/1/2022, indicated Resident 1 received [MEDICATION(S)] 10 mg daily at bedtime. A review of Resident 1's Medication Administration dated 2/1/2022, indicated Resident 1 received [MEDICATION(S)] 500 mg at daily at bedtime. A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 2/2/2022, indicated Resident 1 was cognitively intact for daily decision making and independent with activities of daily living. A review of Resident 1's Progress Notes, dated 2/15/2022, timed at 1:12 pm, indicated a safety check (room search) was conducted in the resident's room and had a strong odor for which Resident 1 admitted to smoking marijuana in his room with his two peers (unidentified) and handed two lighters. A review of Resident 2's Admission Record indicated, Resident 2 was admitted on [DATE] with multiple diagnoses including [CONDITION(S)] disorder, presbyopia (age related gradual loss of your eyes' ability to focus on nearby objects) and sleep related bruxism (involuntary clenching and grinding of the teeth during sleep). A review of Resident 2's MDS dated [DATE], indicated Resident 2 was cognitively intact for daily decision making and independent with activities of daily living. A review of Resident 2's Medication Review Report (physician orders), with an order date of 1/20/2022, indicated for the resident to receive [MEDICATION(S)] (a class of medications called benzodiazepines, works by decreasing abnormal electrical activity in the brain), 2 mg one tablet by mouth at bedtime related to [CONDITION(S)] disorder. A review of Resident 2's Medication Administration dated 2/1/2022, indicated Resident 2 received [MEDICATION(S)] 2 mg one tablet daily by mouth at bedtime. A review of Resident 2's Progress Notes, dated 2/15/2021, timed at 11:56 am, indicated, ADM notified Resident 2's responsible party about facility staff finding Resident 2 with marijuana. The notes indicated the resident's responsible party agreed to not give Resident 2 so much money (unidentified amount) since Resident 2 did not need a lot of money at the facility. A review of Resident 3's Admission Record indicated Resident 3 was admitted on [DATE] with multiple diagnoses including paranoid [CONDITION(S)] (a serious mental disorder in which people interpret reality abnormally), [CONDITION(S)] (a condition in which your [CONDITION(S)] doesn't produce enough of certain crucial hormones) and [CONDITION(S)] (a low number of red blood cells). A review of Resident 3's Medication Review Report (physician orders), with an order date of 8/12/2020, indicated for the resident to receive [MEDICATION(S)] ([MEDICATION(S)], antipsychotic medication used to treat the symptoms of [CONDITION(S)] [a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions]), 20 mg, one tablet a day related to paranoid [CONDITION(S)]. A review of Resident 3's MDS, dated [DATE], indicated Resident 3 was cognitively intact for daily decision making and independent with activities of daily living. A review of Resident 3's Medication Administration dated 2/1/2022, indicated Resident 3 received [MEDICATION(S)] 20 mg one tablet daily. During an interview on 2/23/2022, at 12:58 pm, Resident 1 stated he was smoking marijuana and got caught like a week ago, when the Activity Director (AD) and SSD found a pipe (is used to inhale the smoke of a burning substance) in his backpack. Resident 1 could not remember the exact date and time he was caught. Resident 1 stated he obtained marijuana from PC who would roll the marijuana up and dropped it in the morning by the tree or curb in the parking lot and would tell Resident 1 where he dropped the marijuana and Resident 1 would find it, put it away and save it for the night. Resident 1 stated, he started off getting the marijuana for free then the PC started asking him to pay. The most he paid PC was $20.00 for two years. During an interview on 2/23/2022, at 1:35 pm, Resident 2 stated PC gave her a joint, (another term for marijuana) last summer (unidentified time). Resident 2 did not answer when asked how much she paid PC for the marijuana. During an interview on 2/23/2022, at 1:46 pm, Resident 3 stated she obtained marijuana from Resident 1 who bought it from PC. Resident 3 stated she paid $5.00 (five dollars) for a joint. Resident 3 stated Resident 2 and another resident (unidentified) who was no longer at the facility told her PC gave them joints, edibles brownies or cookies with weed (another term for marijuana) in it. During an interview on 2/23/2022, at 3:20 pm, ADM stated Resident 1 was found to have marijuana in his room on 2/15/22 during a room search (the facility's weekly process of checking resident rooms for unauthorized items including contrabands [goods that have been imported or exported illegally] along with tidying up the room). ADM stated marijuana was considered a contraband and was not allowed in the facility. During an interview on 2/24/2022, at 11 am, ADM stated, the incident on 2/15/2022 was not reported to CDPH since the facility did not know who gave the marijuana to Residents 1, 2, and 3, until facility started their investigation on 2/18/2022. ADM stated she failed to report the incident to CDPH within twenty-four hours. ADM also stated PC was terminated from employment. During an interview on 2/28/22, at 10:28 am, SSD stated Resident 1, and Resident 2 were observed on 2/15/22, (time unidentified), by a Certified Nursing Assistant (unidentified) smoking cigarettes in the back patio during a non-smoking schedule. A room search was conducted by SSD and AD on the same day after the residents were interviewed. More cigarette lighters, a pipe to smoke marijuana according to Resident 1 and what appeared to be a rolled joint that looks like a white paper rolled, just a little bit of some green stuff in it, were found in Resident 1's room who stated it was marijuana. SSD bagged the marijuana and threw it in the locked dumpster outside of the building. No marijuana or contraband was found in Resident 2's room. SSD stated the incident was reported to ADM on the same day, time undetermined. According to MedlinePlus it is possible to overdose on marijuana if someone takes a very high dose. Symptoms of an overdose include anxiety (nervousness), panic (sudden uncontrollable fear or anxiety), and a rapid heartbeat. In rare cases, an overdose can cause paranoia (an unrealistic distrust of others or a feeling of being persecuted) and hallucinations (involve sensing things such as visions, sounds, or smells that seem real but are not). Retrieved from https://medlineplus.gov/marijuana.html According to BMJ Journals, cannabis (marijuana) use might be associated with worse clinical outcomes in [CONDITION(S)] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) by contributing towards failure of antipsychotic treatment. Retrieved from https://bmjopen.bmj.com/content/6/3/e 8 According to U.S. National Library of Medicine National Institutes of Health, daily use of marijuana increases the risk of psychotic (a mental disorder characterized by a disconnection from reality) illness development. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 38/#:~:text=Frequent%20use%20of%20cannabis%2C%20especially,high%20potency%20THC%20%5B18%5D. According to Northpoint Recovery, antipsychotic medications are used to manage the symptoms of [CONDITION(S)], especially as they present in patients with [CONDITION(S)] disorder or [CONDITION(S)]. However, using marijuana while taking an antipsychotic can result in reduced blood plasma levels of the medication. Not only does this limit their effectiveness, but marijuana use is also itself associated with psychotic events, worsened depressive episodes, and rapid, unpredictable mood cycling. Complicating this problem is the fact that regular weed users are not typically compliant with their medication schedules. This is particularly important because missing even a single dose of a mood-stabilizing medication can trigger psychotic flareups. Retrieved from: https://www.northpointrecovery.com/blog/warning-mixing-marijuana-and-207-other-common-substances-what-not-to-do/ Benzodiazepines are prescribed as anti-anxiety medications, sleeping aids, anticonvulsants, and muscle relaxants. As with barbiturates, the concurrent use of both benzos and weed can lead to over-sedation, with such side effects as confusion, inability to concentrate, excessive drowsiness. This can lead to accidents, injury, and dangerous dosage errors Retrieved from: https://www.northpointrecovery.com/blog/warning-mixing-marijuana-and-207-other-common-substances-what-not-to-do/