Every finding on record at Monterey Healthcare & Wellness Centre, LP

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive, resident centered care plan for Resident 1, who demonstrated a change in behavioral condition characterized by increased aggression, delusions (false or unrealistic beliefs), and frustration, resulting in Resident 1 hitting another resident on the back on 6/19/2026 and striking at a different resident on 7/30/2026. This deficient practice had the potential to result in unmet behavioral health (the connection between your daily habits, actions, and overall well-being) needs, inadequate guidance for staff, and increased risk for psychosocial distress (mental and emotional suffering caused by a mix of personal feelings and social pressures) and injury.Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included bipolar type schizoaffective disorder (mental illness that causes dramatic shifts in a person's mood, energy and ability to think clearly), schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life). During a review of Resident 1's History and Physical (H&P), dated 7/8/2026, the H&P indicated Resident 1 can make needs known but cannot make medical decisions. During a review of Resident 1's [NAME] Data Set (MDS, a resident assessment tool), dated 7/13/2026, the MDS indicated Resident 1's cognition (ability to think, remember, and reason) is moderately impaired, and needed supervision or touching assistance in toilet hygiene, shower, and personal hygiene. During a review of Resident 1's Change in Condition Evaluation (CIC), dated 6/19/2026, the CIC indicated Resident 1 had increased delusion aggressive behavior and punched another resident on 6/19/2026. During a review of Resident 1's Care Plan (CP), dated 7/6/2026, the CP indicated Resident 1 was at risk for injury due to aggression and agitation with interventions that indicated to assess Resident 1 for sense of powerlessness, assess the resident for the ability to regulate emotions, encourage healthy coping techniques such as meditation or writing down emotions in a journal for self-reflection, and encourage verbal expression of feelings and concerns. During a review of Resident 1's CP, dated 7/6/2026, the CP indicated Resident 1 was physically aggressive due to hitting another resident's back. The CP indicated a goal that Resident 1 will have effective coping and management strategies for frustration, fear and anxiety. The interventions included appropriate solutions proportional to the event to be considered in accordance with legislation and organizational requirements. During a review of Resident 1's CIC, dated 7/30/2026, the CIC indicated Resident 1 had a behavioral symptom of striking at another resident unprovoked because he wants to go. The CIC indicated Resident 1 continued to show signs of aggressive behavior. During a review of Resident 1's CP, dated 7/30/2026, the CP indicated Resident 1 struck at another resident, with the goal that Resident 1 will refrain from aggressive behavior and striking out at others. The interventions included to educate resident on relaxation techniques, educate resident on the risks associated with aggressive behavior, encourage resident to express feelings or concerns openly. During an interview on 8/12/2026 at 2:00 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that he does not know what appropriate solutions proportional to the event to be considered in accordance with legislation and organizational requirements means. LVN 2 stated that the resident's care plan was too general and not specific to Resident 1's needs. LVN 2 further stated that he does not assess the resident for a sense of powerlessness or for the ability to regulate emotions, as outlined in the care plan. During a concurrent interview and record review on 8/12/2026 at 3:00 PM with the Assistant Director of Nursing (ADON), Resident 1's care plan and progress notes dated 7/21/2026 to 8/12/2026 were reviewed. The ADON stated that there was no documented evidence that Resident 1's care plan had been implemented and that there was no documentation showing that staff assessed the resident for feelings of powerlessness, emotional regulation, or coping skills as indicated in the resident's CP. The ADON further stated that the resident's CP did not contain measurable objectives or specific interventions and confirmed that the plan was not individualized to Resident 1's needs. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-centered Care Planning, dated 9/7/2023, the P&P indicated the facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being.

Based on interviews and record reviews, the facility failed to ensure that Resident 1 received the necessary behavioral support services to address ongoing frustration related to physical impairment and having to remain in the facility, by failing to: Ensure licensed vocational nurse (LVN) 2 reported that Resident 1 verbalized being frustrated and failing to develop a plan of care to address this behavioral concern.Ensure registered nurse (RN)1 reviewed Resident 1's Psychological Consultation (PC) assessment, dated 7/21/2026 to address the resident's behavior of frustration due to physical impairment and having to be in the facility.Ensure an Interdisciplinary Team (IDT - a coordinated group of experts from several different fields) meeting was conducted to develop and implement a plan of care to address the resident's identified psychosocial needs. This deficient practice had the potential to adversely affect Resident 1's behavioral health status and psychosocial well being.Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included bipolar type schizoaffective disorder (mental illness that causes dramatic shifts in a person's mood, energy and ability to think clearly), schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life). During a review of Resident 1's History and Physical (H&P), dated 7/8/2026, the H&P indicated Resident 1 can make needs known but cannot make medical decisions. During a review of Resident 1's [NAME] Data Set (MDS, a resident assessment tool), dated 7/13/2026, the MDS indicated Resident 1's cognition (ability to think, remember, and reason) is moderately impaired, and needed supervision or touching assistance in toilet hygiene, shower, and personal hygiene. During a review of Resident 1's Psychological Consultation (PC), dated 7/21/2026, the PC indicated Resident 1 is dealing with confusion/disorientation due to schizoaffective disorder, with symptoms of anxiety (a group of mental disorders characterized by significant feelings of fear that affect with daily activities), depression, and psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality). The PC indicated Resident 1 discussed frustration with being physically impaired and having to be in the facility. The PC further indicated the treatment plan included ongoing psychological support (help that gives a person a safe space to share feelings, lower stress, and cope with hard times). During an interview on 8/12/2026 at 11:05 AM with LVN 1, LVN 1 stated she was not aware that Resident 1 was experiencing frustration related to physical impairment and the need to remain in the facility. LVN 2 stated she does not know how to provide psychological support to the residents. LVN 2 further stated that room visits should be provided to the resident, but she was unsure of the frequency. During an interview on 8/12/2026 at 12:40 PM with LVN 2, LVN 2 stated that he recalled Resident 1 telling him that Resident 1 did not need to take any medications because Resident 1 did not need to be in the facility. LVN 2 further stated that he did not develop any care plan to address this. During an interview on 8/12/2026 at 1:00 PM with RN 1, RN 1 stated that when the psychiatrist visits the residents, he does not review their reports. RN 1 further stated that he only carries out the orders if they are directly communicated to him. During an interview on 8/12/2025 at 2:00 PM with LVN 2, LVN 2 stated that he was not sure what psychological support means or how to provide care to a resident who requires such support. LVN 2 further stated that there should be a care plan addressing Resident 1's frustration related to physical impairment and the need to remain in the facility, including detailed interventions to guide staff in providing appropriate care. During a concurrent interview and record review on 8/12/2026 at 3:00 PM with the Assistant Director of Nursing (ADON), Resident 1's care plan and progress notes dated 7/21/2026 to 8/12/2026 were reviewed. The ADON confirmed that there was no care plan or IDT meeting addressing Resident 1's behavior of frustration related to physical impairment and the need to remain in the facility. The ADON stated that RNs should review the psychiatrist's assessment and confirmed that an IDT meeting should be held to discuss, develop, and implement interventions such as monitoring and providing emotional support, including room visits. During a review of the facility's policies and procedures (P&P) titled, Behavior/Psychoactive Drug Management, revised 1/25/2024, the P&P indicated the facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents.

