Every finding on record at Meadowbrook Behavioral Health Center

Based on interview and record review, the facility failed to conduct and document a physical and mental status assessment prior to one of three residents (Resident 1) leaving the facility out on pass (OOP - a temporary, physician-approved leave from a facility) for therapeutic leave on 7/10/2026 according to the facility's policy and procedures (P&P) titled Out on Pass, last reviewed by the facility on 1/21/2026. As a result, on 7/10/2026 Resident 1 eloped (when a resident leaves the facility without the knowledge or permission of the staff) from a restaurant while out on pass, placing Resident 1 at increased risk for falls, injuries, hospitalization, and death.Findings:During a review of Resident 1's admission Record dated 7/17/2026, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including paranoid schizophrenia (a mental health condition characterized by disturbances in thought and extreme suspicion) and hypertension (high blood pressure; a condition where the force of blood pushing against artery walls is consistently too high). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 7/3/2026, the MDS indicated Resident 1's cognition (ability to think, read, learn, remember, reason, express thoughts and make decisions) was intact. The MDS indicated Resident 1 had no impairment to both sides of his upper extremities (shoulder, elbow, wrist, and hand) and lower extremities (hip, knee, ankle, and foot) and did not require the use of mobility devices (products designed to help individuals move around more easily). During a review Resident 1's Superior Court Conservatorship Correspondence dated 7/8/2026, the Superior Court Conservatorship Correspondence indicated Resident 1 was under the continued power of conservatorship (a legal arrangement where a judge appoints a responsible person to manage the personal and/or financial affairs of an adult who is unable to care for themselves due to physical or mental limitations). During a review of Resident 1's care plan report, dated 7/2/2026, the care plan report indicated Resident 1 was a High risk for elopement due to a history of substance abuse. During a review of Resident 1's Physician's Order dated 7/10/2026, the physician's order indicated Resident 1 was permitted to leave the facility OOP for therapeutic leave on 7/10/2026 at 11 AM and was expected to return to the facility by 7 PM the same day. During a review of Resident 1's Interdisciplinary Team (IDT - a group of healthcare professionals from different disciplines) Care Conference (CC) form dated 7/9/2026, the IDT CC form indicated Resident 1's conservator (a court-appointed person who makes medical and personal care choices for an adult who can no longer care for themselves) and primary physician had agreed to allow Resident 1 to leave the facility OOP with family member (FM 1). During a review of Resident 1's Situation Background Assessment Recommendation (SBAR -a framework used to standardize and streamline communication between healthcare professionals) Communication Form dated 7/10/2026, the SBAR Communication Form indicated Resident 1 eloped while under the custody of FM 1 during a therapeutic OOP with FM 1 at a restaurant outside the facility. During an interview on 7/17/2026 at 8:02 AM with the Director of Nursing (DON), the DON stated that Resident 1 had not been located after Resident 1 eloped from a restaurant on 7/10/2026 during an OOP therapeutic leave from the facility. During an interview on 7/17/2026 at 1:29 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated immediately prior to a resident leaving the facility to go OOP, a licensed nurse had to assess the resident's physical and mental status and document the assessments on the resident's progress notes in the medical record. LVN 1 stated that resident assessment was performed to ensure the safety of the resident and ensure the resident was safe to leave the facility for the day. LVN 1 stated if the resident assessment information was not documented in the medical chart, then it was not done. During an interview on 7/17/2026 at 2:40 PM with the DON, the DON stated immediately before a resident left the facility to go OOP, a licensed nurse had to assess the resident's physical and mental status. The DON stated that the assessment was important to assess the resident's readiness to leave the facility for the day and had to be documented in the resident's medical record along with the time the resident left the facility. The DON reviewed Resident 1's medical record, the DON could not find any documented evidence by a licensed nurse of Resident 1's assessment prior to Resident 1 leaving OOP. The DON stated, if this assessment was not documented, then it did not happen. During a review of the facility's P&P titled, Out on Pass last reviewed by the facility on 1/21/2026, the P&P indicated Prior to the resident leaving on pass, a Licensed Nurse will assess the resident's physical and mental status. During a review of the facility's P&P titled, Charting and Documentation last reviewed by the facility on 1/21/2026, the P&P indicated The following information is to be documented in the resident medical record: Objective observations; Medications Administered; Treatments or services performed. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on interview and record review, the facility failed to have a system in place and develop a policy on how to supervise and monitor one of one resident (Resident 1) who was transported by court personnel to attend in person court proceedings on 6/22/2026. The facility was aware Resident 1 was a high risk for elopement and had repeated verbalized wanting to leave/elope (is when a patient leaves a healthcare facility against medical advice, when doing so poses an imminent threat to the patient's health or safety) the facility. As a result, on 6/22/2026 at approximately 3 P.M., Resident 1 eloped from the court during the resident's court proceedings and has not been located. Findings: During a review of Resident 1's admission record, dated 1/2/2026, indicated Resident 1 was admitted to the facility on 1/2/2026 with a diagnosis of paranoid schizophrenia (a severe brain disorder when a person loses touch with reality causing intense fears that others will harm them). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 4/15/2026, indicated Resident 1 was cognitively intact (mental ability to make decisions) and was able to ambulate (to walk) without assistive devices. During a review of an e-mail (electronic mail) from Resident 1's Psychiatrist (PSY) to the Administrator (Admin), dated 6/24/2026, indicated, On Monday, 6/22/2026 at approximately 3 P.M, while I was in the process of completing testimony for (Resident 1) in her conservatorship trial and the court was rendering their opinion that the client remained gravely disabled, (Resident 1) became upset with the ruling and stated she did not want to return to the (Facility). Despite the court's admonishment to remain seated and complete her program at the (Facility), (Resident 1) then bolted from the courtroom. The Judge stated, '(Resident 1) has exited the courtroom.' During a review of Resident 1's Interdisciplinary (IDT - is a coordinated group of medical and support professionals who collaborate to plan, deliver, and evaluate unified patient care) Care Conference notes, dated 3/8/2026, indicated, Resident verbalized wanting to leave the facility. Staff will continue to provide support, encouragement, and monitoring to assist the resident in progressing toward treatment goals. During a review of Resident 1's Social Services Progress Notes, dated 4/7/2026, indicated, Resident verbalized a desire to leave the facility and how, and Resident 1 was placed on 1:1 monitoring (when one staff member constantly watches one person) for 72 hours. The progress notes also indicated, (Resident 1) kept saying that we will miss her tomorrow and said she would break a window to leave. During a review of Resident 1's Elopement Evaluation Note, dated 4/7/2026, indicated: Does the resident have a history of elopement or an attempted elopement while at home: Yes. Does the resident have a history of attempting to leave the facility without informing staff: Yes. During a review of Resident 1's progress notes, dated 6/20/2026, indicated, She (Resident 1) shared that she contacted her conservator and expressed a desire to leave the facility and stated that she does not feel she can continue participating in the program. During an interview on 6/24/2026 at 2:16 P.M. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, She (Resident 1) was excited to go to the court hearing on 6/22/2026 and also said that she wanted to leave the facility. CNA 1 stated she could not remember if she notified her supervisor of Resident 1's desire to leave the facility. During an interview on 6/25/2026 at 9:47 A.M. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated once a resident is transferred outside of the facility for their court proceeding, staff is not aware of when they will return. LVN 1 stated he was on duty on 6/22/26 when Resident 1 was picked up and transported for court proceeding outside the facility. LVN 1 stated, The LVN/Charge nurse will perform a behavioral and elopement risk assessment prior to the resident transferring out of the facility for court proceedings. LVN 1 stated a resident requires a physician order to attend court proceedings outside the facility by a psychiatrist (a medical doctor who treats mental illness). LVN 1 stated that if a resident does not return from the court proceedings/hearing, the facility will call the court transport driver to receive an update on the resident. LVN 1 stated the facility staff do not know exactly when the resident will return. LVN 1 stated that residents usually just return by the end of the day. LVN 1 stated he did not talk to court staff who transferred (Resident 1) to court on 6/22/2026 did not know which facility staff handed over the resident to the court staff. During an interview on 6/25/2026 at 11:30 A.M. with the Social Services Director (SSD), the SSD stated he did not know if a physician's order was needed for a resident to transfer outside of the facility to attend in-person court proceedings. The SSD stated he did not know if the facility had a policy for resident transfer outside of facility for in-person court proceedings. During an interview on 6/25/2026 at 12:25 P.M. with the Director of Nursing (DON), the DON stated he did not know: The reason residents are not escorted by facility staff when transferred outside of the facility to attend in-person court proceedings. If court staff who transferred Resident 1 to the court proceeding on 6/22/2026 were aware Resident 1 was high risk for elopement. If the facility had a policy and procedures for when a resident is transferred/transported outside the facility to attend an in-person court proceeding. During an interview on 6/25/2026 at 12:35 P.M. with the Administrator (Admin), the Admin stated that Resident 1 was at risk for elopement and had verbalized to facility staff she wanted to leave the facility. The Admin stated that the court staff who transferred Resident 1 to attend court proceedings on 6/22/2026 were not licensed nurses. The Admin stated, She (Resident 1) has a right to leave. During an interview on 6/25/2026 at 1:49 P.M. with the PSY, the PSY stated: Resident 1 was found gravely disabled by the court, so she cannot provide food, shelter, clothing, and so is mandated to be in a locked facility. On 6/22/2026, Resident 1's conservator was present at Resident 1's court proceeding. I am not aware if the conservator is a licensed practitioner. During a concurrent interview and record review on 6/25/2026 at 3:08 P.M. with the Admin and DON, the Admin and DON stated a facility policy is a guideline that staff need to follow and and accessible to all staff in order to properly care for the residents. The Admin and DON stated that if a resident on 1:1 monitoring (a dedicated staff member is assigned to stay in the room and directly supervise a single high-risk patient and for patient safety) is left unsupervised could potentially cause harm to the resident or even result in death. The Admin and DON confirmed and stated that the facility does not have policy for when a resident attends court proceedings outside of the facility. During a review of the facility's policy and procedures (P&P) titled, Out on Pass, with a review date of 1/21/2026, indicated, The Facility will make reasonable efforts to ensure the resident safety and uphold resident rights. During a review of the facility's P&P titled, Wandering and Elopements, with a review date of 1/21/2026, indicated, The Facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

Based on interview and record review, the facility failed to inform a physician of an abnormal laboratory (lab) result for one of four sampled residents (Resident 61) according to the facility's policy and procedures (P&P) titled Change in Condition: Notification of reviewed 1/21/2026. This deficient practice placed the resident at risk for not having appropriate treatment for abnormal laboratory results and as a result on 11/13/2025, Resident 61 was transferred to a general acute hospital (GACH) from a doctor's appointment for chronic anemia. Findings: A review of Resident 61's admission record indicated the facility admitted the resident on 4/19/2017 and was re-admitted on [DATE] with diagnoses that included chronic kidney disease stage 4 (sever kidney damage and are not properly filtering waste from the blood ), iron deficiency anemia( a condition where the body does not have enough healthy red blood cells) and anemia in chronic kidney disease. A review of Resident 61's care plan on Anemia (low blood count), initiated 7/1/2020, indicated the resident has anemia due to chronic kidney disease. The same care plan also indicated due to the anemia Resident 61 was at risk for low hemoglobin, weakness, shortness of breath and fatigue. The same care plan goal indicated that the resident be observed for signs and symptoms of anemia complications. The care plan interventions included administer medication as ordered, assess for increased fatigue and shortness of breath and lab work as ordered and notify the physician of results per policy. A review of Resident 61's lab result, dated 5/15/2025, indicated the resident's hemoglobin (HGB - the protein contained in red blood cells that is responsible for the delivery of oxygen to the tissues) level was 9.7 grams per deciliter (g/dl - a unit of volume)]. The lab result also indicated this was a low value (L) and the normal reference range was 11 to 18 g/dl. A review of Resident 61's lab result, dated 11/11/2025, indicated the resident's hemoglobin (HGB - the protein contained in red blood cells that is responsible for the delivery of oxygen to the tissues) level was 8.8 grams per deciliter (g/dl - a unit of volume)]. The lab result also indicated this was a low value (L) and the normal reference range was 11 to 18 g/dl. A further review of the lab result indicated this was 0.9 points less than the previous lab result on 5/15/2025. A review of Resident 61's Nurses Progress Note, dated 11/13/2025, indicated the resident went to Nephrology (pertaining to the kidneys) appointment for regular follow-up with escorts. The note also indicated the physician sent the resident to a GACH due to chronic anemia from the appointment. The Progress Note further indicated Resident 61's responsible party was informed. A review of Resident 61's Emergency Department (ED - the department of a hospital that provides immediate treatment for acute [sudden onset] illness and trauma) Progress Note, dated 11/13/2025, indicated Resident 61 was sent to the ED by for the evaluation of chronic anemia and kidney disease by the resident's nephrologist (a medical doctor that specializes in kidney diseases). The Progress Note indicated Resident 61 was experiencing some chest pain. The Progress Note further indicated the resident's anemia was due to a gastrointestinal bleed at this time and the resident was given intravenous (inside a vein) fluids of normal saline (a blood volume substitute mad e of salt and water, a temporary substitute for lost blood). The Progress Note also indicated the plan was to admit the resident for continued care and management which would include close monitoring and treatment of unstable vital signs, cardiorespiratory and neurological status, while maintain tight balance of fluid, respiratory, and cardiac interventions. A review of Resident 61's Nurses Progress Note, dated 11/14/2025, indicated the resident returned from the GACH at 7:45 PM. The Note further indicated Resident 61 had two blue discolored areas on the right upper arm (one 2cm, another one 4cm long in size). During a concurrent interview and record review on 4/3/2026 at 3:19 PM, Resident 61's electronic medical chart was reviewed with RN 1. RN 1 stated Resident 61 went to the ED on 11/13/2025 and returned on 11/14/2025 due to anemia. Upon review of Resident 61's lab results dated 11/11/2025, RN 1 stated Resident 61's hemoglobin was 8.8 [g/dl]. RN 1 stated this was a low number and required the physician to be notified. Upon review of Resident 61's progress notes and change of condition forms, RN 1 stated, there was no evidence the physician was notified of the lab result. RN 1 further stated RN 1 stated nursing staff is to notify the physician of abnormal labs that way the physician could change the residents medications, perform further tests or send the resident to the ED for treatment. A review of the facility's policy and procedures (P&P), titled Change in Condition: Notification of, reviewed 1/21/2026, indicated, The purpose was to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition. Facility must immediately inform the resident, consult with the Resident's physician and/or Nurse Practitioner, and notify, consistent with his/her authority, Resident Representative where there is: A significant change in the Resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment).A review of the facility's P&P, titled, Lab and Diagnostic Test Results - Clinical, reviewed 1/21/2026, indicated When test results are reported to the facility, a nurse will first review the results.a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor,charge nurse, etc.) should follow or coordinate the procedure.2. Before contacting the physician, the person who is to communicate results to a physician will gather, review, and organize the information and be prepared to discuss the following (to the extent that such information is available): a. The individual's current condition and details of any recent changes in status, including vital signs and mental status; b. Major diagnoses, allergies, current medications, any recent pertinent lab work, actions already taken to address results treat the resident/patient and pertinent aspects of advance directives (for example, limitations on testing and treatment); c. Why the lab and diagnostic tests were obtained (for example, as a routine screen or follow-up; to assess a condition change or recent onset of signs and symptoms, or to monitor a serum medication level; d. How test results may relate to the individual's current condition and treatment; and e. Any concerns and questions the physician will be expected to address regarding the resident.3. A nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality, and the individual's current condition.4. A nurse will try to determine whether the test was done. a. As a routine screen or follow-up; b. To assess a condition change or recent onset of signs and symptoms; or c. To monitor a drug level. 1. The reason for getting a test often affects the urgency of acting upon the result 2. If the reason for performing the test cannot be identified, the nurse should proceed as though the tests were ordered to assess a condition change or recent onset of signs and symptoms.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 28) participated in care plan meetings to discuss his psychotropic (A drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications according to the facility's policy and procedures (P&P), Care Planning - Interdisciplinary Team, reviewed 1/21/2026. This deficient practice had the potential to violate Resident 28's right to be an active participant in his own care. Findings: A review of Resident 28's admission Record indicated the facility admitted the resident on 10/14/2024 with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought) and general anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities). A review of the Minimum Data Set (MDS - a resident assessment tool), dated 1/24/2026, indicated Resident 28's cognition (ability to think, read, learn, remember, reason, express thoughts and make decisions) was intact. The MDS also indicated the resident had hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). A review of Resident 28's risk for complications care plan, initiated 10/14/2024, indicated the resident was at risk for complications related to the use of psychotropic medications including Seroquel, Zyprexa and Trazodone. The care plan goal was for the resident medication to be effective without side effects. The care plan interventions included for staff to monitor for changes in mental status and functional level and report to physician, monitor for continued need of medication as related to behavior and mood and to provide informed consent to resident or healthcare decision maker. A review of Resident 28's Physician Orders indicate the physician ordered the resident to receive the following:On 1/26/2026, Trazodone 100 milligrams (mg) by mouth at bedtime for problematic sleep related to schizophrenia and generalized anxiety disorderOn 2/9/2026, Seroquel (antipsychotic medication) XR 300 milligrams (mg) by mouth at bedtime for delusions related to schizophrenia and generalized anxiety disorderOn 3/10/2026, Zyprexa (an antipsychotic medication) 20 mg by mouth at bedtime for schizophrenia manifested by delusions A review of Resident 28's interdisciplinary team (IDT - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] Care Conference (CC) forms indicated the following:On 2/18/2026 an IDT CC was held to discuss Resident 28's psychotropic medication management. The IDT CC indicated the Program Director (PD) and Registered Nurse Supervisor (RNS) 1 attended the meeting. The form did not list Resident 28 as an attendee.On 3/6/2026 an IDT CC was held to discuss Resident 28's weight. The attendees listed included PD, DSD, the Registered Dietician (RD), Resident 28 and Resident 28's conservator (CONSV).On 3/11/2026 an IDT CC was held to discuss Resident 28's psychotropic medication management. The IDT CC indicated the PD, RNS 1, the Director of Staff Development (DSD) and Assistant Program Director (APD) attended the meeting. The form did not list Resident 28 as an attendee. During an interview on 3/31/2026 at 8:25 AM Resident 28 stated he hasn't been able to speak to anyone about his medications. Resident 28 stated he has a diagnosis of schizophrenia and Resident 28 stated his medications are making him more confused and he has started hearing more voices since beginning his current medications. Resident 28 stated he has attended IDT meetings but his medications were not addressed. During a concurrent interview and record review on 4/1/2026 at 11:22 AM, Resident 28's IDT CC forms were reviewed. RNS 1 stated all residents are educated on their medications and any changes to their medications. RNS 1 further stated the resident and the resident's responsible party are part of the IDT Care Conference. RNS 1 also stated Resident 28's last care conference to discuss his medications were held on 3/11/2026 and the resident's increased dosage of Zyprexa was discussed. RNS 1 also stated that there was no indication that Resident 28 attended the conference or was invited. RNS 1 stated the resident should have input and be involved in their own care planning so we know if the medication is working. A review of the facility's policy and procedures (P&P), Care Planning - Interdisciplinary Team, reviewed 1/21/2026, indicated,The care plan is based on the resident's comprehensive assessment and is developed by an Interdisciplinary Team which (Deludes but is not necessarily limited to the following personnel.a. The resident's Attending Physician.b. A registered nurse with responsibility for the resident.c. The Dietary Manager/Dietitian.d. The Social Services Worker responsible for the resident.e. The Activity Director/Coordinator.f. Specialized Rehabilitative Service Therapists, as applicable.g. To the extent practicable, the participation of the resident and the resident's representative(s).