Based on observation, interview, and record review, the facility failed to provide necessary medical social services to one of two sampled residents (Resident 3) when the Social Service Coordinator (SSC) did not follow up or encourage Resident 3 to participate in dental care services, and did not explain the potential risk and benefits of declining dental treatments as indicated in the Resident's care plan after Resident 3 reportedly refused dental treatments on 4/1/26. This deficient practice had the potential to result in unmet dental needs, delayed identification and treatment of oral health issues, and a possible decline in Resident 3's overall health and quality of life due to lack of appropriate follow-up and support from facility staff. Findings: During a review of Resident 3's admission Record, the record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety, 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 3's Minimum Data Set (MDS- a resident assessment tool) dated 2/20/26, the MDS indicated Resident 3 was cognitively intact and independent for most cares. During a review of Resident 3's Care Plan initiated on 9/8/25 and revised on 4/1/26, the care plan indicated Resident 3 was resistive to care related to schizoaffective disorder bipolar type and schizophrenia. The care plan also indicated that Resident 3 declined dental services on 4/1/26. The care plan indicated interventions to educate Resident 3 of the possible outcome of not complying with treatment or care, encourage as much participation/interaction as possible during care activities, and to give clear explanation of all care activities prior to and as they occur during each contact. During a review of the facility's Dental Visit Summary Log dated 4/1/26, the log indicated Resident 3 declined dental treatments and indicated for the dental consultant to try again in the next visit. During a concurrent interview and record review with the SSC on 5/1/26 at 12:37 PM, Resident 3's progress notes were reviewed. The SSC stated there was no documentation that indicated Resident 3 declined dental treatment on 4/1/26. The SSC stated she did not know why Resident 3 declined the dental visit. During an interview with Resident 3 on 5/1/26 at 12:47 PM, Resident 3 stated he had waited for the dentist on 4/1/26, but the dentist never came. Resident 3 stated he never declined dental visits or treatments and wanted continued evaluation for his broken tooth. During another interview with the SSC on 5/1/26 at 2:59 PM, the SSC stated that when a resident refused a consultation, the SSC was responsible for assessing and addressing the reason for the refusal. The SSC stated she should have followed up with Resident 3 on 4/1/26 to determine why, or whether Resident 3 declined his dental visit but did not do so. During an interview with the Director of Registered Nursing (DON) on 5/1/26 at 3:27 PM, the DON stated that when residents refused treatments, staff should explain the necessity of the treatment and the risk and benefits of declining a treatment. The DON also stated it was important to address the residents' reason for refusing care to ensure residents complied and received the care they needed. During a review of the facility's Policy and Procedure (P&P) titled, Referrals to Outside Services and dated 12/1/13, the P&P indicate The Director of Social Services coordinated the referral of residents to outside agencies/programs to fulfil residents' needs for services not offered by the facility. During a review of the undated Social Service Coordinator Job Description Manual, the job description indicated the SSC arranged ancillary services that have been determined necessary to maintain the residents' concrete needs.

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) on abuse for one of two sampled residents (Resident 4) when Certified Nursing Assistant (CNA) 1 failed to report an alleged resident-to-resident altercation between Residents 4 and 5 on 4/28/26. This deficient practice had the potential to place Resident 4 at risk for unrecognized abuse, delayed assessment of injuries, and failure to ensure resident safety, protection, and timely reporting in accordance with the facility's Abuse and Neglect policy. Findings: During a review of Resident 4's admission Record, the record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety, and depression. During a review of Resident 4's History and Physical (H&P) dated 4/25/26, the H&P indicated Resident 4 could make his needs known but could not make medical decisions. During an interview with Resident 4 on 4/30/26 at 7:35 AM, Resident 4 stated that on 4/28/26, Resident 5 spat on him and threw a walker at him. Resident 4 stated that he told CNA 1 about the altercation and was separated from Resident 5 but was not assessed for injuries by a licensed nurse. During an interview with CNA 1 on 4/30/26 at 9:07 AM, CNA 1 stated that on 4/28/26 Resident 4 came to her and told her that another resident hit him with a walker. CNA 1 stated that she notified Licensed Vocational Nurse (LVN) 2 and Registered Nurse (RN) 2 at the nurses' station. CNA 1 stated she did not further investigate on who the alleged resident was who threw the walker at Resident 4 because she was busy helping another resident. During an interview with LVN 2 on 4/30/26 at 11:33 AM, LVN 2 stated he was never notified of a resident altercation that involved Resident 4. During an interview with RN 2 on 4/30/26 at 12:13 PM, RN 2 stated he was never notified of a resident altercation that involved Resident 4. During another interview with CNA 1 on 4/30/26 at 12:43 PM, CNA 1 stated that, on 4/28/26, Resident 4 came to CNA 1 near the nurses' station and said, Look, he hit me. He threw his walker and hit me. CNA 1 stated she observed a red scratch on Resident 4's right knee. CNA 1 stated she brought Resident 4 to the nurses' station where LVN 2 and RN 2 were working. CNA 1 stated she reported the allegation to LVN 2 then walked away. CNA 1 stated she was not sure if LVN 2 actually heard her because she walked away to help another resident. CNA 1 stated she did not follow up on the incident any further after that. During an interview with the Director of Registered Nursing (DON) on 5/1/26 at 3:27 PM, the DON stated that when a staff member was made aware of an alleged altercation between residents, the staff member was expected to notify the abuse coordinator (the facility's administrator [ADM]) so that the facility could investigate the alleged abuse and report to the proper agencies. The DON stated CNA 1 should have reported Resident 4's allegation of being spat at and struck by a walker so that the facility could have assessed Resident 4 for injuries and sent Residents 4 and 5 out for medical evaluation. During a review of the facility's Policy and Procedure (P&P) titled, Abuse and Neglect and dated 12/22/21, the P&P indicated that allegations of abuse, neglect, mistreatment, exploitation or reasonable suspicion of a crime were to be reported to the ADM or designated representative immediately. The P&P indicated the facility reported all allegations of abuse and criminal activity, as required by law and regulations, to the appropriate agencies.

Based observation, interview, and record review, the facility failed to implement proper infection control for 66 of 66 sample residents per the facility's Water Management Plan for the Prevention of Waterborne Pathogens (bacteria, viruses, or parasites found in contaminated water) by failing to ensure: 1. The Water Heater 1's mercury temperature gauge (a glass tube filled with mercury that can be used to measure changes in temperature) was not broken and functional. 2. The Water Heater 2's mercury temperature gauge reading was maintained at 110 degrees Fahrenheit ( F, a unit of temperature), not at 145 F. 3. The water temperature reading at Nursing Station A ranged from 86 F - 105 F, which was below the 110 degrees Fahrenheit as indicated on the facility's Water Management Program. 4.The water temperature at Nursing Station B ranged from 116 F - 120 F, which was above the 110 F as indicated on the facility's Water Management Program. 5. A monitoring log indicated the visual checks of the facility's water heaters to monitor and identify any changes in the water appearance to indicate biofilm, rust, sediment, or contamination. These failures had the potential to result in waterborne pathogen (microorganisms-bacteria, viruses, and parasites that spread through contaminated drinking or recreational water) growth such as Legionella's (a bacteria that may grow in the water systems and can make people sick when they breathe in contaminated water droplets, which may result in Legionnaires' disease [severe form of pneumonia, where the Legionella bacteria infected the lungs]) and other virus and bacteria that could lead to a widespread infection in the facility. Findings: 1.During a concurrent observation and interview on 3/25/2026 at 8:20 AM with the Maintenance Supervisor (MS) behind the laundry room in a locked shed ,Water Heater 1 was observed. The MS stated Water Heater 1 distributed hot water to Nursing Station A's side of the facility. The MS stated the mercury temperature gauge on Water Heater 1 appeared broken and not working. The MS stated that he did not know how long it had been when the temperature gauge stopped working. During another concurrent observation and interview on 3/25/2026 at 8:30 AM with the MS, behind the kitchen in a locked shed, Water Heater 2 was observed. The MS stated Water Heater 2 distributed hot water to Nursing Station B's side of the facility. The MS stated the mercury temperature gauge of Water Heater 1 was at 110 F. The MS stated that the water heater temperature gauges should be 110 F. 2. During a concurrent observation and interview on 3/25/2026 at 8:41 AM with the MS, in Nursing Station A, the MS was observed checking the temperature of the sink with a digital thermometer (an electronic device used to measure temperature changes and convert to a digital reading). The MS stated, the water temperature of Nursing Station A's sink ranged between 86 F - 105 F. The MS stated the water temperature of Nursing Station A was too low. The MS stated the water temperature at the sinks should be at 110 F. During a concurrent observation and interview on 3/25/2026 at 8:43 AM with the MS, in Nursing Station B, the MS was observed checking the temperature of the sink with a digital thermometer. The MS stated, the water temperature of Nursing Station B's sink ranged between 116 F - 120 F. The MS stated the water temperature of Nursing Station B was too high. The MS stated the water temperature for all sinks, toilets, and showers should be at least 110 F. During an interview on 3/25/2026 at 8:50 AM with the MS, the MS stated it was important to maintain the correct temperature of the water heaters that distributed water to the facility. The MS stated that if the water temperature was below 110 F, it provided an opportunity for water borne pathogens such as Legionella to grow and potentially affect all residents, visitors, and staff of the facility. The MS stated that if the water temperature was above 110 F, it created a safety issue because too hot water may cause burns. 3.During an interview on 3/26/2026 at 9:30 AM with the MS, the MS stated, he performs a visual check of the facility's water heaters by draining the water heaters and inspecting the initial drained water for any crystal-like structures that may indicate potential growth of waterborne pathogens such as Legionella. The MS stated there was currently a log to indicate when and which water heaters were flushed, but there currently was no log to indicate the visual monitoring of the appearance of the drained water from the water heaters. During a concurrent record review and interview on 3/26/2026 at 4:30 PM with the Infectious Preventionist Nurse (IPN), the facility's Water Management Plan for the Prevention of Waterborne Pathogens (Water Management Plan), dated 2/2/2026, was reviewed. The IPN stated, according to the Water Management Plan, the water temperature of the water heaters should be 145 degrees F. The IPN stated that when the water was distributed to the sinks, toilets, and showers within the facility, the water temperature should be at least 110 degrees F.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety for the facility's one of one kitchen used by 66 residents when the facility did not ensure the dishwasher machine thermometer was functioning properly. This deficient practice had the potential to spread foodborne illnesses throughout the facility through dishes that were not sanitized properly. Findings: During an interview with the Dietary Supervisor (DS) on 3/24/26 at 9:18 AM and concurrent observation of the facility's kitchen, the facility's dishwashing machine was observed. The DS stated the dishwashing machine was a low temperature dishwasher and the staff were required to check and log two temperatures when the dishwasher ran: the Wash Temperature and Rinse Temperature. The DS stated the wash temperature and rinse temperatures should both be at a minimum of 120 degrees Fahrenheit ( F) to properly clean the dishware. The dishwashing machine was run three times and had the following temperatures: Run 1: Wash temp 100 F, Rinse temp 102 F Run 2: Wash temp 110 F, Rinse temp 112 F Run 3: Wash temp 110 F, Rinse temp 112 F The DS stated that the dishwashing machine's water temperatures had not reached the goal temperature of at least 120 F after running it three times. The DS stated that the staff would have to use the facility's three-compartment dishwashing sinks to handwash the facility's dishes while the dishwashing machine was out of order. During an interview with the facility's Dietitian on 3/24/26 at 9:25 AM, the Dietitian stated that if the dishwasher did not reach the goal temperatures of 120 F - 150 F, the dishes would not be cleaned and pathogens from dirty dishes could transfer to the residents. During another interview with the DS on 3/25/26 at 8:14 AM, the DS stated that the dishwashing machine's company sent a repair person to assess the machine and discovered that the dishwashing machine's thermometer was not reading accurately. The DS stated she did not know how long the thermometer was not working. During a review of the facility's policy and procedure (P&P) titled Dish Machine Temperature Recording revised 10/1/14, the P&P indicated the dish machine would be routinely monitored during use to ensure appropriate temperatures.