Based on observation, interview and record review the facility failed to provide timely nutritional intervention/s to prevent continuous significant weight loss for one of two sampled residents (Resident 51) who had weight loss, by failing to: 1. Initiate a change of condition (COC- refers to a significant alteration in a person's physical, mental, or functional health status compared to their previous baseline, often requiring new interventions) form for an 18 pounds (Ibs - unit of measurement) weight loss documented on 3/3/2026.2. Conduct a weight variance Interdisciplinary team (IDT - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) when Resident 51 experienced weight loss.3. Revise the interventions on Nutritional Risk Weight Loss care plans. This deficient practice placed the resident at risk for continued weight loss. Findings: A review of Resident 51's admission Record indicated the facility admitted the resident on 11/24/2025 with diagnoses including included paranoid schizophrenia (type of schizophrenia associated with feelings of being persecuted or plotted against), high cholesterol and high blood pressure. A review of Resident 51's admission History and Physical, dated 11/24/2025, indicated the resident's current weight was 241 lbs. A review of the Minimum Data Set (MDS - a resident assessment tool), dated 3/3/2026, indicated Resident 51 cognitive (ability to learn, reason, understand, make decisions, and make needs known) skills for daily decision-making was intact. The MDS indicated the resident was could independently perform all activities of daily living (ADLs- activities such as bathing, dressing, eating and toileting a person performs daily) The MDS also indicated the resident weighed 224 lbs had experienced a weight loss of 5% or more in the last month or a loss of 10% in the last 6 months and was not on a physician-prescribed weight loss regimen. A review of Resident 51's weight log indicated Resident 51 weight was as follows:On 11/24/2026 - 241 IbsOn 11/27/2026 - 236 lbsOn 12/3/2026 - 232 lbs (4.5 % weight loss)On 1/1/2026 - 224 lbsOn 2/4/2026 - 224 lbsOn 3/3/2026 - 206 lbs (8.1% weight loss) A review of Resident's 51 SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated 1/5/2026, indicated the resident had an eight pound weight loss and the physician recommended an registered dietitian evaluation. A review of Resident SBAR forms indicated no change of condition was initiated for the 3/32026 18 lb weight loss. A review of Resident 51's weight loss care plan, initiated 1/5/2026, indicated the resident's weight went from 230 lbs to 224 pounds in one month and the resident was at risk for further weight loss due to parodic [sporadic/periodic?] refusal of breakfast. The goal was for the resident to consume 50 percent (%) or more of breakfast daily. The care plan interventions included for the Certified Nursing Assistant (CNA) to inform the charge nurse of breakfast or meal refusal, for the CNA to monitor and document the residents meal intake at lunch and dinner and report poor intake for the charge nurse for follow up and for a registered dietician evaluation for recommendations. A further review of the care plan indicated no new interventions were put in place when the resident continued to lose weight on 3/3/2026. A review of Resident 51's Nutritional Risk Care plan, initiated 1/6/2026, indicated the resident experienced a significant weight loss of 5.1% in one month. The care plan goal was for the resident to avoid a change in weight of greater than or equal to five percent. The care plan interventions included to weigh monthly, offer snacks and honor [NAME] preferences within the meal plan. A further review of the care plan indicated the care plan was not updated or revised after 1/6/2026 and not after the resident's continued weight loss on 3/3/2026. During a concurrent interview and record review on 4/1/2026 at 11:02 AM, Resident 51's electronic health chart was reviewed. The Registered Nurse Supervisor (RNS 1) stated residents are weighed monthly. If a significant change is noted, we do a change in condition right away, we contact the physician and the interdisciplinary team (IDT, - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) meets to determine if the weight loss is favorable or not favorable. RNS 1 further stated Resident 51 was 241 pounds when he was first admitted in November 2025. RNS 1 further stated Resident 51 started losing weight and the weight loss was care planned and the dietician recommended the resident to have a half sandwich as a morning snack to improve caloric intake and to maintain his weight. RNS 1 further stated Resident 51 did cut his hair recently but that could not account for an 18 pound weight loss. RNS 1 stated Resident 51's his nutrition care plans were not updated and IDT was not held since the significant weight loss was discovered on 3/3/26. RNS 1 stated a Weight Variance IDT should have been held. The care plan is for continuity of care and to know the changes that need to be made for the resident's health and to prevent the weight loss from continuing. During an observation on 4/1/2026 at 12:03 PM, Resident 51 ate 100% of lunch. During an interview on 4/3/2026 at 11:59 AM, Resident 51 stated he was happy with is weight loss and he went to his first IDT meeting for his weight loss a couple of days ago. Resident 51 also stated his hair did not account for the 18 lb weight loss. The Registered Dietician for the facility was not available to interview. A review of the facility's policy and procedure (P&P) titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, reviewed 1/21/2026, indicated, The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. The P&P also indicated The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes.a. Treatment decisions should consider all pertinent evidence and relevant issues (e.g., food intake, resident/ patient wishes, overall condition and prognosis, etc.), and should not be based solely on lab or diagnostic test results (albumin, cholesterol, swallowing studies, etc.).

Based on observation, interview and record review the facility failed to follow the facility's policy and procedure (P&P) titled, Smoking, by not performing quarterly smoking assessments for two of two sampled residents (Resident 35 and Resident 71). This deficient practice placed Resident 35 and Resident 71 at increased risk for injury related to smoking. a. A review of Resident 35's admission record indicated the facility admitted the resident, on 11/18/2025 with diagnoses that included paranoid schizophrenia (type of schizophrenia associated with feelings of being persecuted or plotted against), Syphilis (a common, curable sexually transmitted infection (STI) caused by bacteria (tiny, single-celled living organisms found everywhere in the world). A review of Resident 35's Quarterly Minimum Data Set (MDS- a resident assessment tool), dated 3/3/2026, indicated Resident 35's cognition (mental ability to make decisions of daily living) was intact. A review of Resident 35's Smoking Evaluation, dated 11/20/2025, indicated Resident 35 could safely smoke without the use of a smoking apron. A review of Resident 35's Smoking Evaluation indicated Resident 35's last smoking evaluation was completed on: 03/30/2026 [more than 4 months later]. A review of Resident 35'sMay smoke with supervision care plan, initiated 11/20/2025, the resident's supervisory needs were made based on the smoking assessment. A review of the same care plan indicated the goal was for Resident 35 to smoke safely. The same care plan interventions included to supervise Resident 35 with smoking in accordance with assessed needs, inform and remind patient application of smoking areas and times, and Inform family and significant others that the patient needs supervision while smoking. During a concurrent interview and record review on 4/3/2026 at 12:21 PM, Resident 35's smoking assessments were reviewed with the Registered Supervisor (RNS) 1. RNS 1 stated Resident 35's last smoking assessment was completed on 03/30/2026 and prior to that the smoking assessment was done on 11/20/2025. RNS 1 further stated there should have been a smoking assessments completed by in February 2026. RNS 1 stated the smoking assessment is completed to evaluate if the resident could smoke safely. RNS 1 further stated by not completing a smoking assessment Resident 35 was at risk for smoking injury and it could affect the resident's health. A review of the facility's policy and procedures (P&P) titled, Smoking, reviewed 1/21/2026, indicated, It was the policy of this facility to accommodate residents who desire to smoke by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents. 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. A 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 (IDT) for review. b. A review of Resident 71's admission record indicated the facility admitted the resident, on 3/1/2021 with diagnoses that included paranoid schizophrenia (type of schizophrenia associated with feelings of being persecuted or plotted against), high cholesterol and high blood pressure. A review of Resident 71's MDS, dated [DATE], indicated Resident 71's cognition (mental ability to make decisions of daily living) was intact. A review of Resident 71's Smoking Evaluation, dated 3/12/2025, indicated the resident could safely smoke without the use of a smoking apron. A review of Resident 71's Smoking Evaluations indicated a Resident 71's last two smoking evaluations were completed on: 9/12/2025 then again on 4/1/2026 [more than 6 months later]. A review of Resident 71'sMay smoke with supervision care plan, initiated 3/1/2021, the resident's supervisory needs was made based on the smoking assessment. A review of the same care plan indicated the goal was for the resident to smoke safely. The same care plan interventions included to supervise Patient (Resident 71) with smoking in accordance with assessed needs, inform and remind patient application of smoking areas and times, and Inform family and significant others that the patient needs supervision while smoking. During an observation on 4/2/2026 at 9:46 AM, Resident 71 was observed entering the smoking patio. Facility staff handed Resident 51 a pack of cigarettes. Resident 71 removed one cigarette from the pack and returned the pack to the staff member. The staff member then lit Resident 71's cigarette and Resident 71 proceeded to smoke on the patio. During a concurrent interview and record review on 4/3/2026 at 12:21 PM, Resident 71's smoking assessments were reviewed with the Registered Supervisor (RNS) 1. RNS 1 stated Resident 71's last smoking assessment was completed on 4/1/2026 and prior to that the smoking assessment was done on 9/12/2025. RNS 1 further stated there should have been smoking assessments completed by in December 2025 and March 2026. RNS 1 stated the smoking assessment is completed to evaluate if the resident could smoke safely. RNS 1 further stated by not completing a smoking assessment Resident 71 was at risk for smoking injury and it could affect the resident's health. A review of the facility's policy and procedures (P&P) titled, Smoking, reviewed 1/21/2026, indicated, It was the policy of this facility to accommodate residents who desire to smoke by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents. 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. A 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 (IDT) for review.

Based on observation, interview and record review, the facility failed to ensure licensed nurses notify the physician for orders for blood glucose monitoring twice daily as indicated in the plan of care under the physician's progress notes for one of the three residents (Resident 1). This deficient practice of failing to notify the physician for orders as indicated in the physician's plan of care had the potential to cause adverse effects of hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar) for Resident 1. Findings: During a review of Resident 1's admission Record (face sheet - a document containing demographic and diagnostic information) indicated Resident 1 was admitted to the facility on [DATE] with the following diagnoses: paranoid schizophrenia (a serious mental disorder characterized by prominent symptoms like intense paranoia, delusions [fixed, false beliefs not based in reality], and hallucinations [seeing, hearing, feeling things that are not there]), Type 1 diabetes mellitus with ketoacidosis without coma (a serious medical emergency where insulin deficiency causes high blood sugar and accumulation of acid often leading to symptoms like nausea, abdominal pain, and extreme thirst without causing loss of consciousness; it requires immediate hospitalization for intravenous insulin and fluids) and long term use of insulin (safe and effective for managing diabetes when monitored by a doctor, essential for Type 1). During a review of Resident 1 care plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) with an initiation date of 12/05/2025 and a target date of 4/05/2026, indicated, Resident 1 had a diagnosis of diabetes, dependent on insulin. The CP goal indicated Resident 1 will be free of all signs and symptoms of hypoglycemia (low blood sugar of <60 milligrams per deciliter [mg/dL]=a unit of measurement used to express the concentration blood glucose within a specific volume of blood) and hyperglycemia (high blood sugar > 400 mg/dL). The CP interventions included access and record blood glucose levels. During a review of Resident 1 Minimum Data Set (MDS - a resident assessment tool) dated 1/13/2026, indicated, Resident 1's cognition is intact (a person's thinking and reasoning abilities are functioning properly and are not significantly impaired). The MDS also indicated, Resident 1 does not use any mobility devices (helps a person walk or move from place to place when one has a disability or injury) when ambulating (walking). During a review of Resident 1's Progress Notes (captures the details of a patient's health status, treatment progress, and any changes in their condition over time) history and physical (H&P - a physician's complete patient examination) dated 1/05/2026, 1/20/2026, 1/29/2026, 2/06/2026 and 3/03/2026 indicated, Resident 1 had the diagnoses of type 1 diabetes mellitus with ketoacidosis without coma, paranoid schizophrenia and long-term use of insulin. The Progress Notes also indicated to continue blood glucose monitoring twice daily. During a review of Resident 1's blood glucose level monitoring in January 2026, Resident 1's blood glucose levels were checked from 1/01/2026 until 1/06/2026. The blood glucose levels were as follows:1/01/2026 at 9:55 AM = 112 mg/dL1/01/2026 at 8:06 PM = 142 mg/dL1/02/2026 at 9:41 AM = 125 mg/dL1/02/2026 at 8:43 PM = 88 mg/dL1/03/2026 at 8:42 AM = 127 mg/dL1/03/2026 at 8:08 PM = 124 mg/dL1/04/2026 at 8:44 AM = 130 mg/dL1/04/2026 at 8:10 PM = 122 mg/dL1/05/2026 at 8:55 AM = 139 mg/dL1/06/2026 at 8:41 AM = 135 mg/dL During a review of Resident 1's medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for January 2026, indicated, Resident 1's insulin medication glargine (a long-acting insulin that provides a steady, 24-hour blood sugar control) started on 12/18/2025 at 9 PM and was discontinued on 1/06/2026 at 1:52 PM. The order also indicated to hold this insulin when the blood glucose level is less than 100 mg/dL. During a review of Resident 1's MAR for February, March, and April 2026 indicated, Resident 1 had an order for metformin (oral medication used primarily to treat diabetes by lowering blood sugar levels). The MAR for February, March and April 2026 also indicated metformin was started on 12/03/2025 with no end date. During an interview on 4/03/2026 at 1:02 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Nurse Practitioner (NP) 1's plan of care indicated continue blood glucose monitoring twice daily. LVN 1 stated LVN 1 did not know how often nurses checked or read a physician or nurse practitioner's plan of care. LVN 1 stated the physician [or NP] needs to tell the nurse their order. During an interview on 4/03/2026 at 1:47 PM with Registered Nurse Supervisor (RNS) 1, RNS 1 did not provide an answer when asked what was the physician's progress note if it's not read by the nurses. RNS 1 stated a blood glucose monitoring will, tell me whether [Resident 1] is hyperglycemic or hypoglycemic. RNS 1 stated we [nurses] are suppose to read the physician's progress notes but we all don't read the progress notes. During a review of the facility's undated policy and procedure (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Diabetes - Clinical Protocol revised 3/2025, indicated blood glucose monitoring for the resident on oral mediation(s) who is well controlled to monitor blood glucose levels at least twice weekly (or more frequently.) and for resident receiving oral medication(s) who is poorly controlled, monitor blood glucose levels twice to four times daily as needed. During a review of the facility's P&P titled Physician Orders with a review date of 1/21/2026 indicated, other orders will include a description complete enough to ensure clarity of the physician's plan of care.

AmendedBased on observation, interview, and record review, the facility failed to meet the requirement of 80 square feet per resident in 17 out of 27 resident rooms (Rooms 1, 3, 5, 7, 8, 9, 13, 15, 17, 18, 20, 21, 23, 24, 25, 26, and 27) did not meet the requirement of 80 square feet per resident. This deficient practice had the potential to result in inadequate usable living space for resident Rooms 1, 3, 5, 7, 8, 9, 13, 15, 17, 18, 20, 21, 23, 24, 25, 26, and 27. Findings: During record review, the facility's room waiver letter and the client accommodations analysis form completed by the facility on 3/31/2026, indicated the following seven rooms provided less than 80 square feet of livable space per resident.room [ROOM NUMBER]. Beds 2. Room Size (ft.) 140.6. Sq. Ft/Bed 70.3room [ROOM NUMBER]. Beds 6. Room Size (ft.) 140.6. Sq. Ft/Bed 78.1room [ROOM NUMBER]. Beds 5. Room Size (ft.) 336. Sq. Ft/Bed 67.2room [ROOM NUMBER]. Beds 2. Room Size (ft.) 138. Sq. Ft/Bed 69room [ROOM NUMBER]. Beds 2. Room Size (ft.) 138. Sq. Ft/Bed 69room [ROOM NUMBER]. Beds 2. Room Size (ft.) 138. Sq. Ft/Bed 69room [ROOM NUMBER]. Beds 2. Room Size (ft) 236.3. Sq. Ft/Bed 78.8room [ROOM NUMBER]. Beds 3. Room Size (ft) 236.3. Sq. Ft/Bed 78.8room [ROOM NUMBER]. Beds 2. Room Size (ft) 156.8. Sq. Ft/Bed 78.4room [ROOM NUMBER]. Beds 2. Room Size (ft) 156.8. Sq. Ft/Bed 78.4room [ROOM NUMBER]. Beds 3. Room Size (ft) 236.3. Sq. Ft/Bed 78.8room [ROOM NUMBER]. Beds 3. Room Size (ft) 236.3 Sq. Ft/Bed 78.8room [ROOM NUMBER]. Beds 3. Room Size (ft) 236.3. Sq. Ft/Bed 78.8room [ROOM NUMBER]. Beds 3. Room Size (ft) 236.3. Sq. Ft/Bed 78.8room [ROOM NUMBER]. Beds 3. Room Size (ft) 236.3. Sq. Ft/Bed 78.8room [ROOM NUMBER]. Beds 3. Room Size (ft) 236.3. Sq. Ft/Bed 78.8room [ROOM NUMBER]. Beds 3. Room Size (ft) 236.3. Sq. Ft/Bed 78.8 During a concurrent observation and interview on 3/31/2026 at 10:52 AM Resident 28 stated the room gave each resident adequate space. During record review, the facility's room waiver request letter, dated 3/31/2026, the facility, serves individuals diagnosed with chronic and persistent mental illnesses, often accompanied by significant behavioral and emotional disturbances. Unlike traditional geriatric or physically compromised skilled nursing facility populations, our residents are generally ambulatory, physically stable, and capable of independent egress without staff assistance.