Based on observation, interview, record review, the facility failed to develop and implement a comprehensive-person centered care plan for three of three sample residents (Resident 9, 35, and 5) by failing to ensure: 1. The care plan was not implemented for Resident 9 with a history of hemolytic anemia (a blood disorder where the red blood cells [RBC] are destroyed faster than the bone marrow can replace them, leading to fatigue, jaundice [yellowing of skin], and dark urine) to monitor the resident for signs and symptoms of anemia (a blood condition where there is not enough healthy RBC or hemoglobin [HGB, protein that carries blood to the tissues; normal range 11 - 16 grams per deciliter (g/dL)]). This deficient practice had the potential for Resident 9 not to receive the necessary care and interventions for her history of hemolytic anemia that could lead to a decline in the resident's physical and psychosocial well-being that may lead to foreseeable risks, including unrecognized progression of anemia, severe weakness, hypoxia, and the need for emergency blood transfusions and hospitalizations. [Cross Reference to F684] 2. A care plan was created for Resident 35 who exhibited new behaviors of making verbal threats to others after Licensed Vocational Nurse (LVN) 1 observed Resident 35 regularly saying, I want to hit you to staff. This failure had the potential for Resident 35 to not receive the proper interventions and necessary care related to his behaviors and had the potential for Resident 35 to escalate his behavior and physically attack staff or other residents. On 3/24/26, Resident 35 was witnessed throwing coffee toward Resident 58 during activities and Resident 35 was transferred to a general acute care hospital (GACH) for medical and psychiatric evaluation. [Cross reference F580] 3. A care plan was created when Resident 5 was admitted to the facility with poor vision and required assistance with activities. This failure had the potential for Resident 5 to decline psychosocially from not participating in group activities and physically from not being able to perform his activities of daily living (ADLs). Findings: 1.During a review of Resident 9's admission Record (AR), the facility admitted Resident 4/17/2025 and readmitted Resident 9 on 11/17/2025 with diagnoses of acquired hemolytic anemia, hypertension (HTN, high blood pressure), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 9's care plan, initiated on 11/17/2025, the care plan indicated Resident 9 had hemolytic anemia with interventions, initiated on 11/17/2025, that included to educate Resident 9 and their caregivers to expect her stool to change from dark green to black and to monitor/document/report the following signs and symptoms of anemia such as pallor (unhealthy pale color), fatigue, dizziness, syncope (faint), headache, palpitations, weakness, feelings of cold, low hemoglobin and hematocrit, shortness of breath upon activity, sore tongue, chest pain, tinnitus (ringing in ears), headache, and changes in condition. Durning a review of Resident 9's Minimal Data Set (MDS, a resident's assessment) dated 1/23/2026, the MDS indicated that Resident 9's cognitive (a resident's thought process) was intact. The MDS indicated that Resident 9's active diagnoses include anemia, heart failure (chronic condition where the heart cannot effectively pump blood to the rest of the body), HTN, and renal insufficiency (condition where the kidneys cannot effectively filter the blood of impurities). During a review of Resident 9's Change of Condition Evaluation (CoC) record, dated 2/18/2026 timed at 7:57 PM, the CoC indicated Resident 9's had abnormal blood pressure of 94/43, heart rate of 99, respiratory rate of 16, and temperature of 98.8 degrees Fahrenheit (F, unit of temperature). The record indicated that Resident 9's had a critical laboratory result and blood pressure. Physician 1 (Primary Care Physician) recommended to transfer Resident 9 to the GACH via 911. During a review of Resident 9's care plan, initiated on 11/17/2025, revised on 2/24/2026, indicated that Resident 9 had low HGB of 3.8 and low HCT of 14% on 2/18/2026. The care plan did not indicate any new interventions related to hemolytic anemia after Resident 9's hospitalization on 2/18/2026 and readmission to the facility on 2/23/2026. During a review of Resident 9's HP, dated 2/25/2026, the HP indicated that Resident 9 did not have the capacity to understand and make decisions. During an interview on 3/26/2026 at 3:20 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 9 had routine laboratory orders and her HGB results would sometimes be low. LVN 4 stated, she did not know if Resident 9 had a diagnosis of anemia, but Resident 9 was hospitalized recently for low HGB. During a concurrent interview and record review on 3/26/2026 at 6:15 PM with the ADON, Resident 9's care plans and physician orders were reviewed. The ADON stated, the facility monitored Resident 9's anemia through routine laboratory orders every three (3) months but there was no monitoring conducted to ensure that Resident 9 was monitored for signs and symptoms of hemolytic anemia such as pallor, fatigue, dizziness, syncope, headache, palpitations, weakness, feelings of cold, low hemoglobin and hematocrit, shortness of breath upon activity, sore tongue, chest pain, tinnitus, and changes in condition. During a concurrent interview and record review on 3/26/2026 at 6:15 PM with the Assistant Director of Nursing (ADON), Resident 9's care plans and active orders were reviewed. The ADON stated that Resident 9's care plan indicated to monitor, document, and report if Resident 9 experienced any physical signs and symptoms of anemia. The ADON stated that there was no documented evidence to monitor if Resident 9 experienced any physical signs and symptoms of anemia. During an interview on 3/27/2026 at 10:40 AM with Registered Nurse (RN) 1, RN 1 stated it was important follow Resident 9's care plan to monitor for signs and symptoms of anemia such as pallor, dark tarry stool, and bleeding because if Resident 9 was not monitored, the signs and symptoms of anemia may be missed, which may result in hospitalization. During an interview on 3/27/2026 at 11 AM with the Director of Nursing (DON), the DON stated it was important to specifically monitor any signs and symptoms of anemia to identify any changes in Resident 9's condition and to notify Physician 1 as soon as possible. During a review of the facility's policies and procedures (P&P) titled Comprehensive—Person Centered Care Planning, revised 8/24/2023, the P&P indicated the facility must develop and implement a comprehensive person-centered care plan for each resident rights and provide services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. During a review of the same facility's P&P titled Comprehensive—Person Centered Care Planning, revised 8/24/2023, the P&P indicated that the comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 2. During a review of Resident 35's admission Record, the record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and auditory hallucinations (perceptual experiences in which an individual hears sounds, often voices, with no external auditory stimulus present). During a review of Resident 35's Minimum Data Set (MDS- a resident assessment tool) dated 1/27/26, the MDS indicated Resident 35 had moderately impaired cognition (the mental process of how a person learns, remembers, understands, and uses information) and required supervision or touch assistance for most cares such as personal hygiene and toileting. The MDS also indicated Resident 35 did not exhibit verbal behavioral symptoms directed towards others such as threatening others, screaming at others, or cursing at others. During a review of Resident 35's care plan initiated on 1/21/26, the care plan indicated Resident 35 had a mood disorder with interventions to monitor/record/report to physician the risk of Resident 35 harming others: increased anger, labile mood or agitation, threatened by others or thoughts of harming someone. During a review of Resident 35's provider progress notes dated 2/9/26 at 4:02 PM and signed by NP 1, the notes indicated Resident 35 denied / expressed no suicidal ideations, homicidal ideations, and violent behavior. During a review of Resident 35's Change in Condition (CIC- a communication tool used by healthcare workers when there is a change of condition among the residents) Form dated 3/24/26 at 9:50 AM, the CIC indicated, During scheduled coffee social activities in the dining room, [Resident 35] started exhibiting physical aggression [related to] throwing coffee at another resident unprovoked. [Resident 35] was sitting down and stood up from his chair while speaking loudly. [Resident 35] threw a cup of coffee in the direction of another resident. The CIC also indicated Nurse Practitioner (NP) 1 was notified of this incident and ordered to transfer Resident 35 to a GACH on a 5150 hold (a 72 hour hold for psychiatric evaluation when a resident is a danger to themselves, a danger to others, or are unable to care for their basic needs due to a mental health condition) for evaluation. During an interview with LVN 1 on 3/27/26 at 10:28 AM and concurrent record review of Resident 35's progress notes, CICs, and care plans from 1/2026 to 3/2026, LVN 1 stated there was no documentation of Resident 35 making verbal threats to staff. LVN 1 stated Resident 35 was known to easily be triggered when he did not get what he wanted and expressed his frustrations at staff by verbalizing, I want to hit you. LVN 1 further explained Resident 35's verbal threats to hit staff was new and he did not exhibit threatening behaviors until 2/2026, around a month after being admitted to the facility. LVN 1 stated she did not update Resident 35's care plan with Resident 35's verbal threats toward staff because Resident 35 was already known to be verbally aggressive and required frequent redirection. LVN 1 stated she should have created a CIC and notified Resident 35's physician of Resident 35's new behavior of making verbal threats to staff so that Resident 35 and his medications could have been reassessed by the physician. LVN 1 also stated that when residents stated they want to harm themselves or others, the facility's protocol is to place that resident on one-to-one supervision for safety to protect the resident or others from harm. During an interview with the Director of Registered Nursing (DON) on 3/27/26 at 11:20 AM, the DON stated she was not aware that Resident 35 was making verbal threats to hit staff. The DON stated that when a resident expressed verbal threats toward others such as, I want to hit you, staff should create a CIC to communicate the change in the resident's behavior to the rest of the staff, update the care plan to implement interventions, and notify the resident's physician in order to have the resident's medications reevaluated or sent to a GACH for further evaluation. The DON further explained that a CIC should have been created when Resident 35 first made verbal threats to harm others. 3. During a review of Resident 5's admission Record, the record indicated Resident 5 was admitted to the facility 9/2/25 with diagnoses including schizophrenia, lack of coordination, depression, and anxiety. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had intact cognition and impaired vision (resident could see large print, but not regular print in newspapers/books). During an observation on 3/26/26 at 3:46 PM in the facility's dining room, Resident 5 was observed participating in the facility's karaoke activity. Resident 5 was observed to be sitting close to the TV, holding a microphone, and looking down at the floor but not singing. Resident 5 was observed telling the activity staff that he wanted to hear the song but could not sing along because he could not read the words on the TV. Resident 5 was observed squinting his eyes at the TV and squinting his eyes when looking at staff. During an interview with Resident 5 on 3/24/26 at 10:33 AM, Resident 5 stated that he had difficulty seeing because he was partially blind. Resident 5 stated he wanted to participate in more activities but could not due to his impaired vision. During another interview with Resident 5 on 3/26/26 at 1:59 PM, Resident 5 stated that he told the facility's staff of his vision impairment but did not feel the heard by the facility. Resident 5 stated he was frustrated and further stated, I feel like they [the facility] don't care. During an interview with Activity Staff (AS) 1 on 3/26/26 at 2:04 PM, AS 1 stated that Resident 5 often complained about not being able to see well and stated that Resident 5 did not participate in some activities due to his poor vision. AS 1 stated that Resident 5 would not attend group activities that could not accommodate his poor vision. During an interview with the activities director (AD) on 3/26/26 at 2:30 PM, the AD stated that Resident 5 required one-to-one activity visits because the activity staff noticed that Resident 5 was not actively participating in group activities. The AD stated Resident 5 presented with low self-esteem and would state he felt like a burden when he could not participate in activities. During an interview with the DON on 3/27/26 at 12:35 PM and concurrent record review of Resident 5's care plan, the DON stated there should have been a care plan for Resident 5's poor vision so that proper interventions could have been in place and Resident 5 could perform his ADLs. The DON further stated that if Resident 5 continued to refuse activities, he could isolate and his psychosocial and mental wellbeing could decline. During a review of the facility's Policy and Procedure (P&P) titled, Person-Centered Care Planning dated 5/22/25, the P&P indicated the facility must develop and implement a comprehensive person-centered care plan for each resident rights and provide services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to provide interventions to one of three sample residents (Resident 54) with increased verbal aggression towards other staffs or residents and increased episodes of delusion (misconceptions or beliefs that are firmly held, contrary to reality) to ensure safety to other residents by implementing interventions to prevent Resident 54 from aggression towards residents and staffs. As a result, Resident 54 hit Resident 25 on the right cheek without major injury. In addition, Resident 54 had the potential to emotionally and physically harm other residents and staff due to aggression and delusional thoughts.Findings: During a review of Resident 25's admission Record (AR), the facility admitted Resident 25 on 6/30/2021 and readmitted Resident 25 on 2/13/2026 with diagnoses that included paranoid schizophrenia (mental health disorder where a resident experiences intense, irrational suspicion, paranoia, and hallucinations [perceptual experiences in the abuse of real external sensory stimuli]), dementia (a progressive state of decline in mental abilities), and blindness in one eye. During a review of Resident 25's Minimal Data Set (MDS, a resident assessment), dated 2/5/2026, the MDS indicated that Resident 25's cognitive (a resident's thought process) skills were intact. The MDS indicated that Resident 25 had delusions. The MDS indicated that Resident 25's active diagnoses included anxiety disorder (mental health condition characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life), depression (mental health condition characterized by persistent sadness, loss of interest in activities, and low energy), bipolar disorder (manic-depressive disorder; mood swings that range from lows of depression to elevated periods of emotional highs), psychotic disorder (other than schizophrenia), and schizophrenia (a mental illness that is characterized by disturbances in thought). The MDS indicated that Resident 25 had routine antipsychotic (medication that affects mood and behavior) medication. During a review of Resident 54's admission Record (AR), the facility admitted Resident 54 on 2/23/2023 and readmitted Resident 54 on 2/13/2026 with diagnoses that include schizophrenia, anxiety disorder, and bipolar disorder. During a review of Resident 54's MDS, dated [DATE], the MDS indicated that Resident 54's cognitive was intact. The MDS indicated that Resident 54 had delusions. The MDS indicated that Resident 54's active diagnoses included anxiety disorder, depression, bipolar disorder, psychotic disorder, and schizophrenia. The MDS indicated that Resident 54 received routine antipsychotic medications. During a review of Resident 54's Conservatorship (legal order in which an appointed person