Based on observation, interview, and record review, the facility failed to ensure three of 27 resident rooms (rooms [ROOM NUMBER]) accommodated no more than 4 residents per room. Rooms 3, and 4 had six residents, and 5 had five residents. This deficient practice had the potential to affect the delivery of care and safety of the residents, especially during an emergency. Findings: During initial tour of the facility on 3/31/2026 at 10:52 AM Rooms 3, 4 and 5 were observed. In room [ROOM NUMBER], there were six beds in the rooms all with curtains. Resident 28 stated there are no problems with the number of residents in this room. Everyone comes and goes as they please without any difficulty. During record review, the facility's room waiver request letter, dated 3/31/2026, the letter indicated the facility, serves individuals diagnosed with chronic and persistent mental illnesses, often accompanied by significant behavioral and emotional disturbances. Unlike traditional geriatric or physically compromised skilled nursing facility populations, our residents are generally ambulatory, physically stable, and capable of independent egress without staff assistance.

Cross Reference F742 Based on interview and record review, the facility failed to protect one of four residents (Resident 3) from inappropriate touching by Resident 4 according to facility policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Abuse Prohibition, with a review date of 2/23/2021. The facility was aware that Resident 3 was unable to defend himself from Resident 4 and that Resident 4 had a behavior of poor personal boundaries and inappropriate physical contact with residents and staff. This deficient practice caused Resident 3 to experience psychological stress and emotional distress by stating that Resident 4 should not be touching him (Resident 3). This deficient practice increased the risk for peer conflict and safety concerns and posed a significant risk to the safety and well-being of other residents in the facility.Findings: During a review of Resident 4's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 4 was admitted to the facility on [DATE] with the following diagnoses: paranoid schizophrenia (a serious mental disorder characterized by prominent symptoms like intense paranoia, delusions [fixed, false beliefs not based in reality], and hallucinations [seeing, hearing, feeling things that are not there]). During a review of Resident 4's Care Plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) initiated on 7/13/2017 with revision dates of 4/30/2021, 2/07/2025, and 7/31/2025, indicated, Resident 4 had demonstrated repeated bizarre or inappropriate social behaviors related to poor boundaries as evidenced by incidents of standing too close, hovering, or touching others. The CP interventions included to encourage psych/behavioral health consultation, participate in Special Treatment Program for management of physical behaviors, engage in 1:1 (one to one - a staff provides dedicated, focused attention and assistance to a single individual, ensuring their needs and well-being are met with personalized support) counseling focused on social skills to encourage appropriate social interactions with peers/staff. During a review of Resident 4's Behavior Monthly Summary for 2024 for behavior manifestation of intense staring, standing too close, intrusiveness as evidenced by poor boundaries indicated, Resident 4 had the following number of episodes during the day shift (7 AM to 3 PM) from 1/2024 through 12/2024:January=61February=50March=58April=58May=61June=63July=63August=56September=63October=62November=62December=28The Behavior Monthly Summary for 2024 indicated a total 684 episodes for behavior manifestation of intense staring, standing too close, intrusiveness as evidenced by poor boundaries. During a review of Resident 4's Behavior Monthly Summary for 2024 for behavior manifestation of masturbating in public and inappropriate touching indicated, Resident 4 had the following number of episodes during the day shift (7 AM to 3 PM) from 1/2024 through 12/2024:January=23February=23March=29April=30May=38June=39July=36August=41September=36October=46November=48December=6The Behavior Monthly Summary for 2024 indicated a total 395 episodes for behavior manifestation of intense staring, standing too close, intrusiveness as evidenced by poor boundaries. During a review of Resident 4's history and physical (H&P - a physician's complete patient examination) dated 7/24/2025 indicated, Resident 4 had the diagnosis of paranoid schizophrenia and is under a conservatorship (a legal process for adults with severe mental illness who are gravely disabled; they cannot provide for their basic needs and manage their medical treatment, and placement to facilities due to their illness). During a review of Resident 4's Physician Progress Notes (a doctor's written record that documents a patient's health status, treatment, and care plan) dated 9/25/2025 indicated, Resident 4 had a routine medical follow-up but the physician did not receive any new, specific complaints. During a review of Resident 4's Psychotherapy Progress Notes (a standardized tool used by psychologists to record resident's mental and emotional state, behavior and any changes in their condition, to inform care planning and treatment) dated 10/06/2025, indicated, at the time of consultation, Resident 4 was experiencing paranoia, anxious, intrusive, impulsive, had delusional thinking, auditory hallucination, and was disoriented. During a review of Resident 4's Psychotherapy Progress Notes dated 10/24/2025 indicated, Resident 4 reported remembering previous discussion about the importance of maintaining physical boundaries with the other residents. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 10/31/2025, indicated, Resident 4 has an intact cognition (a person's thinking and reasoning abilities are functioning properly and are not significantly impaired). During a review of Resident 4's Nursing Progress Notes dated 11/25/2025 at 12:09 PM, Resident 4 was grabbing others.but redirected to walk. During a review of Resident 4's Nursing Progress Notes dated 12/06/2025 at 8:29 AM indicated, Resident 4 was placed on a 1:1 monitoring. During a review of Resident 4's Room Transfer form dated 12/06/2025 at 2:50 PM, the form indicated Resident 4 was transferred from Room A to Room B. During a review of Resident 4's CP initiated on 12/07/2025 indicated, Resident 4 had poor personal boundaries and inappropriate physical contact with peers, increasing risk for peer conflict and safety concerns. The CP's interventions included, staff will teach resident proper space rules and explain why touching others without consent is unsafe and unacceptable and staff to provide firm, consistent redirection when boundary issues occur. During a review of Resident 4's X-ray results dated 12/07/2025 at 8:42 AM, the report indicated, Resident 4 had no acute fracture or dislocation of the skull/face (no evidence of recent bone breakage or joint displacement found at the time of the scan). During a review of Resident 4's x-ray report dated 12/07/2025, indicated, No acute fracture or dislocation of the skull/face (no evidence of a recent break or out of normal alignment in any of the bones of the skull or face). During a review of Resident 4's Nursing Progress Notes dated 12/08/2025 at 10:10 PM, indicated Resident 4 had verbal expressions of distress up to 5 days a week. The progress notes also indicated Resident 4 was being monitored for intrusive behavior, needed multiple redirections to focus on self and treatment plan and encouraged to maintain proper boundaries with peers. During a review of Resident 4's Physician Order Summary Report dated 12/09/2025, indicated, a physician ordered Resident 4 to have an x-ray of Resident 4's face. During a review of Resident 4's Nursing Progress Notes (captures the details of a patient's health status, treatment progress, and any changes in their condition over time) dated 12/09/2025 at 6:21 AM, indicated Resident 4 remained on every 15-minute checks for intrusive behavior. During a review of Resident 3's admission record indicated Resident 3 was admitted to the facility on [DATE] with the following diagnoses: paranoid schizophrenia (a serious mental disorder characterized by prominent symptoms like intense paranoia, delusions [fixed, false beliefs not based in reality], and hallucinations [seeing, hearing, feeling things that are not there]). During a review of Resident 3's H&P dated 5/28/2025 indicated, Resident 3 had a diagnosis of paranoid schizophrenia and was under a conservatorship. During a review of Resident 3's MDS dated [DATE], indicated, Resident 3 had intact cognition. During a review of Resident 3's physician progress notes dated 10/28/2025 indicated, Resident 3 has a diagnosis of paranoid schizophrenia and is under conservatorship. During a review of Resident 3's Psychotherapy Progress Notes dated 12/07/2025 indicated, Resident 3's chief complaint was that [Resident 4] shouldn't be touching me. Resident 3 reported understanding concerns regarding Resident 4's inappropriate boundaries such as touching. During a review of Resident 3's CP initiated on 12/07/2025 on risk for emotional distress and physical harm. The CP interventions included staff will provide reassurance, validation of feelings, and reinforce staff availability for protection and support. During a review of Resident 3's Interdisciplinary Care Conference (ICC - collaborative meetings where healthcare professionals-such as doctors, nurses, therapists, and social workers-coordinate care for complex patients, developing unified treatment plans to improve outcomes, reduce hospital stays, and enhance communication) notes dated 12/08/2025 indicated, while (Resident 3) was urinating in the shared bathroom, [Resident 4] attempted to touch Resident 3's private area without permission. Resident 3 felt scared and uncomfortable.or threatened.[Resident 3] reacted by hitting [Resident 4] to protect [Resident 3] instead of calling for staff support. During a review of facility undated In-Service Education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance) titled Sexual Trauma, Physical Abuse, Monitoring and Intervention indicated, a resident-to-resident aggression is also abuse and requires staff intervention. One of the in-service lesson plan topics indicated review past behaviors of residents who are at risk for abusing others. During an interview on 12/09/2025 at 11:57 AM Resident 3 stated Resident 4 opened the door to the bathroom without permission while Resident 3 was using the bathroom. Resident 3 asked Resident 4 what Resident 4 was doing in the bathroom, Resident 3 stated Resident 4 did not provide an answer. Resident 3 stated hitting Resident 4 with his right fist because [Resident 4] was in the bathroom and I got there first. During an interview on 12/09/2025 at 2:04 PM with Resident 5, Program Counselor (PC) 3 translated for Resident 5's language of choice. Resident 5 was Resident 4's roommate. Resident 5 stated [Resident 4] likes touching people a lot. During an interview on 12/09/2025 at 2:14 PM, Certified Nurse's Aide (CAN) 1 stated [Resident 4] likes to touch residents like their top-shoulders, arms, without their consent. CNA 1 stated Resident 3 may have felt anger and violated when Resident 4 allegedly touched Resident 3 inappropriately and without permission. During an interview on 12/09/2025 at 2:53 PM, Licensed Vocational Nurse (LVN) 1 stated that on 12/06/2025, PC 2 reported to LVN 1 about a physical altercation between Resident 3 and Resident 4. LVN 1 stated that during an interview with Resident 4, Resident 4 said, I went to the bathroom, I touched him (Resident 3).I touched him.I touched him. repeatedly, but Resident 4 did not state which part of Resident 3's body Resident 4 touched. LVN 1 stated both residents were separated, Resident 4's room was changed from Room A to Room B on the same day the alleged physical altercation happened. LVN 1 also stated that during the same interview, Resident 3 told LVN 1, [Resident 4] came in there bathroom) and tried to touch my penis. LVN 1 stated that Resident 3 slapped Resident 4 on the face when Resident 4 tried to touch his penis. LVN 1 stated the bathroom is shared by residents in rooms on either sides. LVN 1 also stated PC 2 told LVN 1 that PC 2 witnessed the physical altercation between Resident 3 and Resident 4 where Resident 4 was in bed and Resident 3 stood over Resident 4 with arms stretched. LVN 1 stated Resident 4 was cowering and covering his head and face with both arms covering both as if to protect himself from a possible physical altercation from Resident 3. LVN 1 also stated PC 2 told LVN 1 that PC 2 heard Resident 3 angrily ask Resident 4, what are doing in the bathroom? when Resident 3 was using the bathroom? but Resident 4 did not answer Resident 3. LVN 1 described Resident 4's behavior towards other residents as intrusive.likes to touch people.doesn't understand boundaries.this has been [Resident 4's] behavior since he's been here. When LVN 1 was asked what has the staff done to ensure the safety of the other residents when Resident has a history of intrusiveness, LVN 1 answered we counsel.redirect to a program or tv (television) room, supervise [Resident 4] . CNAs are standing in the hallways, when they see [Resident 4] touching someone, CNAs redirect him. LVN 1 stated Resident 3 may have felt disrespected, anger and violated when Resident 4 allegedly touched Resident 3 inappropriately and without permission. On 12/9/2025 at 4:56 PM, Resident 4's psychologist (PSY - a mental health professional with advanced education [usually a doctorate] who studies the mind, emotions, and behavior, using talk therapy, assessment, and interventions to help individuals cope with life issues, mental disorders, or improve overall wellness, focusing on psychological strategies rather than medication) was contacted with no response. A voice mail was left for the psychologist to call back the author. During a phone interview on 12/10/2025 at 9:59 AM, PC 2 stated one of the residents got PC 2's attention to go to Room A (Resident 4's room) due to an alleged physical altercation. PC 2 stated PC 2 witnessed Resident 4 sitting on the bed with '[Resident 4's] hands up like a defensive move, Resident 3 was standing up in front of Resident 4. PC 2 added, Resident 3 angrily said to Resident 4 don't try to touch me like that. PC 2 also stated PC 2 asked Resident 4 to back off and Resident 4 immediately complied. PC 2 stated Resident 3 then turned around to face PC 2 and to told PC 2, [Resident 4] tried to touch me on my private part, when PC 2 asked Resident 3 if that was the only thing that happened, Resident 3 said yes. PC 2 stated Resident 3 continued to say that Resident 3 was using the bathroom when Resident 4 entered the bathroom without permission. PC 2 stated that Resident 3 slapped Resident 4's hand because, it was close to [Resident 3's] private part. PC 2 said PC 2 assumed the reason why Resident 3 walked into Resident 4's room after the bathroom incident was to tell [Resident 4] to back off and to ask Resident 4 why [Resident 4] tried to touch Resident 3's private part. PC 2 stated rooms [ROOM NUMBERS] share the same bathroom. PC 2 described Resident 4's behavior towards other residents as very disoriented.he touches everything, people.not just men or women, it's both.you know how a blind man touches something, [Resident 4] is like that. PC 2 was asked what has the staff done to ensure the other residents' safety, PC 2 stated there is always a CNA in the hallway or the tv room.we know [Resident 4] has problems with touching, it's not gonna stop no matter how much we talk to [Resident 4].we redirect.we tried to use words like safe hands meaning to keep [Resident 4's] hand to self. PC 2 stated Resident 3 felt definitely disrespected when Resident 4 allegedly touched Resident 3 inappropriately and without permission. During an interview on 12/10/2025 at 1:23 PM, Registered Nurse Supervisor (RNS) 1 stated Resident 4's behavior towards other residents is that [Resident 4] always touching stuff and other residents without their consents . wants to touch people . has to be redirected frequently. RNS 1 stated that per doctor's order from 12/06/2025 until 12/09/2025, Resident 4 was put on 1:1 monitoring (a caregiver provides dedicated, focused attention and assistance to a single individual, ensuring their needs and well-being are met with personalized support) for 72 hours. During an interview on 12/10/2025 at 3:08 PM, the Director of Nursing (DON) stated, I've never come upon an inappropriate behavior from [Resident 4]. DON stated, [Resident 4] was on 1:1 after the incident, staff making rounds, [Resident 4] was redirected, frequent checks on [Resident 4]. When DON was asked how Resident 3 felt when Resident 3 was allegedly sexually abused by Resident 4, DON stated frustration, feeling inappropriate especially the private area, violated, anger. During a phone interview on 12/11/2025 at 8:46 AM, the PSY was asked if PSY was aware of the following about Resident 4:1. On 2/6/2025 - Episodes of poor boundaries where Resident 4 went into a shared bathroom while another resident was using the bathroom.2. On 7/31/2025, Resident 4 attempted to kiss a female staff member while the staff was cleaning Resident 4's room as indicated on Resident 4's care plan with an initiated on 7/13/2017 and a revision date of 7/31/2025.The PSY stated, I didn't know about that (above); they are both boundary violations; and about [Resident 4] attempting to kiss a staff member.that is a big deal and needs to be dealt with. The PSY stated the facility did not inform PSY about the two incidents. When the author informed the PSY about Resident 4's Behavior Monthly Summary of 2024, where staff documented Resident 4 had episodes of masturbating in public, had 395 episodes of inappropriate behaviors during the day shift in 2024, had 685 episodes of intense staring, standing too close, episodes of intrusiveness during the day shift in 2024, the PSY expressed shock with a 5 second pause then, with intermittent pauses PSY said, I don't have that information.masturbating in public.I am not aware of that.I didn't know about that . I only know about the inappropriate touching like touching someone's shoulder. The PSY stated I am so in shock, I don't even know what to say . what you shared with me, more has to be done. The PSY stated, I will speak to the DON and the Administrator.let them know I need to make suggestions.like when you shared with me about the staff kissing and the Behavior Monthly Summary. The PSY stated if Resident 4's inappropriate touching behaviors continued and not addressed, we would find [Resident 4] a different placement, something more suitable.they (the staff) cannot continue the way that they have, something's got to change.we need to keep the other residents safe. The PSY stated now knowing what I know, that would impact other residents' experience . I am not sure . is that why Resident 3 punched Resident 4? We don't know how the other residents are going to react when they are triggered. During a review of the facility policy and procedures (P&P) titled Abuse Prohibition, with a review date of 2/23/2021, section 6.2.2 indicated, The facility is responsible for identifying residents who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. The P&P's section 6.2.5 indicated, The facility will seek alternative placement for the resident exhibiting the abusive behavior, if warranted.