makes decisions for another adult who cannot care for themselves) Letter record, filed 2/10/2026, the record indicated that Resident 54 remains gravely disabled as a result of mental disorder and is unable to provide for basic personal needs of food, clothing, and/or shelter and that the conservatorship of the person and estate should be granted. During a review of Resident 54's care plan, initiated on 2/13/2026, the care plan indicated that Resident 54 had the potential to be verbally aggressive related to ineffective coping skills, mental and emotional illness, and poor impulse control. The care plan's interventions included to analyze key times, places, circumstances, triggers, and what de-escalates behavior and document and assess resident's copying skills and support systems. During a review of Resident 54's care plan, initiated on 2/13/2026, indicated Resident 54 was physically aggressive, hitting others, related to poor impulse control and bipolar disorder. The goal of the care plan was for the resident to not harm herself or others. Interventions include analyzing triggers, circumstances, and effective de escalation strategies; anticipating and assessing the resident's needs; and identifying and addressing any contributing sensory deficits. During a review of Resident 54's Change of Condition Evaluation (CoC) record, dated 3/9/2026 timed at 5:30 PM, the CoC record indicated that Resident 54 was verbally aggressive, cursing, yelling, shouting [at] staff and other residents. The CoC record indicated the staff redirected Resident 54 and closely monitored her for safety. Physician 4 (Primary Care Physician) recommendation was to monitor [Resident 54] at this time. During a review of Resident 54's Nursing Progress Notes (PN), dated 3/9/2026 timed at 8:51 PM, 3/10/2026 timed at 6:21 AM and 2:14 PM, 3/11/2026 timed at 2:31 PM, and 3/12/2026 timed at 1 PM, were reviewed. The Nursing PN indicated that Resident 54 had multiple episodes of increase verbal aggression towards staff and residents, and there were times the staff was successful at redirect Resident 54 and other times the staff was unable to redirect Resident 54. During a review of Resident 54's Nursing PN written by the Assistant Director of Nursing (ADON), dated 3/10/2026 timed at 11:11 AM, the PN indicated that he spoke to Physician 5 (Psychiatrist) about Resident 54's medication and indicated that Physician 5 will visit the facility on Friday (3/13/2026) and evaluate the patient and review all medications. During a review of Resident 54's Dietary PN written by the Registered Dietitian (RD), dated 3/10/2026 at 1:43 PM, the PN indicated that during lunch time, Resident 54 had accused the RD that the RD was stealing her medication. During a review of Resident 54's Nursing PN written by the ADON, dated 3/13/2026 timed at 2 PM, the PN indicated that the ADON attempted to call Physician 5 regarding his visit with Resident 54, but the ADON was unable to get a hold of [Physician 5] at this time. During a review of Resident 54's Medication Administration Record (MAR), dated for March 2025, the MAR indicated there was documented evidence that Resident 54 had 13 - 16 episodes of increased delusions and aggression towards other staff members and residents between 3/9/2026 to 3/15/2026. During a review of Resident 54's CoC record, dated 3/16/2026 timed at 7 AM, the record indicated CNA 3 had witnessed Resident 54 have an episode of physical aggression by elbowing Resident 25 to the right check. The CoC record indicated that Resident 54 stated [Resident 25] flipped as I did a back flip and [Resident 25] saw my pubic area. Physician 4's recommendation was to transfer Resident 54 to the general acute care hospital (GACH) for psychiatric evaluation. During a review of the Certified Nurse Assistant (CNA) 3's written statement record (written statement of the facility's internal investigation), dated 3/16/2026, the record indicated that Resident 25 was reading her Bible quietly in her wheelchair in the alcove by Resident 25's room, and Resident 54 stood next to Resident 25 as she waited for CNA 3 to open her locker, then Resident 54 asked Resident 25 what are you going to do black bitch, and Resident 54 hit Resident 25 with an elbow to the right side of the face. During a review of the License Vocational Nurse (LVN) 1 written statement record (written statement of the facility's internal investigation), dated 3/16/2026, the record indicated in an interview Resident 54 stated she hit Resident 25 because [Resident 25] flipped her [Resident 54] as she [Resident 54] was walking by and [Resident 25] saw her public area. The record indicated that Resident 25 stated she was sitting in her wheelchair reading her Bible when Resident 54 came up to [Resident 25] had said what are you going to do black bitch? During an observation and interview on 3/24/2026 at 11:25 AM with Resident 25 in the hallway, Resident 25 was sitting forward in her wheelchair and stated Resident 54 touched her right cheek. Resident 25 stated, she did not know why Resident 54 had touched her cheek. During an interview on 3/26/2026 at 3:10 PM with CNA 4, CNA 4 stated that about one to two weeks before 3/16/2026, Resident 54 had increased episodes of verbal aggression towards staff members and other residents and had increased episodes of withdrawal and laying in her bed in her room. CNA 4 stated that the staff members' interventions were to calmly interact and redirect Resident 54 during her episodes of verbal aggression. During an interview on 3/26/2026 at 3:20 PM with LVN 4, LVN 4 stated, Resident 54 was had increased verbal aggressive with increased delusions from her baseline for the last three weeks. Resident 54 would claim multiple times that someone was stealing her medication. During a concurrent interview and record review on 3/26/2026 at 5:42 PM with the Assistant Director of Nursing (ADON), Resident 54's CoC record from 3/9/2026 and a nursing progress note from 3/10/2026 were reviewed. The ADON reported that Resident 54 had shown increased verbal aggression and notified Physician 5 on 3/10/2026 to discuss possible medication adjustments. Physician 5 stated he would conduct an in person evaluation before making any changes. The ADON also explained that although the resident had a history of verbal aggression with interventions that included closely monitoring the resident's behavior, redirecting her, and encouraging participation in group or individual activities, the interventions were not effective, and the resident had the potential to harm others. During the same concurrent interview and record review on 3/26/2026 at 5:50 PM with the ADON, Resident 54's Nursing PN dated 3/13/2026 timed at 2 PM was reviewed. The ADON stated he attempted to follow up with Physician 5 on 3/13/2026 and was not able to contact the physician and he did not come to the facility on 3/10/26 to 3/13/26 to assess Resident 54. The ADON stated he did not notify Physician 5's Nurse Practitioner (NP) or the Psychiatric Medical Director because he expected the physician to come in to see the resident on 3/10/26 to 3/13/26. ADON further stated that Resident 54's physical aggression toward Resident 25 on 3/16/2026 could have been avoided if he continued to follow up with Physician 5 and informed the NP or the Psychiatric Medical Director to assess Resident 54 for further recommendations regarding increased hallucinations, delusions, and aggressions towards others. During an interview on 3/27/2026 at 9:35 AM with LVN 1, LVN 1 stated upon interviewing Resident 54, Resident 54 stated, she made an elbowing motion because she wanted Resident 25 to move out of the way out in the small alcove room by Resident 25's room. During the same interview on 3/27/2026 at 9:40 AM with LVN 1, LVN stated 1 Resident 54's baseline personality fluctuates between verbal aggression to being withdrawn and shutting people out. LVN 1 stated, there were times Resident 54 did not comply with redirection from the staff members and would ignore everyone around her and will not listen to what we say. During a review of the facility's policies and procedures (P&P) titled Resident Safety, dated 4/15/2021, the P&P indicated that residents will be evaluated when there is a change of condition to identify circumstances that pose a risk for the safety and welling of the resident.

Based on interview and record review, the facility failed to revise or update the care plan for one of one sampled residents (Resident 72) to address new interventions related to paranoid schizophrenia (chronic mental disorder characterized by intense, irrational paranoia, delusions [false beliefs], and auditory hallucinations [hearing voices]) due to increased hallucinations when readmitted to the facility on [DATE] after hospitalization. This deficient practice had the potential to result in Resident 72 not receiving appropriate interventions and treatment and/or services and negatively affect the resident's psychosocial wellbeing. Findings: During a review of Resident 72's admission Record (AR), the AR indicated the resident was readmitted on [DATE] with diagnoses that included paranoid schizophrenia (chronic mental disorder characterized by intense, irrational paranoia, delusions [false beliefs], and auditory hallucinations [hearing voices]), schizophrenia, and diabetes mellitus (chronic metabolic disorder characterized by high blood sugar [hyperglycemia] resulting from insufficient insulin [hormone produced by the pancreas that acts as a key, allowing cells to absorb glucose from the blood for energy, and lowering blood sugar levels] production [Type 1] or ineffective insulin use [Type 2]) due to underlying condition with diabetic chronic kidney disease (high blood sugar damages the kidney's filtering units causing them to leak protein into the urine and eventually reducing their function). During a review of Resident 72's History and Physical (H&P), dated 3/25/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 72's Order Summary Report dated 3/16/2026 indicated a physician order was made for transfer to General Acute Care Hospital (GACH) for psych evaluation and 7-day bed hold (resident's right to have their own bed held for seven days while they are in the hospital). During a review of Resident 72's Change in Condition Evaluation dated 3/11/2026 indicated Resident 72 complained of pain over the lower back and alleged that she had a fall from 50 feet elevator. The evaluation indicated Resident 72 was able to ambulate and move lower extremities without difficulty. The evaluation indicated resident denied numbness on lower extremities and denied head injury. The evaluation indicated resident was noted with increased hallucinations and delusions with recommendations from Resident's physician for transfer to hospital for psych evaluation. During a review of Resident 72's care plans, no care plan revision was indicated for resident's transfer to hospital on 3/11/2026 for increased hallucinations and delusion. During a concurrent interview and record review of Resident 72's care plans on 3/27/2026 at 12:45 PM, the Director of Nursing (DON) confirmed Resident 72 did not have a care plan for resident's transfer to the GACH on 3/11/2026. The DON stated should be a revised care plan for the resident's change of condition/transfer so they can follow the resident's plan of care. The DON stated the care plan includes interventions that follow's MD orders and to help prevent whatever is going on with resident. A review of the facility's policy and procedure (P&P) titled Person-Centered Care Planning, dated 5/22/2025 indicated comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. A review of the facility's P&P titled Discharge and Transfer of Residents, dated 3/21/2025 indicated in the case of the transfer or discharge being necessary for the resident's welfare because the resident's needs cannot be met in the facility, the following information should be included, if the information is not already included in the most current discharge care plan: (1) a written description of the specific resident's needs that cannot be met; (ii) facility attempts to meet the resident's needs; and (iii) the services available at the receiving facility that meet the resident's needs.

Based on observation, interview, and record review, the facility failed to assess and monitor one of three sample residents (Resident 9 ), diagnosed with hemolytic anemia (a blood disorder where the red blood cells [RBC] are destroyed faster than the bone marrow can replace them, leading to fatigue, jaundice [yellowing of skin], and dark urine) with symptoms of blood loss in accordance with the care plan and professional standards of practice by failing to: 1.Monitor and assess Resident 9 for any signs and symptoms of hemolytic anemia such as skin pallor, shortness of breath upon activity, sore tongue, chest pain, tinnitus (ringing in ears), palpitations, and changes in condition. 2.Follow up with Resident 9's Clinic 1 (Hematology Clinic) regarding the after visit care regarding the plan of care for resident's management of hemolytic anemia. These failures resulted in Resident 9 being transferred to the General Acute Care Hospital (GACH) 1 on 2/18/2026 with low blood pressure (BP, measure of the force of blood against artery walls; normal: 120/80 millimeters of mercury [mmHg]) of 94/43 mmHg, low hemoglobin (HGB, protein that carries blood to the tissues; normal range 11 - 16 (g/dL) results of 3.8 g/dL, and hematocrit (HCT, percentage of the total blood volume that consist of RBC; normal range 35 - 52%) of 14%. Resident 9 received a total of four (4) units of packed red blood cells and stayed in the GACH from 2/18/2026 to 2/23/2026. Findings: During a review of Resident 9's admission Record (AR), the facility admitted Resident 4/17/2025 and readmitted Resident 9 on 11/17/2025 with diagnoses of acquired hemolytic anemia, hypertension (HTN, high blood pressure), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 9's Minimal Data Set (MDS, a resident's assessment) dated 1/23/2026, indicated Resident 9's cognitive (a resident's thought process) was intact. During a review of Resident 9's care plan, initiated on 11/17/2025, indicated Resident 9 had hemolytic anemia with interventions, that included to educate Resident 9 and their caregivers to expect her stool to change from dark green to black and to monitor/document/report the following signs and symptoms of anemia such as pallor (unhealthy pale color), fatigue, dizziness, syncope (faint), headache, palpitations, weakness, feelings of cold, low hemoglobin and hematocrit, shortness of breath upon activity, sore tongue, chest pain, tinnitus (ringing in ears), headache, and changes in condition. During a review of Resident 9's Lab Result Report record, dated 2/18/2026, the record indicated Resident 9's blood specimen was collected on 2/18/2026 timed at 9:39 AM and the results were reported on 2/18/2026 at 7:30 PM. The record indicated Resident 9's red blood cells (RBC; normal RBC is 3.9-5.5 millions per microliter [million/mcL])) was 0.98 million/mcL (abnormally low) , hemoglobin (HGB, protein that carries oxygen to the tissues; normal HGB is 11-16 grams per deciliter [g/dL]) was 3.8 g/dL (abnormally low), and hematocrit (HCT, percentage of total blood volume; normal 35 - 52%) was 14% (abnormally low). During a review of Resident 9's Change of Condition Evaluation (CoC) record, dated 2/18/2026 timed at 7:57 PM, the CoC indicated Resident 9's had abnormal blood pressure of 94/43, heart rate of 99, respiratory rate of 16, and temperature of 98.8 degrees Fahrenheit ( F, unit of temperature). The record indicated that Resident 9's had a critical laboratory result and blood pressure. Physician 1 (Primary Care Physician) recommended to transfer Resident 9 to the GACH via 911. During a review of Resident 9's GACH records, the laboratory results records dated 2/18/2026 timed at 9:10 PM, were reviewed. The records indicated that Resident 9's RBC levels were 0.76 million/mcL (abnormally low), HGB levels were 3.4 g/dL (abnormally low), and HCT levels were 10.5% (abnormally low). During a review of Physician 2 (GACH 1's Attending Physician) history and physical (HP) record, dated 2/19/2026 timed at 7:06 AM, the record indicated that Resident 9 had reported diffuse body aches while lying still, the facility checked Resident 9's blood pressure, and her systolic blood pressure (the top number of a blood pressure reading; the amount of force blood pushes against the vessels; normal systolic blood pressure is 120) was reported in the 80's, and 911 was