Cross Reference F600 Based on interview and record review, the facility failed to notify the psychologist (PSY - a mental health professional with advanced education [usually a doctorate] who studies the mind, emotions, and behavior, using talk therapy, assessment, and interventions to help individuals cope with life issues, mental disorders, or improve overall wellness, focusing on psychological strategies rather than medication) for one of four residents (Resident 4) who had several documented incidents of repeated inappropriate behaviors of touching Resident 3, other residents, and staff. This deficient practice caused Resident 3 to experience psychological stress and emotional distress by stating that Resident 4 should not be touching him (Resident 3). This deficient practice increased the risk for peer conflict and safety concerns and posed a significant risk to the safety and well-being of other residents in the facility.Findings: During a review of Resident 4's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 4 was admitted to the facility on [DATE] with the following diagnoses: paranoid schizophrenia (a serious mental disorder characterized by prominent symptoms like intense paranoia, delusions [fixed, false beliefs not based in reality], and hallucinations [seeing, hearing, feeling things that are not there]). During a review of Resident 4's Care Plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) initiated on 7/13/2017 with revision dates of 4/30/2021, 2/07/2025, and 7/31/2025, indicated, Resident 4 had demonstrated repeated bizarre or inappropriate social behaviors related to poor boundaries as evidenced by incidents of standing too close, hovering, or touching others. The CP interventions included to encourage psych/behavioral health consultation, participate in Special Treatment Program for management of physical behaviors, engage in 1:1 (one to one - a staff provides dedicated, focused attention and assistance to a single individual, ensuring their needs and well-being are met with personalized support) counseling focused on social skills to encourage appropriate social interactions with peers/staff. During a review of Resident 4's Behavior Monthly Summary for 2024 for behavior manifestation of intense staring, standing too close, intrusiveness as evidenced by poor boundaries indicated, Resident 4 had the following number of episodes during the day shift (7 AM to 3 PM) from 1/2024 through 12/2024:January=61February=50March=58April=58May=61June=63July=63August=56September=63October=62November=62December=28The Behavior Monthly Summary for 2024 indicated a total 684 episodes for behavior manifestation of intense staring, standing too close, intrusiveness as evidenced by poor boundaries. During a review of Resident 4's Behavior Monthly Summary for 2024 for behavior manifestation of masturbating in public and inappropriate touching indicated, Resident 4 had the following number of episodes during the day shift (7 AM to 3 PM) from 1/2024 through 12/2024:January=23February=23March=29April=30May=38June=39July=36August=41September=36October=46November=48December=6The Behavior Monthly Summary for 2024 indicated a total 395 episodes for behavior manifestation of intense staring, standing too close, intrusiveness as evidenced by poor boundaries. During a review of Resident 4's history and physical (H&P - a physician's complete patient examination) dated 7/24/2025 indicated, Resident 4 had the diagnosis of paranoid schizophrenia and is under a conservatorship (a legal process for adults with severe mental illness who are gravely disabled; they cannot provide for their basic needs and manage their medical treatment, and placement to facilities due to their illness). During a review of Resident 4's Physician Progress Notes (a doctor's written record that documents a patient's health status, treatment, and care plan) dated 9/25/2025 indicated, Resident 4 had a routine medical follow-up but the physician did not receive any new, specific complaints. During a review of Resident 4's Psychotherapy Progress Notes (a standardized tool used by psychologists to record resident's mental and emotional state, behavior and any changes in their condition, to inform care planning and treatment) dated 10/06/2025, indicated, at the time of consultation, Resident 4 was experiencing paranoia, anxious, intrusive, impulsive, had delusional thinking, auditory hallucination, and was disoriented. During a review of Resident 4's Psychotherapy Progress Notes dated 10/24/2025 indicated, Resident 4 reported remembering previous discussion about the importance of maintaining physical boundaries with the other residents. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 10/31/2025, indicated, Resident 4 has an intact cognition (a person's thinking and reasoning abilities are functioning properly and are not significantly impaired). During a review of Resident 4's Nursing Progress Notes dated 11/25/2025 at 12:09 PM, Resident 4 was grabbing others.but redirected to walk. During a review of Resident 4's Nursing Progress Notes dated 12/06/2025 at 8:29 AM indicated, Resident 4 was placed on a 1:1 monitoring. During a review of Resident 4's Room Transfer form dated 12/06/2025 at 2:50 PM, the form indicated Resident 4 was transferred from Room A to Room B. During a review of Resident 4's CP initiated on 12/07/2025 indicated, Resident 4 had poor personal boundaries and inappropriate physical contact with peers, increasing risk for peer conflict and safety concerns. The CP's interventions included, staff will teach resident proper space rules and explain why touching others without consent is unsafe and unacceptable and staff to provide firm, consistent redirection when boundary issues occur. During a review of Resident 4's X-ray results dated 12/07/2025 at 8:42 AM, the report indicated, Resident 4 had no acute fracture or dislocation of the skull/face (no evidence of recent bone breakage or joint displacement found at the time of the scan). During a review of Resident 4's x-ray report dated 12/07/2025, indicated, No acute fracture or dislocation of the skull/face (no evidence of a recent break or out of normal alignment in any of the bones of the skull or face). During a review of Resident 4's Nursing Progress Notes dated 12/08/2025 at 10:10 PM, indicated Resident 4 had verbal expressions of distress up to 5 days a week. The progress notes also indicated Resident 4 was being monitored for intrusive behavior, needed multiple redirections to focus on self and treatment plan and encouraged to maintain proper boundaries with peers. During a review of Resident 4's Physician Order Summary Report dated 12/09/2025, indicated, a physician ordered Resident 4 to have an x-ray of Resident 4's face. During a review of Resident 4's Nursing Progress Notes (captures the details of a patient's health status, treatment progress, and any changes in their condition over time) dated 12/09/2025 at 6:21 AM, indicated Resident 4 remained on every 15-minute checks for intrusive behavior. During a review of Resident 3's admission record indicated Resident 3 was admitted to the facility on [DATE] with the following diagnoses: paranoid schizophrenia (a serious mental disorder characterized by prominent symptoms like intense paranoia, delusions [fixed, false beliefs not based in reality], and hallucinations [seeing, hearing, feeling things that are not there]). During a review of Resident 3's H&P dated 5/28/2025 indicated, Resident 3 had a diagnosis of paranoid schizophrenia and was under a conservatorship. During a review of Resident 3's MDS dated [DATE], indicated, Resident 3 had intact cognition. During a review of Resident 3's physician progress notes dated 10/28/2025 indicated, Resident 3 has a diagnosis of paranoid schizophrenia and is under conservatorship. During a review of Resident 3's Psychotherapy Progress Notes dated 12/07/2025 indicated, Resident 3's chief complaint was that [Resident 4] shouldn't be touching me. Resident 3 reported understanding concerns regarding Resident 4's inappropriate boundaries such as touching. During a review of Resident 3's CP initiated on 12/07/2025 on risk for emotional distress and physical harm. The CP interventions included staff will provide reassurance, validation of feelings, and reinforce staff availability for protection and support. During a review of Resident 3's Interdisciplinary Care Conference (ICC - collaborative meetings where healthcare professionals-such as doctors, nurses, therapists, and social workers-coordinate care for complex patients, developing unified treatment plans to improve outcomes, reduce hospital stays, and enhance communication) notes dated 12/08/2025 indicated, while (Resident 3) was urinating in the shared bathroom, [Resident 4] attempted to touch Resident 3's private area without permission. Resident 3 felt scared and uncomfortable.or threatened.[Resident 3] reacted by hitting [Resident 4] to protect [Resident 3] instead of calling for staff support. During a review of facility undated In-Service Education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance) titled Sexual Trauma, Physical Abuse, Monitoring and Intervention indicated, a resident-to-resident aggression is also abuse and requires staff intervention. One of the in-service lesson plan topics indicated review past behaviors of residents who are at risk for abusing others. During an interview on 12/09/2025 at 11:57 AM Resident 3 stated Resident 4 opened the door to the bathroom without permission while Resident 3 was using the bathroom. Resident 3 asked Resident 4 what Resident 4 was doing in the bathroom, Resident 3 stated Resident 4 did not provide an answer. Resident 3 stated hitting Resident 4 with his right fist because [Resident 4] was in the bathroom and I got there first. During an interview on 12/09/2025 at 2:04 PM with Resident 5, Program Counselor (PC) 3 translated for Resident 5's language of choice. Resident 5 was Resident 4's roommate. Resident 5 stated [Resident 4] likes touching people a lot. During an interview on 12/09/2025 at 2:14 PM, Certified Nurse's Aide (CAN) 1 stated [Resident 4] likes to touch residents like their top-shoulders, arms, without their consent. CNA 1 stated Resident 3 may have felt anger and violated when Resident 4 allegedly touched Resident 3 inappropriately and without permission. During an interview on 12/09/2025 at 2:53 PM, Licensed Vocational Nurse (LVN) 1 stated that on 12/06/2025, PC 2 reported to LVN 1 about a physical altercation between Resident 3 and Resident 4. LVN 1 stated that during an interview with Resident 4, Resident 4 said, I went to the bathroom, I touched him (Resident 3).I touched him.I touched him. repeatedly, but Resident 4 did not state which part of Resident 3's body Resident 4 touched. LVN 1 stated both residents were separated, Resident 4's room was changed from Room A to Room B on the same day the alleged physical altercation happened. LVN 1 also stated that during the same interview, Resident 3 told LVN 1, [Resident 4] came in there bathroom) and tried to touch my penis. LVN 1 stated that Resident 3 slapped Resident 4 on the face when Resident 4 tried to touch his penis. LVN 1 stated the bathroom is shared by residents in rooms on either sides. LVN 1 also stated PC 2 told LVN 1 that PC 2 witnessed the physical altercation between Resident 3 and Resident 4 where Resident 4 was in bed and Resident 3 stood over Resident 4 with arms stretched. LVN 1 stated Resident 4 was cowering and covering his head and face with both arms covering both as if to protect himself from a possible physical altercation from Resident 3. LVN 1 also stated PC 2 told LVN 1 that PC 2 heard Resident 3 angrily ask Resident 4, what are doing in the bathroom? when Resident 3 was using the bathroom? but Resident 4 did not answer Resident 3. LVN 1 described Resident 4's behavior towards other residents as intrusive.likes to touch people.doesn't understand boundaries.this has been [Resident 4's] behavior since he's been here. When LVN 1 was asked what has the staff done to ensure the safety of the other residents when Resident has a history of intrusiveness, LVN 1 answered we counsel.redirect to a program or tv (television) room, supervise [Resident 4] . CNAs are standing in the hallways, when they see [Resident 4] touching someone, CNAs redirect him. LVN 1 stated Resident 3 may have felt disrespected, anger and violated when Resident 4 allegedly touched Resident 3 inappropriately and without permission. On 12/9/2025 at 4:56 PM, Resident 4's psychologist (PSY - a mental health professional with advanced education [usually a doctorate] who studies the mind, emotions, and behavior, using talk therapy, assessment, and interventions to help individuals cope with life issues, mental disorders, or improve overall wellness, focusing on psychological strategies rather than medication) was contacted with no response. A voice mail was left for the psychologist to call back the author. During a phone interview on 12/10/2025 at 9:59 AM, PC 2 stated one of the residents got PC 2's attention to go to Room A (Resident 4's room) due to an alleged physical altercation. PC 2 stated PC 2 witnessed Resident 4 sitting on the bed with '[Resident 4's] hands up like a defensive move, Resident 3 was standing up in front of Resident 4. PC 2 added, Resident 3 angrily said to Resident 4 don't try to touch me like that. PC 2 also stated PC 2 asked Resident 4 to back off and Resident 4 immediately complied. PC 2 stated Resident 3 then turned around to face PC 2 and to told PC 2, [Resident 4] tried to touch me on my private part, when PC 2 asked Resident 3 if that was the only thing that happened, Resident 3 said yes. PC 2 stated Resident 3 continued to say that Resident 3 was using the bathroom when Resident 4 entered the bathroom without permission. PC 2 stated that Resident 3 slapped Resident 4's hand because, it was close to [Resident 3's] private part. PC 2 said PC 2 assumed the reason why Resident 3 walked into Resident 4's room after the bathroom incident was to tell [Resident 4] to back off and to ask Resident 4 why [Resident 4] tried to touch Resident 3's private part. PC 2 stated rooms [ROOM NUMBERS] share the same bathroom. PC 2 described Resident 4's behavior towards other residents as very disoriented.he touches everything, people.not just men or women, it's both.you know how a blind man touches something, [Resident 4] is like that. PC 2 was asked what has the staff done to ensure the other residents' safety, PC 2 stated there is always a CNA in the hallway or the tv room.we know [Resident 4] has problems with touching, it's not gonna stop no matter how much we talk to [Resident 4].we redirect.we tried to use words like safe hands meaning to keep [Resident 4's] hand to self. PC 2 stated Resident 3 felt definitely disrespected when Resident 4 allegedly touched Resident 3 inappropriately and without permission. During an interview on 12/10/2025 at 1:23 PM, Registered Nurse Supervisor (RNS) 1 stated Resident 4's behavior towards other residents is that [Resident 4] always touching stuff and other residents without their consents . wants to touch people . has to be redirected frequently. RNS 1 stated that per doctor's order from 12/06/2025 until 12/09/2025, Resident 4 was put on 1:1 monitoring (a caregiver provides dedicated, focused attention and assistance to a single individual, ensuring their needs and well-being are met with personalized support) for 72 hours. During an interview on 12/10/2025 at 3:08 PM, the Director of Nursing (DON) stated, I've never come upon an inappropriate behavior from [Resident 4]. DON stated, [Resident 4] was on 1:1 after the incident, staff making rounds, [Resident 4] was redirected, frequent checks on [Resident 4]. When DON was asked how Resident 3 felt when Resident 3 was allegedly sexually abused by Resident 4, DON stated frustration, feeling inappropriate especially the private area, violated, anger. During a phone interview on 12/11/2025 at 8:46 AM, the PSY was asked if PSY was aware of the following about Resident 4:1. On 2/6/2025 - Episodes of poor boundaries where Resident 4 went into a shared bathroom while another resident was using the bathroom.2. On 7/31/2025, Resident 4 attempted to kiss a female staff member while the staff was cleaning Resident 4's room as indicated on Resident 4's care plan with an initiated on 7/13/2017 and a revision date of 7/31/2025.The PSY stated, I didn't know about that (above); they are both boundary violations; and about [Resident 4] attempting to kiss a staff member.that is a big deal and needs to be dealt with. The PSY stated the facility did not inform PSY about the two incidents. When the author informed the PSY about Resident 4's Behavior Monthly Summary of 2024, where staff documented Resident 4 had episodes of masturbating in public, had 395 episodes of inappropriate behaviors during the day shift in 2024, had 685 episodes of intense staring, standing too close, episodes of intrusiveness during the day shift in 2024, the PSY expressed shock with a 5 second pause then, with intermittent pauses PSY said, I don't have that information.masturbating in public.I am not aware of that.I didn't know about that . I only know about the inappropriate touching like touching someone's shoulder. The PSY stated I am so in shock, I don't even know what to say . what you shared with me, more has to be done. The PSY stated, I will speak to the DON and the Administrator.let them know I need to make suggestions.like when you shared with me about the staff kissing and the Behavior Monthly Summary. The PSY stated if Resident 4's inappropriate touching behaviors continued and not addressed, we would find [Resident 4] a different placement, something more suitable.they (the staff) cannot continue the way that they have, something's got to change.we need to keep the other residents safe. The PSY stated now knowing what I know, that would impact other residents' experience . I am not sure . is that why Resident 3 punched Resident 4? We don't know how the other residents are going to react when they are triggered. During a review of the facility policy and procedures (P&P) titled Abuse Prohibition, with a review date of 2/23/2021, section 6.2.2 indicated, the facility is responsible for identifying residents who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. The P&P's section 6.2.5 indicated, the facility will seek alternative placement for the resident exhibiting the abusive behavior, if warranted.

Based on interview and record review, the facility failed to ensure that staff that was having signs and symptoms of respiratory infection (an illness caused by germs, like viruses or bacteria, that get into your breathing system -nose, throat, lungs, and airways and cause problems) stay home according to the facility's policy and procedures (P&P) titled Oxygen Therapy revised 1/27/2025. This deficient practice resulted in four out of 77 residents being positive for covid (COVID 19-A highly contagious respiratory disease).Findings: During a record review, Resident 6's admission Record indicated the facility admitted Resident 6 on 3/18/2019 and readmitted Resident 6 on 9/22/2021 with diagnoses including paranoid schizophrenia (a condition where someone has trouble telling what's real from what's not, experiencing intense paranoia, like believing they're being targeted or watched), major depressive disorder (a serious mood disorder where someone experiences a persistent deep sadness, loss of interest, or lack of pleasure in most activities), and unspecified convulsions (involuntary, sudden, and often violent muscle contractions that can occur in various parts of the body). During a record review, Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 7/5/2025, indicated Resident 6 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 6 is independent with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a record review Resident 6's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 8/19/2025, at 10:03 P.M., indicated that Resident 6 tested positive for COVID 19. During a review, Resident 7's admission Record indicated the facility admitted Resident 7 on 5/19/2025 with diagnoses including schizophrenia (a chronic mental health condition that affects a person's thoughts, feelings, and behavior), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and depression (persistent feelings of sadness, hopelessness, and loss of interest). During a record review, Resident 7's MDS dated [DATE], indicated Resident 7 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 6 is independent with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a record review, Resident 7's SBAR, dated 8/19/2025, at 11:50 P.M., indicated that Resident 7 tested positive to COVID 19. During a record review, Resident 8's admission Record indicated the facility admitted Resident 8 on 6/12/2017 and readmitted Resident 8 on 10/30/2018 with diagnoses including paranoid schizophrenia (a condition where someone has trouble telling what's real from what's not, experiencing intense paranoia, like believing they're being targeted or watched), hypertension (HTN-high blood pressure), and hyperglyceridemia (having too much of a certain type of fat, called triglycerides, in the blood). During a record review, Resident 8's MDS dated [DATE], indicated Resident 8 was cognitively intact. The MDS indicated Resident 6 is independent with ADLs. During a record review Resident 8's SBAR, dated 8/19/2025, at 10:19 P.M., indicated that Resident 8 tested positive to COVID 19. During a record review Resident 9's admission Record indicated the facility admitted Resident 9 on 3/10/2025 with diagnoses including schizoaffective disorder (a mental health condition that combines symptoms of a psychotic disorder, like schizophrenia [a condition where someone has trouble telling what's real from what's not, experiencing intense paranoia, like believing they're being targeted or watched], with symptoms of a mood disorder, such as bipolar disorder [a mental health condition characterized by extreme shifts in mood, energy, and behavior] or depression [persistent feelings of sadness, hopelessness, and loss of interest]), HTN, and hyperlipidemia (a condition where there are high levels of fats [lipids] in the blood). During a record review, Resident 9's MDS dated [DATE], indicated Resident 9 was cognitively impaired. The MDS indicated Resident 9 is independent with ADLs. During a record review, Resident 9's SBAR, dated 8/19/2025, at 7:03 P.M., indicated that Resident 9 tested positive to COVID 19. During an interview on 8/20/2025, at 2:34 P.M., with Certified nursing assistant 3 (CNA 3), CNA 3 stated that on Saturday, 8/16/2025, she did not feel well, she was having body aches, her throat was hurting and was feeling congested. On Monday, CNA 3 stated that she continued to feel unwell, had a runny nose and was coughing. On Tuesday, 8/19/2025, CNA 3 stated she still did not feel well and that's when she took a COVID test tested at the facility and tested positive for COVID. CNA 3 stated she was not supposed to come into work feeling sick and that she did not make the right decision. CNA 3 stated she should have stayed home to prevent spreading the infection in the facility. During an interview on 8/20/2025, at 4:30 P.M., with the infection prevention nurse (IPN), IPN stated that if a staff member if feeling sick and is having symptoms of runny nose, sore throat, coughing, sneezing, headache, teary eyes, red eyes or any other signs and symptoms of respiratory illness the staff need to stay home because if they come into the building with these symptoms it may cause the symptoms to go around the building and we need to keep the resident safe as the resident in the facility are vulnerable. The IPN stated that she called CNA 1 and asked her why she came to work when she was sick. IPN stated CNA 1 should not have come to work. During an interview on 8/20/2025, at 12 P.M., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated that staff should stay away from work if they are exhibiting any signs and symptoms of respiratory infection such as sneezing, runny nose, fever to prevent them from passing the infection to the residents. During a record review, the facility Policy and Procedure (P&P), titled, Infection Prevention and Control Program effective 9/18/2024, indicated, PurposeAn infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.a. The facility has established policies and procedures regarding infection control among employees, contractors, vendors, visitors, and volunteers, including:1. Situations when these individuals should report their infections or avoid the facility (for example, . respiratory infections with considerable coughing and sneezing.

Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included essential (primary) hypertension (when a person has abnormally high blood pressure that's not the result of a medical condition), paranoid schizophrenia (Persistent, false beliefs, often centered around persecution, where the individual believes they are being harmed or negatively affected by others). During a review of Resident 1's History and Physical (H&P) dated 10/30/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions, however, he can make needs known. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 6/4/2025, the resident's cognition (a person's mental ability to think, learn, remember, use judgement, and make decisions) was intact. The MDS indicated Resident 1 could communicate needs and wants; however, Resident 1 could not make medical decisions concerning care. During a review of Resident 1's Situation Background Assessment Recommendation (SBAR- is a structured communication framework that can help teams share information about the condition of a patient or team member or about another issue your team needs to address) Summary for providers dated 7/8/2025 at 10:44pm, the SBAR indicated that on 7/7/2025 at approximately 7:50pm, male peer (Resident 2) walked in the television (TV) room and hit resident (Resident 1) with close fist in the face area times three without provocation. The SBAR indicated a medical doctor (MD) and conservator (is a person appointed by a court to manage the financial affairs and/or healthcare decisions of an adult who is deemed unable to do so themselves due to a mental or physical disability) were notified, and the MD ordered X-ray to rule out (R/O) fracture (break in a bone). During a review of Resident 1's Care Plan (CP) titled Resident with Potential/risk to exhibit Psycho-Social (refers to anything that negatively impacts a person's mental well-being, like their thoughts, feelings, and emotions) distress related to abuse allegation, and initiated on 7/7/2025, indicated to monitor Resident 1 for potential for psychosocial harm, due to physical assault on two occasions, the first on 7/7/2025 and the second on 7/8/2025. During a review of Resident 1's Room Transfer/New Roommate Change Form., dated 7/7/2025 at 9 pm indicated Resident 1 (Resident 2's roommate) was moved to another room after an incident with roommate (Resident 2) on 7/7/2025. During a review of Resident 1's Progress Note dated 7/7/2025, the progress note indicated Resident 1 was placed on Q (every) 15 minutes monitoring (every 15 minutes report on the whereabouts and activity of the resident) checks for 72 hours per Medical Doctor (MD) 1 orders after witnessed incident of resident to resident (one resident abusing another resident withing the facility) abuse. During a review of Resident 1's Body Check Assessment Form dated 7/8/2025 indicated Skin coloration under right eye 1.5 cm X 3 cm, applied ice compress (cold therapy- is the application of cold to a body part to reduce pain, swelling, and inflammation [the body's response to injury or infection]) on affected area, and MD 1 notified. During a review of Resident 1's physician telephone order dated 7/8/2025 at 1:04pm, the physician telephone order indicated to perform stat (now) x-ray of the face to rule out fracture. During a review of Resident 1's Follow-up Documentation dated 7/10/2025 at 2:17pm, the follow up documentation indicated . Resident 1 has a purplish discoloration under right eye, swelling noted, and no visual disturbances noted. During a review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included essential hypertension paranoid schizophrenia During a review of Resident 2's H&P dated 10/30/2024, the H&P indicated Resident 2 did not have the capacity to understand and make decisions, however, the resident could make needs known. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident's cognition was intact. The MDS indicated Resident 2 could communicate needs and wants but did not have the capacity to make decisions concerning care. During a review of Resident 2's CP titled physical altercation related to poor impulse control and resolving interpersonal conflicts initiated on 4/17/2025 and revised on 7/8/2025, the CP indicated to monitor Resident 2 to help prevent potential future physical altercations, related to Resident 2 hit male peer (Resident 1) three times in the head on 7/7/2025. The CP also indicated that on 7/8/2025, Resident 2 hit male peer (Resident 1) in the face with his hands. The CP interventions indicated that Resident 2 was on (Q) (every) 15 minutes (every 15 minutes report on the whereabouts and activity of the resident) checks monitoring. During a review of Resident 2's Nursing Note dated 7/7/2025 at 9:23 pm, the nursing note indicated a change of condition (COC- acute change of condition (ACOC), or significant change of condition) that Resident 2 hit another resident (Resident 1) in the face three times without provocation. The Nursing Note indicated MD 1 was notified and MD 1 gave an order for Resident 2 to be placed on Q15-minute checks for 72 hours. During a review of Resident 2 MD 1 telephone order dated 7/8/0225 at 6:38 pm, the telephone order indicated MD 1 placed Resident 2 on one to one (1:1) (close supervision to prevent aggressive behavior) monitoring precautions after the second incident of resident to resident (Resident 2 on Resident 1) abuse on 7/8/2025. Order stated the following: ok to place resident on 1:1 close supervision due to (d/t) aggressive behavior During an interview on 7/22/2025 at 9:07 am Resident 1 stated, on 7/7/2025 in the evening, Resident 1 was sitting in the residents group meeting room when Resident 2 came into the room and started punching him (Resident 1) in the face for no reason. Resident 1 stated facility staff came and stopped Resident 2 from hitting him in the face. Resident 1 stated that the next morning on 7/8/2025 both Resident 1 and Resident 2 were in another resident group activity on 7/8/2025, when Resident 2 came over to him and began hitting Resident 1 in the face for no reason. During an interview on 7/22/2025 at 10:35am, Behavioral Specialist (BS) (staff that assist residents and help monitor activity of residents throughout the day) 1 stated, that on 7/8/2025 during the first group meeting called News of the Day, both Resident 2 and Resident 1 were attending the same group. BS 1 stated once the group was over, Resident 2 walked over to Resident 1 and started hitting Resident 1 for no reason. BS 1 stated he told Resident 2 to stop hitting Resident 1, and Resident 2 complied and stopped hitting Resident 2. BS 1 stated Resident 2 was on Q15 minutes monitoring protocol. BS stated that Q15 means that certified nursing assistant (CNA) checks the residents whereabouts every 15 minutes. During an interview on 7/22/2025 at 11:27am, BS 2 stated that on 7/7/2025 he (BS 2) was downstairs in the dining room assisting with the News of the Day residents group meeting. BS 2 stated both Resident 1 and Resident 2 was in the same group meeting but seated at a different tables. News of the Day, BS 2 stated Resident 2 just got up, and walked over to Resident 1 and started hitting Resident 1 in the face. BS 2 stated Resident 2 did not say anything, just got up like he (Resident 2) was going to leave the room but instead turned and went over to Resident 1 and started hitting Resident 1 in the face. During an interview on 7/22/2025 at 12:08 pm, Certified Nurse Assistant (CNA) 1 stated that on 7/8/2025 she was assigned to monitor Resident 2 every 15 minutes. CNA 1 stated that when staff are assigned to monitor a resident every 15 minutes, that means the resident is on Q15 minute monitoring and that staff assigned to the resident must check on the resident every 15 minutes. CNA 1 stated that Q15 minute monitoring does not mean staying with the resident and reporting to staff every 15 minutes but to check on the whereabouts of the resident every 15 minutes. However, while the resident is in group, the resident is left with the staff that run the group. CNA 1 stated, even though she is assigned to perform to monitor the residents Q15 minutes, she still has six to eight other residents to attend to. During an interview on 7/22/2025 at 12:40 pm, Licensed Vocational Nurse (LVN) 1 stated, he was upstairs at the nursing station when he overheard one of the residents say that there was a fight downstairs. LVN 1 stated he went downstairs to see what was happening. LVN 1 stated once he was downstairs, he noticed that staff had already separated the residents (Resident 1 and Resident 2). LVN 1 stated he performed a visual assessment on Resident 1 to determine if he needed medical attention and Resident 1 stated he (Resident 1) was alright. During an interview on 7/22/2025 at 12:52 pm, the Program Counselor (PC -a staff that assists residents with group activities and assists in monitoring resident behavior) stated that on 7/7/2025, Resident 1 was participating in an evening group activity in the TV room. Resident 2 was not participating in this activity. The PC stated that at the end of the evening group activity, Resident 2 walked into the same TV room and starting hitting Resident 1 in the face. PC stated the facility Assistant Program Director (APD- the supervisor of the program counselors and behavioral specialists) was in the TV room and used crisis communication (firm commands to residents that stops negative behavior) to try and stop Resident 2 from continuing to hit Resident 1 in the face. During an interview on 7/22/2025 at 1:05 pm, the APD stated he was in the television room speaking to one of the counselors when suddenly Resident 2 came into the room and started hitting Resident 1. The APD stated he used verbal crisis communications, and Resident 2 then stopped his aggressive behaviors on Resident 1. During an interview on 7/22/2025 at 1:30pm, the Registered Nursing Supervisor (RNS) stated, after the first incident on 7/7/2025 Resident 2 was placed on Q15 minute monitoring and that after the second incident on 7/8/2025 the resident was placed on 1:1 monitoring by Medical Doctor (MD) 1. RNS stated that on 7/8/2025 the next day after the second incident, Resident 2 assaulted Resident 1 again in a group that they were both attending. During an interview on 7/22/2025 at 1:42 pm, MD1 stated, 1:1 order is used to monitor the residents very closely to prevent them from harming themselves or others. During a review of the facility Policy and Procedures (P&P) titled Resident Rights dated revised 2/25/2025, indicated: Policy StatementEmployees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. A dignified existence;b. Be treated with respect, kindness, and dignity;c. Be free from abuse, neglect, misappropriation of property, and exploitation. During a review of the facility P&P titled Abuse Prohibition Policy and Procedure dated revised 2/25/2025, indicated: Policy: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. The Center will implement an abuse prohibition program through the following: Screening of potential hires; Training of employees (both new employees and ongoing training for all employees); Prevention of occurrences; Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; Protection of patients during investigations; and Reporting of incidents, investigations, and Center response to the results of their investigations.

Based on observation, interview, and record review, the facility's Administrator (ADM) failed to ensure to provide a safe environment and oversee the safety of one of two sampled residents (Resident 10) by failing to: -Ensure Resident 10 who could not make her own decisions and Resident 9 who could not make his own decisions had a safe environment to engage in sexual activities that occurred in the facility. -Ensure all staff including Registered Nurse 1 (RN1) were aware Resident 9 and Resident 10 had sexual activities. These failures resulted for Resident 10 to feel unsafe, have emotional distress (mental suffering), and alleged Resident 9 was sexually and physically aggressive with her (Resident 10). Findings: During a review of Resident 9's admission Record, the admission Record indicated the facility admitted Resident 9 on 3/20/2025 with the diagnoses of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life). During a review of Resident 9's History and Physical (H&P) dated 3/20/2025, the H&P indicated Resident 9 could not make his own medical decisions but can make his needs known. During a review of Resident 9's Minute Order (summaries of the decisions made by the judge during a hearing) dated 5/15/2025, the Minute Order indicated Resident 9's conservatorship ([NAME] arrangement where a court appoints someone [the conservator] to handle the personal or financial affairs of an adult [the conservatee] was still in place. The Minute Order indicated Resident 9 was the conservatee under the care of a conservator. During an interview on 6/6/2025 at 11:43 AM with Resident 9, Resident 9 stated on 6/2/2025 (time not specified) he (Resident 9) went to hang out in Resident 10's room, but Resident 10 did not want to hang out so Resident 9 stated he broke up with Resident 10. Resident 9 stated he left Resident 10's room and went back to his room. Resident 9 stated Resident 10 followed him into his (Resident 9's) room and offered to have sex with him. Resident 9 stated he (Resident 9) had sex with Resident 10. During a review of Resident 10's admission Record, the admission Record indicated the facility admitted Resident 10 on 7/12/2023 with the diagnoses of paranoid (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly) schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 10's H&P dated 10/30/2024, the H&P indicated Resident 10 could not make her own decisions but could make her needs known. During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool) dated 4/27/2025, the MDS indicated Resident 10 had potential indicators (something that gives you a clue or shows you something about a situation, like a sign) for psychosis ((a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) such as hallucinations (experiencing something with your senses that isn't actually there, but feels real) and delusions (having false or unrealistic beliefs). During a review of Resident 10's Sexuality assessment dated [DATE], the Sexuality Assessment indicated Resident 10 was sexually active with Resident 9. During a review of Resident 10's Care Plan Report dated 6/2/2025, the Care Plan Report indicated Resident 10 exhibited psycho-social (focuses on the nature of self-understanding, social relationships, and the mental processes that support connections between the person and his/her social world) emotional distress and feeling unsafe. The Care Plan Report indicated Resident 10 reported I do not want to be here; I don't want to live in a co-ed facility. There is so much drama going to start after this. During a review of Resident 10's Change in Condition note dated 6/3/2025, the Change in Condition note indicated Resident 10 had sexual relations with a male peer (date of event and name of male peer not given). The Change in Condition note indicated Resident 10 broke up With him and seeing him triggered the behavior that resulted to panic anxiety, increased pacing in the hallway. The Change in Condition note indicated New or worsened delusions or hallucinations. The Change in Condition note indicated Resident stated I can ' t stand the COED (a facility where both men and women live) facility, I feel DTO (Danger to others - a person's behavior, actions, or mental state suggests they are likely to physically harm someone else) now, I want to hit someone if I don't leave this facility. During a review of Resident 10's Interdisciplinary (two or more different fields of study or areas of knowledge) Care Conference note dated 6/4/2025 indicated Resident 10 was evaluated by the Psychiatric Mobile Response Team (PMRT, non-law enforcement-based mobile crisis response for clients experiencing a psychiatric emergency) on 6/3/2025 because she (Resident 10) wanted to hurt others. The Interdisciplinary Care Conference note indicated Resident 10 was transferred to a General Acute Care Hosptial (GACH). The Interdisciplinary Care Conference note indicated Resident 10 ' s thoughts were disorganized (having trouble thinking clearly and logically), had auditory hallucinations (hearing sounds or voices that aren't actually there), tangential thoughts (getting sidetracked during a conversation or when thinking about something), and rambling speech (talking in a way that's unclear, confusing, and doesn't stick to one main point). During a review of Resident 10's Social Services Director note dated 6/5/2025 at 5:11 PM, the Social Services Director note indicated the GACH Doctor told Registered Nurse (RN) supervisor Resident 10 alleged her boyfriend (Resident 9) was aggressive with her. During a review of Resident 10's Medication Review Report dated 6/6/2025, the Medication Review Report indicated Resident 10 had an order to transfer to transfer to GACH due to danger to others. During a telephone interview on 6/6/2025 at 11:19 AM with Resident 10 who was at the GACH, Resident 10 stated she (Resident 10) had sex with Resident 9 but could not provide a date and time. Resident 10 was heard speaking very fast and unable to stay on topic. Resident 9 was difficult to understand and at times had rambling speech. Resident 10 stated it was too much (referring to having sex with Resident 9). Resident 10 stated she (Resident 10) did not want to back to the facility where she lived (Resident 10) and wanted to be placed at another facility once discharged from the hospital. During an interview on 6/6/2025 at 12:37 PM with Certified Nursing Assistant 6 (CNA 6), CNA 6 stated Resident 9 and Resident 10 had been hanging around for a while and had been in a relationship. CNA 6 stated Resident 9 and Resident 10 had been boyfriend and girlfriend. CNA 6 stated Resident 9 and Resident 10 had the privilege to have sex, and the facility could not deny them having sex. CNA 6 stated the residents (in general) would need to know what the consequences were for having sex and staff (in general) could offer the residents (in general) protection. CNA 6 stated if residents (in general) wanted to have sex, they (Residents in general) would need to speak with the licensed staff for an assessment. CNA 6 stated if staff saw residents (in general) hanging around together, they (staff in general) needed to alert the program director, especially if the residents (in general) held hands and or kissed. During an interview on 6/6/2025 at 12:58 PM with RN 1, RN1 stated he (RN1) was not aware Resident 9 and Resident 10 were having sex and stated he (RN1) had only seen them walking together. RN 1 stated Resident 9 and Resident 10 had not notified staff they were having sex or asked staff for any condoms. RN 1 stated if the residents (in general) wanted to have sex, the facility would need to monitor the residents (in general) to make sure it was consensual (done with the willing agreement of everyone involved). RN 1 stated residents (in general) could have sex in their room if their roommates were ok with it. [NAME] an interview on 6/6/2025 at 1:1PM with the Director of Nursing, the DON stated Resident 10 spoke very fast and kept changing topics (in general before Resident 10 went to the GACH). The DON stated Resident 10 appeared to be in a manic state (a period of unusually elevated mood and energy). The DON stated Resident 10 told her (DON) she (Resident 10) was DTO and wanted to hit others. The DON stated Resident 10 told her (DON) she (Resident 10) broke up with Resident 9. The DON stated Resident 10 told her she (Resident 10) did not want it (sex) anymore and the girls are talking about me. The DON stated Resident 10 told her (DON) she (Resident 10) did not want to live in a coed facility. During an interview on 6/6/2021 at 3:11 PM with the facility's Administrator (ADM), the ADM stated daily rounds (regular check-in where the medical team visits each patient to review their condition and plan for their care) we done all times. The ADM stated residents who could consent were monitored via the daily rounds and residents (in general) who could not consent needed to be monitored more closely. The ADM stated each program counselor had a specific case load of residents and the program counselors were obligated to check on their specific residents. The ADM stated residents were encouraged to have sex during specified times, specifically between six to seven PM. The ADM stated if the room was closed between six and seven PM, the staff could know to provide privacy and not enter a resident ' s room. The ADM stated residents would report to staff if they felt unsafe and staff were close to the rooms to be able to respond right away. During a review of the facility's investigation report letter dated 6/9/2025, the investigation report letter indicated the facility was investigating an alleged abuse on 6/5/2025 between the alleged victim (Resident 10) and the alleged aggressor (Resident 9). The investigation report letter indicated the facility received a call from the hospital informing the facility Resident 10 reported her boyfriend was sexually and physically aggressive with her during Resident 10 ' s time at the facility. During a review of the facility's job description titled Administrator, revised 10/2020, the job description indicated The primary purpose of this position is to direct the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to residents at all times). The job description indicated the ADM would be responsible for all programs and activities. The job description indicated the ADM would have the following responsibilities: Ensure that each resident receives necessary care and services to attain and maintain the highest practical physical, mental and psychosocial well-being consistent with the resident ' s comprehensive assessment and plan of care Participate in the facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and during emergencies. Ensure the facility and resident environment remain as free of accidents as possible and that each resident receives adequate supervision and assistive devices to prevent accidents, including identifying and analyzing hazards and risks, implementing interventions and monitoring the effectiveness of those interventions when necessary. T Ensure that the therapeutic recreation activity programs are planned, implemented and evaluated to meet the needs and interests of residents to maximize resident quality of life and quality of care. Observe, monitor and evaluate outcomes of all facility programs, policies and procedures to ensure effectiveness and fulfill administrative and professional responsibility. Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas and/or improving services. Develop and implement a facility compliance program that meets state and federal requirements. Ensure that an adequate number of appropriately trained, competent, licensed professionals and nonlicensed personnel are on duty at all times to meet the needs of the residents. Ensure the planning, implementation and evaluation of an environmental safety program that will maintain the health, welfare and safety of residents, staff and visitors. Ensure the facility complies with applicable federal, state and local standards and regulations including the Americans with Disabilities Act, OSHA, Centers for Medicare and Medicaid Services (CMS), Life Safety Code, etc. Ensure that all facility personnel, residents, visitors, etc., follow established safety policies and procedures. Review accident/incident reports (e.g., falls, injuries of an unknown source, abuse, etc.); monitor to determine the effectiveness of the facility ' s safety and risk management programs. Is involved with residents, family members, personnel, visitors, government agencies/personnel, etc., under all conditions/circumstances. Must possess the ability to plan, organize, develop, implement and interpret the programs, goals, objectives, policies, procedures, etc., that are necessary for providing quality care and maintaining a sound operation. During a review of the facility ' s policy and procedure (P&P), titled Administrator, dated 3/2021, indicated A licensed administrator is responsible for the day-to-day functions of the facility. The P&P indicated the ADM would implement established resident care policies, personnel policies, safety and security policies, and other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long-term care facilities and ensuring that the facility admits only those residents for whom it can provide adequate care.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) was free from sexual abuse (non-consensual sexual contact of any type or sexual harassment) from Resident 2 who had a history of exchanging money for sex while residing at the facility. On [DATE] at approximately 8:13 PM Resident 2 went inside Resident 1's room while Resident 1 (who did not have the capacity to consent for sexual activities) was laying down and Resident 2 pulled out his genitals. Resident 1 told Resident 2 to stop, and Resident 2 was masturbating in front of Resident 1 and got on top of Resident 1 while Resident 1 laying down. Resident 2 touched and sucked on Resident 1's breasts. Resident 1 told Resident 2 to stop, and Resident 2 did not stop. This failure resulted for Resident 1 to experience sexual abuse from Resident 2 under the care of the facility and she (Resident 1) felt like an Object, and like I don't matter. On [DATE] at 4:23 PM, the Department called an Immediate Jeopardy Situation (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) related to the failure to protect Resident 1 from sexual abuse from Resident 2 and for allowing Resident 2 to exchange money for sex this placed Resident 1 and other potential unidentified residents in the facility at risk for sexual abuse. On [DATE] at 12:53 PM, the Department removed the IJ situation while onsite after the surveyor verified the facility's implementation of the IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) through observation, interview, and record review, which included: On [DATE], at 8:33 PM, the facility placed Resident 1 in a safe environment and a licensed nurse monitored Resident 1 every 15 minutes and notified Resident 1's Medical Doctor and the local law enforcement. On [DATE], at approximately 10:10 PM, the Program Director initiated a care plan to address the non-consensual sexual relationship with Resident 2 and placed Resident 2 on a one-to-one supervision (one-to-one sitters which patients are highly supervised to ensure safety). On [DATE], at 11:05 PM, the DON initiated a Change in Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive (ability to think and process information), behavioral, or functional domains) to monitor Resident 2 for sexually inappropriate behavior towards Resident 1. On [DATE], at 9:45 PM, the facility sent Resident 1 to a General Acute Care Hospital for further evaluation and possible treatment. The facility readmitted Resident 1 on [DATE] and placed Resident 1 on a one-to-one supervision. On [DATE], at 5:17 PM, Nurse Practitioner 1 (NP1) determined Resident 1 lacked the capacity to consent for sexual activities. On [DATE], at 5:21 PM, NP1 determined Resident 2 lacked the capacity to consent for sexual activities. On [DATE], the DON conducted an audit of residents (77 current residents) with possible sexual activity. On [DATE], at approximately 1:30 to 2 PM, an outside consultant began to educate the staff (in general) including the DON, and Program Director on adherence to new protocols and abuse prevention. On [DATE], at approximately 8:30 PM, the Program Director initiated a care plan for Resident 2 to address behaviors related to exchanging money for sex. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on [DATE] and readmitted on [DATE]. The admission Record indicated the resident had diagnoses that included paranoid (unreasonably suspicious or mistrustful) schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's History and Physical (H&P) dated [DATE], indicated Resident 1 could not make her own decisions but could make needs known. During a review of Resident 1's Mental Health Conservatorship (when a judge appoints another person to act or make decisions for the person who needs help), dated [DATE], the Mental Health Conservatorship indicated Resident 1 was a Conservatee (an adult who, due to a physical or mental condition, is legally deemed unable to manage their own affairs or care for themselves) granted on [DATE] and expired on [DATE]. During a review of Resident 1's Minute Order (a brief, written document that summarizes a judge's decision during a court hearing or proceeding), dated [DATE], the Minute Order indicated a Guardian was reappointed as Resident 1's conservator until [DATE]. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated [DATE], the MDS indicated Resident 1 had potential indicators of psychosis (loss of touch with reality), and delusions (misconceptions or beliefs, contrary to reality). During a review of Resident 1's Care Plan Report dated [DATE], the Care Plan Report indicated Resident 1 was at risk to exhibit psychosocial distress related to an abuse allegation. The Care Plan Report indicated Resident reported to staff experiencing a sexual assault by a male peer. She stated, Resident (unidentified) touched me, sucked my breast, and hugged me while I was saying stop and no. During a review of Resident 1's Nurses Progress Note dated [DATE], timed 8:13 PM, the Nurses Progress Note indicated Resident 2 entered Resident 1's room and pushed himself on Resident 1 digging his hands and face into Resident 1's breasts. The Nurses Progress Note indicated Resident 1 expressed Resident 1 was uncomfortable and asked Resident 2 to stop and Resident 2 refused. During a review of Resident 1's Nurses Progress Notes dated [DATE] at 11:06 PM, the Nurses Progress Notes indicated Resident 1 went to the nurse ' s station (on [DATE]) to report a sexual assault by a male peer (Resident 2). The Nurses Progress Notes indicated Resident 1 did not want Resident 2 to enter Resident 1's room again. The Nurses Progress Notes indicated Resident 1 was encouraged to Alert staff and get help if any man came to her room without her consensus. During a review of Resident 1's Social Service Progress Note dated [DATE] at 1:30 PM, the Social Service Progress Note indicated the DON, met with Resident 1 and Resident (Resident 1) reported that a male resident (Resident 2) entered the room, and although she (Resident 1) told him (Resident 1) to leave, he (Resident 2) proceeded to lie on top of her (Resident 1). The Social Service Progress Note indicated Resident 1 disclosed that she (Resident 1) had been in a brief relationship One week, (unidentified date) with a male resident (Resident 2). The Social Service Progress Note indicated the local police department interviewed (Resident 1). During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on [DATE], with diagnoses that included schizophrenia and personal history of traumatic brain injury (TBI-a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head). During a review of Resident 2's History and Physical dated [DATE] indicated Resident 2 did not have the capacity to make his own decisions but could make needs known. During a review of Resident 2's General Progress Notes dated [DATE] timed at 1:41 PM, the General Progress Notes indicated the Program Counselor was the writer of the General Progress Notes. The General Progress Notes indicated Resident 2 was sexually active with different residents (unidentified) and would give money. During a review of Resident 2's Social Service Progress Note dated [DATE] at 11:52 AM, the Social Service Progress Note indicated the local police department went to speak with Resident 2 on [DATE] at 9:15 am, and did not question Resident 2 because Resident 2 was asleep. During a review of Resident 2's Nurses Progress Note dated [DATE] at 12:34 PM, the Nurses Progress Note indicated Resident 2 stated I touched her (Resident 1) breast, (on [DATE]). The Nurses Progress Note indicated Resident 2 was asked where he (Resident 2) touched Resident 1 and Resident 2 replied, I went to her (Resident 1) room, and I touched her (Resident 1) breast. The Nurses Progress Note indicated Resident 2 stated Resident 1 was in her bed and She (Resident 1) told me to stop then I left the room. The Nurses Progress Note indicated Resident 2 denied pulling down his pants and when asked what would happen if the resident (Resident 2) touched someone without consent, the resident replied, I will be in trouble. During a review of Resident 2's Nurses Progress Note dated [DATE] timed 12:45 AM, the Nurses Progress Note indicated Resident 2 reported he (Resident 2) went to Resident 1 ' s room and touched the resident ' s (Resident 1) breast Because she is hot. During an observation and interview on [DATE] at 8:33 am, Resident 2 was observed asleep in his room not able to be interviewed. During an interview on [DATE] at 1:27 PM, with Resident 2, Resident 2 stated he (Resident 2) touched Resident 1's breasts on [DATE] evening (unidentified time). Resident 2 stated Resident 1 did not give him (Resident 2) permission to touch Resident 1 ' s breasts. During an interview on [DATE] at 1:36 PM with Registered Nurse 1 (RN 1), RN 1 stated he (RN1) saw Resident 2 going in and out of Resident 1's room on the evening of [DATE] (unspecified time prior to 8:13 PM). RN 1 stated he (RN1) notified the ADM and the psychiatrist (a medical doctor who specializes in the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) once Resident 1 informed him (RN1) Resident 2 allegedly sexually assaulted her (Resident 1) on [DATE] at 8:13 PM. During an interview on [DATE] at 2:02 PM with Resident 3 (Resident 1's roommate), Resident 3 stated she (Resident 3) was in the room on [DATE] evening when she (Resident 3) heard Resident 1 said Stop it. During an interview on [DATE] at 2:16 PM, with Certified Nursing Assistant 1 (CNA1), CNA1 stated Resident 1 and Resident 2 were in a relationship in the past (unidentified time and date) and she (CNA1) observed Resident 1 and Resident 2 undressed and having sex. CNA1 stated she (CNA1) could not tell how long ago Resident 1, and Resident 2 had sex. During an observation and interview on [DATE] at 12:19 PM with Resident 1, in the facility ' s meeting room Resident 1 was awake and stated on the day she (Resident 1) was assaulted ([DATE]), she (Resident 1) heard a knock on her door. Resident 1 stated she (Resident 1) saw Resident 2 and told him Hell no and Go away. Resident 1 stated Resident 2 went into her room where Resident 1 was lying down, and Resident 2 pulled out his genitals. Resident 1 stated she (Resident 1) told Resident 2 to stop, and Resident 2 was Jerking off in front of me and got on top of me while I was laying down and was playing with my breasts. Resident 1 stated she (Resident 1) kept asking Resident 2 to stop but Resident 2 did not stop. Resident 1 stated she (Resident 1) did not consent for Resident 2 to touch her (Resident 1). Resident 1 stated when Resident 2 touched her and did not stop, she (Resident 1) felt like an Object and Like I don't matter. During a telephone interview on [DATE] at 1:12 PM, with the Nurse Practitioner who was covering for the Medical Director, the Nurse Practitioner stated he (Nurse Practitioner) was not familiar with the sexual activities of the facility and that the residents (in general) who were not capable of making decisions were not supposed to engage in sexual activities. During the concurrent interview and record review on [DATE] at 1:32 PM with the DON Resident 2's General Progress Notes, dated [DATE], timed at 1:41 PM were reviewed. The DON stated the General Progress Notes indicated Resident 2 was sexually active with different residents (unidentified) and would give money. The DON stated she (DON) did not know and was not aware Resident 2 would give and receive money for sex. The DON stated she (DON) and the facility did not investigate the allegations of Resident 2 receiving money for sex. During an interview on [DATE] at 1:45 PM with the Program Counselor, the Program Counselor stated he (Program Counselor) worked with Resident 2 and he (Program Counselor) was familiar with Resident 2. The Program Counselor stated he (Program Counselor) was the writer of Resident 2's General Progress Notes, dated [DATE], timed at 1:41 PM. The Program Counselor stated Resident 2 told him on [DATE] at 1:41 PM, that he (Resident2) would give and receive money for sexual favors from Resident 1 and other residents (could not remember which residents and how much money). The Program Counselor stated he (Program Counselor) reported what Resident 2 told him regarding the money exchange for sex to a director (unidentified) who no longer worked at the facility. The Program Counselor stated he (Program Counselor) was supposed to also report the money exchange for sex to the DON and to the ADM as another form of abuse exploitation (taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion). During an interview on [DATE] at 1:45 PM, the DON stated she (DON) was not aware until [DATE] regarding the sexual activities between Resident 1 and Resident 2. During an interview on [DATE] at 3:04 PM with Medical Doctor 1 (MD 1), MD 1 stated she (MD1) was not aware Resident 2 would give or receive money for sex. MD 1 stated that any illegal activity needed to be addressed by the facility. MD 1 stated a resident (in general) who would receive or give money for sex would be considered prostitution (the practice or occupation of engaging in sexual activity with someone for payment). During a review of the facility's Abuse Prohibition Policy and Procedure (P&P), with a revision date of [DATE], the P&P indicated Sexual Abuse was a non-consensual sexual contact of any type with a resident and included but was not limited to sexual harassment, sexual coercion or sexual assault. The P&P indicated the facility prohibited abuse, mistreatment, and exploitation for all residents. During a review of the facility's P&P titled Identifying Sexual Abuse and Capacity to Consent last reviewed on [DATE], indicated A resident ' s consent to sexual activity is not valid if obtained from a resident who lacks capacity to consent (means you understand enough about something to make a decision) or if consent was obtained through intimidation, fear, or coercion (using force, threats, or intimidation to make someone do something they don't want to do). The P&P indicated generally sexual contact is non-consensual (something is done without the free and willing agreement) if the resident is either: a. appears to want the contact to occur but lacks the cognitive ability (the skills your brain uses to think, learn, and understand things) to consent (give permission) or b. does not want the contact to occur. The P&P indicated any allegation (claim that someone has done something wrong) or suspicion (feeling that something might be true or has happened) of sexual abuse, the facility would immediately report the allegation to authorities.

Based on observation, interview, and record review, the facility failed to implement its Abuse Prohibition Policy and Procedure (P&P) to prohibit, prevent, and investigate allegations of sexual abuse (non-consensual contact of any type or sexual harassment), for two of six sampled residents (Resident 1 and Resident 2) by failing to ensure Resident 1 was free from sexual abuse from Resident 2 who had a history of exchanging money for sex while residing at the facility. On [DATE] at approximately 8:13 PM Resident 2 went inside Resident 1's room while Resident 1 (who did not have the capacity to consent for sexual activities) was laying down and Resident 2 pulled out his genitals. Resident 1 told Resident 2 to stop, and Resident 2 was masturbating in front of Resident 1 and got on top of Resident 1 while Resident 1 laying down. Resident 2 touched and sucked on Resident 1's breasts. Resident 1 told Resident 2 to stop, and Resident 2 did not stop. This failure resulted for Resident 1 to experience sexual abuse from Resident 2 under the care of the facility, and she (Resident 1) felt like an Object, and like I don't matter. On [DATE] at 4:23 PM, the Department called an Immediate Jeopardy Situation (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) related to the failure to implement P&P on abuse prevention and failure to protect Resident 1 from sexual abuse from Resident 2 and for allowing Resident 2 to exchange money for sex this placed Resident 1 and other potential unidentified residents in the facility at risk for sexual abuse. On [DATE] at 12:53 PM, the Department removed the IJ situation while onsite after the surveyor verified the facility's implementation of the IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) through observation, interview, and record review, which included: On [DATE], at 8:33 PM, the facility placed Resident 1 in a safe environment and a licensed nurse monitored Resident 1 every 15 minutes and notified Resident 1 ' s Medical Doctor and the local law enforcement. On [DATE], at approximately 10:10 PM, the Program Director initiated a care plan to address the non-consensual sexual relationship with Resident 2 and placed Resident 2 on a one-to-one supervision (one-to-one sitters which patients are highly supervised to ensure safety). On [DATE], at 11:05 PM, the DON initiated a Change in Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive (ability to think and process information), behavioral, or functional domains) to monitor Resident 2 for sexually inappropriate behavior towards Resident 1. On [DATE], at 9:45 PM, the facility sent Resident 1 to a General Acute Care Hospital for further evaluation and possible treatment. The facility readmitted Resident 1 on [DATE] and placed Resident 1 on a one-to-one supervision. On [DATE], at 5:17 PM, Nurse Practitioner 1 (NP1) determined Resident 1 lacked the capacity to consent for sexual activities. On [DATE], at 5:21 PM, NP1 determined Resident 2 lacked the capacity to consent for sexual activities. On [DATE], the DON conducted an audit of residents (77 current residents) with possible sexual activity. On [DATE], at approximately 1:30 to 2 PM, an outside consultant began to educate the staff (in general) including the DON, and Program Director on adherence to new protocols and abuse prevention. On [DATE], at approximately 8:30 PM, the Program Director initiated a care plan for Resident 2 to address behaviors related to exchanging money for sex. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on [DATE] and readmitted on [DATE]. The admission Record indicated the resident had diagnoses that included paranoid (unreasonably suspicious or mistrustful) schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's History and Physical (H&P) dated [DATE], it indicated Resident 1 could not make her own decisions but could make needs known. During a review of Resident 1's Mental Health Conservatorship (when a judge appoints another person to act or make decisions for the person who needs help), dated [DATE], the Mental Health Conservatorship indicated Resident 1 was a Conservatee (an adult who, due to a physical or mental condition, is legally deemed unable to manage their own affairs or care for themselves) granted on [DATE] and expired on [DATE]. During a review of Resident 1's Minute Order (a brief, written document that summarizes a judge's decision during a court hearing or proceeding), dated [DATE], the Minute Order indicated a Guardian was reappointed as Resident 1's conservator until [DATE]. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated [DATE], the MDS indicated Resident 1 had potential indicators of psychosis (loss of touch with reality), and delusions (misconceptions or beliefs, contrary to reality). During a review of Resident 1's Care Plan Report dated [DATE], the Care Plan Report indicated Resident 1 was at risk to exhibit psychosocial distress related to an abuse allegation. The Care Plan Report indicated Resident reported to staff experiencing a sexual assault by a male peer. She stated, Resident (unidentified) touched me, sucked my breast, and hugged me while I was saying stop and no. During a review of Resident 1's Nurses Progress Note dated [DATE], timed 8:13 PM, the Nurses Progress Note indicated Resident 2 entered Resident 1 ' s room and pushed himself on Resident 1 digging his hands and face into Resident 1 ' s breasts. The Nurses Progress Note indicated Resident 1 expressed Resident 1 was uncomfortable and asked Resident 2 to stop and Resident 2 refused. During a review of Resident 1's Nurses Progress Notes dated [DATE] at 11:06 PM, the Nurses Progress Notes indicated Resident 1 went to the nurse's station (on [DATE]) to report a sexual assault by a male peer (Resident 2). The Nurses Progress Notes indicated Resident 1 did not want Resident 2 to enter Resident 1 ' s room again. The Nurses Progress Notes indicated Resident 1 was encouraged to Alert staff and get help if any man came to her room without her consensus. During a review of Resident 1's Social Service Progress Note dated [DATE] at 1:30 PM, the Social Service Progress Note indicated the DON, met with Resident 1 and Resident (Resident 1) reported that a male resident (Resident 2) entered the room, and although she (Resident 1) told him (Resident 2) to leave, he (Resident 2) proceeded to lie on top of her (Resident 1). The Social Service Progress Note indicated Resident 1 disclosed that she (Resident 1) had been in a brief relationship One week, (unidentified date) with a male resident (Resident 2). The Social Service Progress Note indicated the local police department interviewed (Resident 1). During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on [DATE], with diagnoses that included schizophrenia and personal history of traumatic brain injury (TBI-a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head). During a review of Resident 2's History and Physical dated [DATE] indicated Resident 2 did not have the capacity to make his own decisions but could make needs known. During a review of Resident 2's General Progress Notes dated [DATE] timed at 1:41 PM, the General Progress Notes indicated the Program Counselor was the writer of the General Progress Notes. The General Progress Notes indicated Resident 2 was sexually active with different residents (unidentified) and would give money. During a review of Resident 2's Nurses Progress Note dated [DATE] timed 12:45 AM, the Nurses Progress Note indicated Resident 2 reported he (Resident 2) went to Resident 1's room and touched the resident's (Resident 1) breast Because she is hot. During a review of Resident 2's Social Service Progress Note dated [DATE] at 11:52 AM, the Social Service Progress Note indicated the local police department went to speak with Resident 2 on [DATE] at 9:15 am, and did not question Resident 2 because Resident 2 was asleep. During a review of Resident 2's Nurses Progress Note dated [DATE] at 12:34 PM, the Nurses Progress Note indicated Resident 2 stated I touched her (Resident 1) breast, (on [DATE]). The Nurses Progress Note indicated Resident 2 was asked where he (Resident 2) touched Resident 1 and Resident 2 replied, I went to her (Resident 1) room, and I touched her (Resident 1) breast. The Nurses Progress Note indicated Resident 2 stated Resident 1 was in her bed and She (Resident 1) told me to stop then I left the room. The Nurses Progress Note indicated Resident 2 denied pulling down his pants and when asked what would happen if the resident (Resident 2) touched someone without consent, the resident replied, I will be in trouble. During an observation and interview on [DATE] at 8:33 am, Resident 2 was observed asleep in his room and not able to be interviewed. During an interview on [DATE] at 1:27 pm, with Resident 2, Resident 2 stated he (Resident 2) touched Resident 1 ' s breasts on [DATE] evening (unidentified time). Resident 2 stated Resident 1 did not give him (Resident 2) permission to touch Resident 1 ' s breasts. During an interview on [DATE] at 1:36 PM with Registered Nurse 1 (RN 1), RN 1 stated he (RN1) saw Resident 2 going in and out of Resident 1 ' s room on the evening of [DATE] (unspecified time prior to 8:13 PM). RN 1 stated he (RN1) notified the ADM and the psychiatrist (a medical doctor who specializes in the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) once Resident 1 informed him (RN1) Resident 2 allegedly sexually assaulted her (Resident 1) on [DATE] at 8:13 PM. During an interview on [DATE] at 2:02 PM with Resident 3 (Resident 1 ' s roommate), Resident 3 stated she (Resident 3) was in the room on [DATE] evening when she (Resident 3) heard Resident 1 said stop it. During an interview on [DATE] at 2:16 PM, with Certified Nursing Assistant 1 (CNA1), CNA1 stated Resident 1 and Resident 2 were in a relationship in the past (unidentified time and date) and she (CNA1) observed Resident 1 and Resident 2 undressed and having sex. CNA1 stated she (CNA1) could not tell how long ago Resident 1, and Resident 2 had sex. During an observation and interview on [DATE] at 12:19 PM with Resident 1 in the facility ' s meeting room, Resident 1 stated she (Resident 1) was awake and stated on the day she (Resident 1) was assaulted ([DATE]), she (Resident 1) heard a knock on her door. Resident 1 stated she (Resident 1) saw Resident 2 and told him Hell no and Go away. Resident 1 stated Resident 2 went into her room where Resident 1 was lying down, and Resident 2 pulled out his genitals. Resident 1 stated she (Resident 1) told Resident 2 to stop, and Resident 2 was Jerking off in front of me and got on top of me while I was laying down and was playing with my breasts. Resident 1 stated she (Resident 1) kept asking Resident 2 to stop but Resident 2 did not stop. Resident 1 stated she (Resident 1) did not consent for Resident 2 to touch her (Resident 1). Resident 1 stated when Resident 2 touched her and did not stop, she (Resident 1) felt like an Object and Like I don't matter. During a telephone interview on [DATE] at 1:12 PM, with the Nurse Practitioner who was covering for the Medical Director, the Nurse Practitioner stated he (Nurse Practitioner) was not familiar with the sexual activities of the facility and that the residents (in general) who were not capable of making decisions were not supposed to engage in sexual activities. During the concurrent interview and record review on [DATE] at 1:32 PM with the DON Resident 2's General Progress Notes, dated [DATE], timed at 1:41 PM were reviewed. The DON stated the General Progress Notes indicated Resident 2 was sexually active with different residents (unidentified) and would give money. The DON stated she (DON) did not know and was not aware Resident 2 would give and receive money for sex. The DON stated she (DON) and the facility did not investigate the allegations of Resident 2 receiving money for sex. During an interview on [DATE] at 1:45 PM with the Program Counselor, the Program Counselor stated he (Program Counselor) worked with Resident 2, and he (Program Counselor) was familiar with Resident 2. The Program Counselor stated he (Program Counselor) was the writer of Resident 2's General Progress Notes, dated [DATE], timed at 1:41 PM. The Program Counselor stated Resident 2 told him on [DATE] at 1:41 PM, that he (Resident2) would give and receive money for sexual favors from Resident 1 and other residents (could not remember which residents and how much money). The Program Counselor stated he (Program Counselor) reported what Resident 2 told him regarding the money exchange for sex to a director (unidentified) who no longer worked at the facility. The Program Counselor stated he (Program Counselor) was supposed to also report the money exchange for sex to the DON and to the ADM as another form of abuse exploitation (taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion). During an interview on [DATE] at 1:45 PM, the DON stated she (DON) was not aware until [DATE] regarding the sexual activities between Resident 1 and Resident 2. During an interview on [DATE] at 3:04 PM with Medical Doctor 1 (MD 1), MD 1 stated she (MD1) was not aware Resident 2 would give or receive money for sex. MD 1 stated that any illegal activity needed to be addressed by the facility. MD 1 stated a resident (in general) who would receive or give money for sex would be considered prostitution (the practice or occupation of engaging in sexual activity with someone for payment). During a telephone interview on [DATE] at 1:12 pm, with the Nurse Practitioner who was covering for the Medical Director, the Nurse Practitioner stated he (Nurse Practitioner) was not familiar with the sexual activities of the facility and that the residents who were not capable of making decisions were not supposed to engage in sexual activities. During an interview and record review on [DATE] at 1:32 pm with the DON Resident 2's General Progress Notes, dated [DATE], timed at 1:41pm were reviewed. The DON stated she (DON) was not aware Resident 2 would give and receive money for sex and that she (DON) and the facility did not investigate the allegations of Resident 2 receiving money for sex. During a review of the facility's Abuse Prohibition Policy and Procedure (P&P), with a revision date of [DATE], the P&P indicated Sexual Abuse was a non-consensual sexual contact of any type with a resident and included but was not limited to sexual harassment, sexual coercion or sexual assault. The P&P indicated the facility prohibited abuse, mistreatment, and exploitation for all residents. The P&P indicated the facility would implement an abuse prohibition program through the following: Reporting of incidents, and the facility would respond to the results of their investigations. The P&P indicated employees were designated as mandated reporters and were obligated to immediately report any suspicion of a crime against a resident. The P&P indicated reporting a suspicion of a crime only to an immediate supervisor does not meet the obligation to report. During a review of the facility's P&P titled Identifying Sexual Abuse and Capacity to Consent last reviewed on [DATE], indicated A resident ' s consent to sexual activity is not valid if obtained from a resident who lacks capacity to consent (means you understand enough about something to make a decision) or if consent was obtained through intimidation, fear, or coercion (using force, threats, or intimidation to make someone do something they don't want to do). The P&P indicated generally sexual contact is non-consensual (something is done without the free and willing agreement) if the resident is either: a. appears to want the contact to occur but lacks the cognitive ability (the skills your brain uses to think, learn, and understand things) to consent (give permission) or b. does not want the contact to occur. The P&P indicated any allegation (claim that someone has done something wrong) or suspicion (feeling that something might be true or has happened) of sexual abuse, the facility would immediately report the allegation to authorities.

Based on interview and record review the facility failed to maintain an infection prevention and control program (prevents or stops the spread of infections in healthcare settings) designed to provide a safe, sanitary (clean), and comfortable environment, and to help prevent the development and transmission of communicable diseases (illnesses that can spread from person to person) and infections for three of three sampled residents (Resident 4, Resident 5, and Resident 7) and infections by failing to: Ensure the facility implement appropriate precautions to prevent transmission of sexually transmitted infection (STI) among residents. Resident 7 who had a diagnosis of sexually transmitted diseases had unprotected sex (Sexual intercourse without a condom) with Resident 4. Resident 4 had also unprotected sex with Resident 5. This failure had a potential risk for Resident 4 and Resident 5 to be exposed or to get sexually transmitted infection. Findings: During a review of Resident 4's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses of paranoid (unreasonably suspicious or mistrustful) schizophrenia (a mental illness that is characterized by disturbances in thought) and impulse control disorder (a person has difficulty resisting strong urges to do something, even if it is harmful to themselves or others). During a review of Resident 4's History and Physical dated 9/16/2024, the History and Physical indicated Resident 4 did not have the capacity to understand and make decisions. During a review of Resident 4's Conservatorship (when a judge appoints another person to act or make decisions for the person who needs help), dated 11/14/2024 indicated Resident 4 was gravely disabled (someone is no longer able to provide for their own food, clothing, or shelter because of a mental health disorder) authorizing the conservator to place him into a facility. During a record review of Resident 4's Nursing Progress Notes dated 3/5/2025 at 4 PM, the Nursing Progress Notes indicated The resident (Resident 4) had an anal contact (through the butt) with female peer (Resident 7) without the use of a condom. During a record review of Resident 4's STI virus test collected on 3/6/2025, the STI virus test indicated it was negative on 3/8/2025. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 10/8/2024 with diagnosis that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 5's History and Physical dated 12/3/2024, the History and Physical indicted Resident 5 did not have the capacity to make her own decision but could make her needs known. During a review of Resident 5's Conservatorship dated 3/18/2024, the Conservatorship indicated Resident 5 was gravely disabled authorizing the conservator to place her into an institute of mental disease (IMD, a psychiatric hospital or other specialized facility that provides care, diagnosis, and treatment for individuals with severe mental health disorders). During a review of Resident 5's Social Services Progress Notes dated 3/11/2025 at 8:05 PM, the Social Services Progress Notes indicated the facility educated Resident 5 about the dangers of unprotected sex. During a review of Resident 5's STI virus test collected on 5/20/2025, the STI virus test indicated it was negative on 5/21/2025. During a review of Resident 5's Nursing Progress Notes dated 5/22/2025 at 12:29 PM, the Nursing Progress Notes indicated Resident 5 had unprotected sex with a male peer (unidentified) on three separate occasions. The Nursing Progress Notes indicated Resident 5 spoke with another female (unidentified) who disclosed she had STI virus and this female also had unprotected sex with the same male. The Nursing Progress Notes nursing notes indicated Resident 5 was anxious about the possibility of having contracted sexually transmitted virus. During a review of Resident 7's admission Record, the admission Record indicted the facility admitted the resident on 2/25/2020 with diagnosis that included paranoid schizophrenia, herpes viral infection, and sexually transmitted virus. During a review of Resident 7's Conservatorship dated 8/24/2024, the Conservatorship indicated Resident 7 was gravely disabled authorizing the conservator to place her into an institute of mental disease. During a review of Resident 7's laboratory (lab) results report dated 11/1/2024, the lab results indicated Resident 7's confirmation of sexually transmitted virus. During a review of Resident 7's History and Physical dated 2/9/2025, the History and Physical indicated Resident 7 did not have the capacity to make her own decisions but could make her needs known. During a review of Resident 7's Care Plan Report dated 1/23/2025, the Care Plan Report indicated the resident was at risk for complications related to history of herpes viral infection. The Care Plan Report indicated the facility would educate Resident 7 on proper personal hygiene (taking care of your body to keep it clean and healthy) and infection control such as using a condom for safe sex. During a review of Resident 7's Medication Administration Record (MAR) dated 6/3/2025, the MAR indicated Resident 7 was taking medication for sexually transmitted virus. During a review of Resident 7's social services progress notes dated 3/11/2025 at 8:02 PM, the social services notes indicated the facility educated Resident 7 about the dangers of unprotected sex. During an interview on 5/23/2025 at 3:23 PM with the Director of Nursing (DON), the DON stated Resident 4 had unprotected sex with Resident 5 on three occasions in the past (specific dates unknown). The DON also stated Resident 4 had sex with Resident 7 in the past (specific dates unknown). During an interview on 5/27/2025 at 10 AM with Resident 7, Resident 7 stated she (Resident 7) had unprotected sex with Resident 4 a few months ago but could not specify the exact dates. During an interview on 5/27/2025 at 10:31 AM with Resident 5, Resident 5 stated she had unprotected sex with Resident 4 on four or five occasions in the past. Resident 5 stated she (Resident 5) could not specify the exact dates. Resident 5 stated she (Resident 5) was worried she (Resident 5) got STI virus because Resident 7 told her (Resident 5) she (Resident 7) had STI virus. During a telephone interview on 5/27/2025 at 1:12 pm, with the Nurse Practitioner who was covering for the Medical Director, the Nurse Practitioner stated he (Nurse Practitioner) was not familiar with the sexual activities of the facility and that the residents (in general) who were not capable of making decisions were not supposed to engage in sexual activities. During an interview on 5/28/2025 at 1:35 PM with Primary Counselor 3 (PC 3), PC 3 stated residents (in general) could engage in sexual activity during Free time, between the hours of 6 to 7 PM. PC 3 stated residents (in general) would need to get consent from a roommate to be able to have sex in their room. PC 3 stated the facility could not force the roommate to leave the room while the residents had sex, but the residents who had sex were asked to keep the curtain closed if the roommate did not leave the room. When asked how the staff knew if the residents were practicing safe sex, PC 3 stated I don't know. When asked how the facility ensured residents practice safe sex, PC 3 stated I don't know. During an interview on 5/28/2025 at 2:04 PM with Certified Nursing Assistant 5 (CNA 5), CNA 5 stated If residents liked it each other, it would be hard to stop them from getting together. CNA 5 stated she (CNA5) would not question the residents who would go in and out of each other's room during Free time. CNA 5 stated she (CNA5) would question a resident (in general) who would go into another resident's room if it was not Free time. During an interview on 5/29/2025, at 3:09 pm, with the Infection Preventionist Nurse (IP, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment), the IP nurse stated the residents (in general) who had unprotected sex with any resident who had STI virus were at risk for contracting STI virus. During a review of the facility's policy and procedures (P&P) titled, Infection Prevention and Control Program, dated 2/26/2025, the P&P indicated the facility would establish and maintain a safe, sanitary and comfortable environment and to help prevent the development and transmission (spread) of communicable diseases and infections. The P&P indicated the infection prevention and control program are a facility-wide effort involving all disciplines (staff) and individuals. The P&P indicated the facility would identify infections or possible complication of existing infections and would institute measures to avoid complications or dissemination (spread). The P&P indicated the facility would follow established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC - an organization that protects the public's health). During a review of the Centers for Disease (CDC) Guideline titled Preventing HIV, dated 9/26/2024, the CDC Guideline indicated not having sex and using condoms help to prevent HIV. Retrieved from https://www.cdc.gov/hiv/prevention/index.html#:~:text=You%20can%20choose%20not%20having,prevent%20transmitting%20HIV%20to%20others During a review of the CDC Guideline titled About HIV, dated 1/14/2025, the CDC Guideline indicated a person can spread HIV through anal or vaginal sex. The CDC guideline indicated body fluids such as blood (cum), pre-seminal fluid (pre-cum), rectal (butt) fluids, and vaginal fluids. The CDC Guideline indicated HIV spread could be prevented by using condoms the right way every time you have sex. Retrieved from: https://www.cdc.gov/hiv/causes/index.html.

Based on interview and record review, the facility failed to protect two of six sampled residents'(Resident 1 and Resident 4) right to be free from physical abuse when: - On 3/21/2025, Primary Counselor (PC) 1 physically fought Resident 1 inside Resident 1's assigned room and - On 4/2/2025 Resident 5 hit Resident 4 in the nose These deficient practices resulted in Resident 1 and Resident 4 being subjected to abuse and requiring x-rays after the assault and had the potential for all residents (77) to feel powerless and unprotected in the facility. Findings: A. A review of Resident 1's Admission Record indicated the facility admitted the resident on 8/28/2024, with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). A review of Resident 1's History and Physical (H&P), dated 10/30/2024, indicated the resident could not make medical decisions but could make needs known. The H&P further indicated the resident's psychological insight/judgement was appropriate. A review of Resident 1's Care Plan for the Potential/Risk to exhibit Psycho-Social Distress, revised on 3/24/2025, indicated Resident 1 had the potential to have psycho-social distress related to an abuse allegation on 3/24/2025. The care plan goal was for Resident 1 to experience no psycho-social distress and for staff to observe no psycho-social distress in the resident. The care plan interventions indicated to allow the resident to verbalize feelings, for staff to provide education regarding the importance of utilizing coping skills and psychology/behavioral health consult as indicated. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/13/2025 indicated the resident's cognitive skills (ability to think, remember and make decisions) for daily decision making was intact. The MDS also indicated Resident 1 was independent with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) but had trouble concentrating on things such as reading the newspaper. A review of Resident 1's Change in Condition (COC - a deviation from a patient's baseline state of health, often involving a sudden or clinically significant worsening) Evaluation, dated 3/22/2025 at 1:33 PM, indicated Resident 1 presented a swollen right palm to the charge nurse and reported falling in the bathroom around 9 PM the night before (on 3/21/2025). The COC also indicated the physician ordered an x-ray of the resident's hand. A review of Resident 1's COC, dated 3/24/2025, indicated Resident 1 reporting having a physical altercation with a staff member on 3/21/2025 at 9:30 PM. The COC further indicated the resident reported that resident's previous statement of falling in the bathroom was not true. The COC indicated the resident further stated he had an abrasion to the right abdominal area due to a scratch when the resident fell to the floor during the altercation. The COC indicated the resident further stated he used his right hand to prevent a fall, but the resident's stomach hit the edge of the roommate's bedside table. A review of Resident 1's Interdisciplinary Care Conference note, dated 3/25/2025, indicated the meeting was conducted on 3/25/2025. A review of the facility's written Follow-Up Investigation Report letter, dated 3/27/2025, indicated Resident 1 reported to the Director of Nursing (DON) the allegation of physical abuse towards Resident 1 by PC 1 on 3/24/2025. Resident 1 reported that he didn't fall but allegedly got into a physical altercation with PC 1. Resident 1 further reported PC 2 watched the altercation by PC 1 which occurred in the resident's room. The Follow-Up Investigation Report letter also indicated PC 2 reported witnessing a fight between Resident 1 and PC 1 after PC 1 and PC 2 approached Resident 1. The Follow-Up Investigation Report also indicated Resident 6 (Resident 1's roommate) witnessed the fight between Resident 1 and PC 1. The Follow-Up Investigation Report also indicated that on 3/28/2025, PC 1 and PC 2 were terminated. During an interview on 4/4/2025 at 10:44 AM, Resident 1 stated there was a physical fight between Resident 1 and PC 1 about two Fridays ago in March 2025. Resident 1 stated PC 1 and Resident 1 previously had physical and verbal altercations in the past. Resident 1 stated developed a bruise on his right abdomen from the fight with PC 1. During an interview on 4/4/2025 at 11:29 AM, Resident 6 stated that Resident 6 and Resident 1 shared a room. Resident 6 stated about a week ago at around 8 PM, Resident 1 and PC 1 fought inside Resident 6's room while PC 2 watched. Resident 6 stated watching the staff fight a resident made them feel unsafe and Resident 6 would like to move to a different facility. During a telephone interview with PC 1 on 4/4/2025 at 1:32 PM, PC 1 started to relay what happened and then the phone disconnected. On 4/4/2025 PC 1 was contacted via telephone, but the phone call went straight to automated voicemail (VM) which indicated that a VM could not be left because a VM was not set up. During an interview on 4/4/2025 at 1:57 PM, the Administrator (ADM) stated they investigated Resident 1's abuse allegation. ADM stated Resident 1's roommate saw the altercation between Resident 1 and PC 1. The ADM further stated based on the facility's investigation and witness statement, a physical altercation did take place between Resident 1 and PC 1 and PC 1 and PC 2 were fired. B. A review of Resident 4's Admission Record indicated the facility admitted the resident on 10/8/2024 with diagnoses that included schizoaffective disorder and high blood pressure. A review of Resident 4's MDS, dated [DATE], indicated the resident could be understood and could understand others. The MDS also indicated the resident's cognition was intact and the resident was independent with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). A review of Resident 4's potential/risk to exhibit psycho-social distress care plan, initiated 11/28/2024, indicated the resident was at risk for negative psychological impact after reporting an abuse allegation in November 2024. The care plan indicated the resident was at risk for negative psychological impact due to an episode on 4/2/2025 when the resident struck a female peer back. The care plan interventions included to assist the resident in identifying coping skills other than hitting back and to provide the resident one on one with resident to explore feelings and thoughts as needed. A review of Resident 4's nose pain care plan, initiated 4/2/2025, indicated the resident exhibited nasal (of the nose) pain related to a physical altercation that day [4/2/2025] with a female peer. The care plan interventions included for staff to monitor for non-verbal signs or symptoms of pain such as increase in agitation, grimace, resistance to care and to medicate for pain as ordered. The interventions also included an x-ray of the Resident 4's facial bones to rule out injury related to a resident-to-resident physical altercation and to report to the physician any significant changes in the resident's condition or significant/abnormal x-ray result. A review of Resident 4's Radiology Results Report, dated 4/2/2025, indicated the resident had an x-ray of the facial bones due to physical trauma to the nose. The Radiology Results Report further indicated there was no significant soft tissue swelling and there was no evident of fracture. c. A review of Resident 5's admission record indicated the facility admitted the resident on 9/5/2024 with diagnoses of schizoaffective disorder, right eye blindness and insomnia (trouble falling asleep or staying asleep). A review of Resident 5's MDS, dated [DATE], indicated the resident's skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were intact. The MDS also indicated the resident's cognition was intact and the resident was independent with all ADLs. A review of Resident 5's COC, dated 4/2/2025, indicated Resident 5 had a physical altercation with a female peer. The COC also indicated the resident began yelling and cursing at the female peer while waiting in the medication line. The COC further indicated Resident 5 walked over to female peer's room and started swinging. Resident 5 was hit on both arms and chest with closed fist. A review of Resident 5's Individual Psychotherapy Progress Note, dated 4/2/2025, indicated the practitioner met with the resident after the resident's altercation with another resident. The Individual Psychotherapy Progress Note also indicated the resident was observed by staff instigating the altercation. The Individual Psychotherapy Progress Note further indicated the practitioner met with the nursing supervisor and advised a safety plan should include monitoring the resident every 15 minutes and staff supervision to avoid further contact with the other resident [Resident 4]. A review of Resident 5's Verbal and Physical Behavior care plan initiated 4/2/2025, the day of the alleged abuse, indicated Resident 5 exhibited verbally aggressive behavior with profanity and physically hit a female peer. The interventions included to assist the resident in identifying coping skills related to anger/agitation towards others, encourage the resident to participate in anger management to assist in management of verbal and physical aggressive behaviors. During an interview on 4/4/2025 at 9:13 AM, Resident 5 stated while walking in the facility hallway, Resident 4 was standing inside the resident's doorway that opened onto the hallway. Resident 5 approached Resident 4 and the two were yelling at each other. Resident 5 stated Resident 5 then hit Resident 4 first and then Resident 4 struck Resident 5 repeatedly and then PC 1 came over and separated Resident 4 and Resident 5. Resident 5 stated previously there was tension between Resident 5 and Resident 4. Resident 5 stated that Resident 4 and Resident 5 had been in verbal altercations previously, but it had never turned physical before. During an interview on 4/4/2025 at 9:30 AM, Resident 4 stated Resident 5 came up to my door and said why you are always staring at me. I said I wasn't staring at you and then (Resident 5) hit me and then I hit (Resident 5) back to protect myself. Resident 4 stated the fight lasted about for a minute before staff arrived to break it up. Resident 4 stated Resident 4 and Resident 5 had gotten into verbal fights in the past and this was the first time the interaction turned physical. Resident 4 stated both Residents 4 and 5 received an x-rays of their faces after the altercation. During an interview on 4/4/2025 at 12:24 PM, PC 3 stated Resident 4 and Resident 5 were yelling at each other. PC 3 stated then Resident 4 and Resident 5 started hitting each other. PC 3 stated although there were staff members closer to the fighting residents, PC 3 had to run over to Residents 4 and 5 because other staff members were not intervening. PC 3 stated the staff should have intervened when Resident 4 and Resident 5 first started yelling at each other. PC 3 stated the fight between Resident 4 and Resident 5 was inevitable because staff did not approach when Resident 4 and Resident 5 first started yelling. During an interview on 4/4/2025 at 2:04 PM, the Administrator (ADM) stated the facility's investigation between Resident 4 and Resident 5 was ongoing, however, it appeared that the investigation will be substantiated as staff witnessed the altercation. During a phone interview on 4/4/2025 at 2:31 PM Licensed Vocational Nurse (LVN) 1 stated LVN 1 and other staff heard Resident 4 and Resident 5 yelling back and forth at each other. LVN 1 stated Resident 5 then crossed to Resident 4's room and started punching Resident 4. LVN 1 further stated Resident 4 was to get a facial x-ray due to the resident stating they were hit in the nose. A review of the facility policy and procedures titled, Abuse Prohibition, revised 10/25/2024, indicated physical abuse includes hitting, slapping, pinching, kicking, etc.com, as well as controlling behavior through corporal punishment . The facility will protect patients from further harm .

Based on interview and record review, the facility failed to follow its' policy and procedures (P&P) by not allowing one of three sampled residents (Resident 1) to return to the facility. Resident 1 was admitted to General Acute Care Hospital (GACH) on [DATE] and was had an order to dicharge back to the facility on [DATE]. This deficient practice resulted in Resident 1 remaining at the hospital longer than necessary (24 days as of [DATE]) and had the potential to affect the resident ' s psychosocial wellbeing. Findings: During a review of the admission record for Resident 1 indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) and diabetes mellitus (DM-a high blood sugar). During a review of the Minimum Data Set (MDS - a resident assessment tool) dated [DATE], indicated Resident 1 had moderate cognitive impairment (a stage of cognitive decline that affects short-term memory and the ability to complete complex tasks). The same MDS indicated Resident 1 was independent for all Activities of Daily Living such as: (ADLs- routine tasks/activities such as eating, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a review of a History and Physical (H&P-a term used to describe a physician's examination of a patient. In an H&P, the physician obtains a thorough medical history from the patient, performs a physical examination, and then documents their findings) for Resident 1 dated [DATE] indicated Resident 1 did not have the capacity to make decisions. During a review of an H&P for Resident 1 dated [DATE] at 10 am, indicated, Resident 1 was admitted to GACH for abdominal pain and shortness of breath. The H&P indicated under assessment diagnosis which included pneumonia (a lung infection that can cause inflammation and fluid in the air sacs of the lungs), fecal impaction (a condition where a large, hard mass of stool (fecal matter), and developmental delay (a condition where a child's development in one or more areas of cognitive, motor, language, social, or adaptive skills lags behind what is typically expected for their age). During a review of Resident 1 ' s GACH physician orders dated [DATE] indicated Please plan to discharge patient on oral Keflex (a cephalosporin antibiotic prescribed to treat bacterial infections) 500 mg (Milligrams- mg- metric unit of measurement, used for medication dosage and/or amount) q (every) 6 + probenecid 1 g (gram) p.o. (by mouth) daily both till [DATE]). During an interview with the Assistant Admissions Coordinator (AAC) on [DATE] at 12:31 pm, the AAC stated residents must be medically cleared and have an active physician ' s order for discharge before they are readmitted to the facility. AAC stated that whenever a resident is transferred to GACH, a 7 day bedhold (a resident ' s right to keep a bed vacant and available for seven days after their transfer to the hospital in anticipation of their return to the facility) goes into effect. AAC stated that she was informed by the Social Worker (SW) that they might be a discharge order for Resident 1 on [DATE], which was the 7th day of his bedhold. AAC stated that she then requested for records for GACH and gave them to the Director of Nursing for review. AAC stated that the DON informed her (AAC) that Resident 1 was not eligible for readmission because he was still on Intravenous (means within a vein. Most often it refers to giving medicines or fluids through a needle or tube inserted into a vein) antibiotics and needed to be on isolation due to his diagnosis of MSSA (Methicillin-Susceptible Staphylococcus aureus- a common cause of skin and soft tissue infections, as well as other infections such as pneumonia and bloodstream infections). AAC stated that she called the SW to notify that Resident 1 was not cleared for discharge because of the IV antibiotics. The SW stated that she was going to ask the physician if they wanted to switch the order to an oral antibiotic. AAC stated that the SW called her later the same day and informed her that the order was changed to an oral antibiotic. AAC stated that she informed the SW that Resident 1 was still not cleared due to the MSSA. AAC stated that on [DATE], Resident 1 ' s bed was then given to a new resident. During an interview with the DON on [DATE] 2:15 pm, the DON stated that Resident 1 was sent to GACH because of abdominal distention, constipation, and weakness where he (Resident 1) was diagnosed with fecal impaction becomes stuck in the rectum) and pneumonia. The DON stated that even though Resident 1 ' s IV antibiotic were changed to oral on the 7th day, the DON stated that Resident 1 should have been in isolation due to the MSSA. The DON confirmed that there was no order for Resident 1 to be in isolation. During a review of the facility's policy and procedures (P&P) titled, Bed-Holds and Returns, revised ,d+[DATE], the P&P indicated, Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. The P&P ' s policy interpretation and implementation included: Residents who seek to return to the facility after the state bed-hold period has expired (or when state law does not provide for bed-holds) are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room provided that the resident: a. still requires the services provided by the facility; and b. is eligible for Medicare skilled nursing facility or Medicaid nursing facility services.

Based on observation, interview and record review, the facility failed to ensure resident's right to examine the results of the most recent survey (an annual inspection of the facility by State or Federal surveyors) and any plan of correction in effect with respect to the facility by not posting the information in a readily accessible place for four of four sampled residents (Residents 68, 22, 74, and 29). This failure resulted in the denial of the resident's rights to information regarding there care while in the facility. Findings: During record review, the admission record indicated Resident 68 was admitted on [DATE], with diagnoses that included, diabetes mellitus (DM-a disease characterized by elevated levels of blood sugar), Schizophrenia (a mental illness that causes people to lose touch with reality), hyperlipidemia (an abnormally high concentration of fats or lipids in the blood). During record review, the Minimum Data Set (MDS - a resident assessment tool) dated 11/20/24, indicated Resident 68's cognition (a person's mental ability to think, learn, remember, use judgement, and make decisions) was intact. The MDS indicated Resident 68 could perform all activities of daily function (ADL- getting out of bed to walk, eating, toilet use and personal hygiene) without assistance. During an interview on 1/22/25 at 10:44 am, Resident 68 stated she was interested in reading/reviewing the results of last year's (20240 recertification survey, however, she did not know where the survey report is located. During record review, the admission record indicated Resident 22 was admitted to the facility on [DATE], with the diagnoses of, but not limited to, hypertension (high or raised blood pressure), DM, and Schizophrenia. During record review, the MDS dated [DATE], indicated Resident 22's cognition was intact. The MDS indicated Resident 22 could perform all ADL (getting out of bed to walk, eating, toilet use and personal hygiene) without assistance. During an interview on 1/22/25 on 10:41 am Resident 22 stated she would like to know the results of 2024 survey, it sounds like interesting reading. However, Resident 22 stated she did not know where the survey report is located. Resident 22 asked if the report was online and if so, how does she get to the report so that she could read it for herself. During record review, the admission record indicated Resident 74 was admitted to the facility on [DATE], with the diagnosis of, but not limited to, Schizophrenia and convulsions (uncontrolled, rapid shaking of the body due to uncontrolled muscle movements). During record review the MDS dated [DATE], indicated Resident 68's cognition was intact. The MDS indicated Resident 68 could perform all ADL (getting out of bed to walk, eating, toilet use and personal hygiene) without assistance. During an interview on 1/22/25 at 10:47 am Resident 74 stated she would be interested in reading the results of 2024 recertification survey to find out what problems were listed and if the facility had fixed the problems. During record review, the admission record indicated Resident 29 was admitted to the facility on [DATE], with diagnoses not limited to Schizophrenia, keratosis (a small, rough bump on the skin that could potentially turn into skin cancer if left untreated). During record review, the MDS dated [DATE], indicated Resident 29's cognition was intact. The MDS indicated Resident 68 could perform all ADL (getting out of bed to walk, eating, toilet use and personal hygiene) without assistance. During an interview on 01/22/25 at 10:49 am Resident 29 stated he would be interested in reading the results of 2024 recertification survey. During an interview on 1/22/25 at 10:53 am, the Program Manager (PM) stated she would investigate and find out where the binder containing 2024 survey results was located. The PM stated she has not seen the survey binder in the facility. During observation on 01/22/25 at 11:16 am of the facility bulletin board for posting information including the results of surveys was observed in an area which has the staff restroom, and the staff exit to the front lobby. The staff exit is locked to prevent residents from wandering outside the facility and the residents are not permitted to enter this area. Also, the binder containing the last three years survey results is kept in an area that is secured by yellow and black quarantine tape that cuts off an area just before the exit door. During an interview on 1/22/25 at 11:26 am, the Assistant Administrator (AA) stated the 2024 survey results are in the quarantine area. AA stated this area (where the survey binder is located) is quarantined to prevent residents from wandering near the door and that the residents are not permitted to enter the quarantined area. AA stated the survey binder cannot be identified when standing behind the quarantine tape, because the letters are too small for anyone to read unless they can get up close to the binder itself. During an interview on 01/22/25 at 12:52 pm, the Staffing Counselor (SC) 1 stated, the area containing the survey binder results is in the caution area and that the caution area (yellow and black taped area) is to inform/alert the residents not to go past the area with the black and yellow boundary line. During an interview on 1/22/25 at 1:22 pm, the Administrator (ADM) stated the survey results are in a binder in the caution area and that the residents do not have access to this area. The ADM stated that he would post something to let the residents know where the survey binder is located so that the residents can read the survey results. During record review, the facility policy and procedure titled STP203-CA Resident Rights dated effective Date: 11/01/17, indicated, Each resident admitted to a Special Treatment Program will have the rights listed below. A list of resident rights will be prominently posted in English and Spanish. [NAME] a right is denied, the reason given for denying the right must be provided to the resident. Rights may not be denied as a condition of admission, as art of a treatment plan, or for the convenience of staff nor may they be treated as a privilege to be earned. Interventions that restrict personal freedom will be used only when absolutely necessary and under the order of a physician. PURPOSE To assure that resident's personal dignity, well-being, and self-determination is maintained. To assure that residents are knowledgeable of their responsibilities in this regard.