activated. The record indicated that Resident 2's laboratory results indicated her HBG of 3.4 g/dL (abnormally low), and Resident 9 received a total of four (4) units of packed RBC during her admission to GACH 1 from 2/18/2026 to 2/23/2026. During a review of Resident 9's HP, dated 2/25/2026, the HP indicated that Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 9's Order Summary Report record, the order, dated 2/25/2026, indicated that Resident 2 had an order for a hematology (physician who specializes in diagnosing, treating, and managing diseases of the blood) consult. During a review of Resident 9's Order Summary Report record, the order, dated 2/26/2026 and 3/2/2026, indicated Resident 9 was scheduled to have an appointment with Physician 3 (Hematologist) on 3/2/2026 and 3/16/2026, respectively. During a review of Clinic 1's note (untitled note from Clinic 1 after Resident 9's appointment), dated 3/2/2026 and 3/16/2026, the note indicated Physician 3 recommended blood laboratory orders and scheduled another appointment in two weeks. During an observation on 3/24/2026 at 10:36 AM in Resident 9's room, Resident 9 was observed sleeping in bed wearing a jacket and covered with a blanket and refused any interaction. During an interview on 3/24/2026 at 2:17 PM with Family Member (FM) 1, FM 1 stated, Resident 9 was transferred to the hospital for a HGB of 4 g/dL in February 2026. During an interview on 3/26/2026 at 3:20 PM with Licensed Vocational Nurse (LVN) 4, LVN 4 stated, Resident 9 had routine laboratory orders and her HGB results would sometimes be low. LVN 4 stated, she did not know if Resident 9 had a diagnosis of anemia, but Resident 9 was hospitalized recently for low HGB. During a concurrent interview and record review on 3/26/2026 at 6:02 PM with the Assistant Director of Nursing (ADON), Resident 9's Medical Chart was reviewed. The AODN stated, the only records from Clinic 1 were the notes that indicated Resident 9's diagnoses, recommended laboratory orders, and next scheduled visit. The ADON stated, Physician 3 did not have any assessment notes in Resident 9's chart, therefore the facility was not aware of Physician 3's assessments or plan of care related to monitoring Resident 9's hemolytic anemia. During a concurrent interview and record review on 3/26/2026 at 6:15 PM with the ADON, Resident 9's care plans and active orders were reviewed. The ADON stated, the facility monitored Resident 9's anemia through routine laboratory orders every three (3) months but the facility did not monitor or assess any possible changes of condition related to Resident 9's hemolytic anemia such as pallor, fatigue, shortness of breath upon activity, or syncope as indicated in her care plan. During a concurrent interview and record review on 3/27/2026 at 9:16 AM with the Medical Records Director (MRD), Clinic 1's notes, dated 3/2/2026 and 3/16/2026, were reviewed. The MRD stated, the two (2) notes only had Resident 2's diagnoses and laboratory that were required before the next clinic visit. The MRD stated that the two (2) notes did not contain a visit summary, Resident 9's assessment and baseline, or Physician 3's plan of care. During an interview on 3/27/2026 at 10:40 AM with Registered Nurse (RN) 1, RN 1 stated, it was important to monitor any signs and symptoms of anemia such as pallor, dark tarry stool, and bleeding because if Resident 9 was not monitored, the signs and symptoms of anemia may be missed, which may result in hospitalization. During an interview on 3/27/2026 at 11 AM with the Director of Nursing (DON), the DON stated it was important to specifically monitor any signs and symptoms of anemia to identify any changes in Resident 9's condition and to notify Physician 1 as soon as possible. During an interview on 3/27/2026 at 11:04 AM with Medical Assistant of Clinic 1 (MA) 1, MA 1 stated, the facility did not contact Clinic 1 to request Physician 3's assessment after the clinic visit to indicate the plan of care for management Resident 9's hemolytic anemia. During a review of the facility's policy and procedures (P&P) titled Resident Safety, revised 4/15/2021, the P&P indicated the interdisciplinary team will establish a person-centered observation or monitoring systems for the resident o address the identified risk factors identified. During a review of the facility's P&P titled Comprehensive Person-Centered Care Planning, revised 8/24/2023, the P&P indicated the facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of resident in order to obtain or maintain the highest physical, mental, and psychosocial well-being. During a review of the same facility's P&P titled Comprehensive-Person Centered Care Planning, revised 8/24/2023, the P&P indicated that the baseline care plan will be developed and implemented, using the necessary combination of problem specific care plans to promote continuity of care and communication among facility staff, increase resident safety, and safeguard against adverse events.

Based on observation, interview, and record review, the facility failed to ensure two of six residents (Resident 9 and Resident 16) was informed of the name and purpose of each medication at the time of administration. This deficient practice had the potential to limit Resident 9 and Resident 16's ability to make informed decisions and participate in their care. Findings: a.During a review of Resident 9's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with diagnoses that included schizophrenia (a mental illness that was characterized by disturbances in thought), depression (constant feeling of sadness and loss of interest, which stopped you doing your normal activities), and anxiety disorder (feelings of fear, dread, and uneasiness that may have occurred as a reaction to stress). During a review of Resident 9's History and Physical (H&P) dated 2/25/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 1/23/2026, the MDS indicated the resident's cognition was intact (sufficient judgement and self-control to manage the normal demands of the environment). The MDS indicated the resident was receiving antipsychotic (prescription medications that helped manage psychosis - symptoms that was hard to tell what was real, such as hearing voices, severe paranoia, or delusions), antianxiety (prescription drugs designed to calm the nervous system, reduce intense fear, and alleviate worry, helping to make anxiety manageable), and antidepressant (prescription medication that helped improve mood, sleep, appetite, and concentration in people with depression or anxiety) medications. During a review of Resident 9's Physician's Order dated 2/23/2026 at 9:22 PM, The Physician's Order indicated an order for benztropine mesylate (a medication primarily used to treat still muscles, muscle spasms, and tremors) oral tablet one milligram (mg- a unit of measurement), give one tablet by mouth two times a day for extrapyramidal symptoms (EPS, involuntary, uncontrollable movement disorders that act as side effects of medications, particularly antipsychotics). During a review of Resident 9's Physician's Order dated 2/23/2026 at 9:22 PM, The Physician's Order indicated an order for Depakote (also known as divalproex sodium, a prescription medication primarily used to treat seizures [a sudden, temporary surge of uncontrolled electrical activity in the brain that caused temporary changes in behavior, movement, feelings, or consciousness], prevent migraine headaches, and manage manic episodes associated with bipolar disorder [a mental health condition characterized by severe, unpredicted shifts in mood, energy, and activity levels]) oral tablet delayed release 500 mg, give one tablet by mouth two times a day for bipolar disorder manifested by (m/b) fluctuation of mood from calm to anger. During a review of Resident 9's Physician's Order dated 2/23/2026 at 9:22 PM, The Physician's Order indicated an order for Keppra (a common prescription anti-seizure medication used to treat epilepsy [a chronic brain disorder characterized by recurrent, unprovoked seizures caused by sudden, abnormal electrical activity] by calming abnormal electrical activity in the brain) oral tablet 500 mg, give one tablet by mouth two times a day for seizure. During a review of Resident 9's Physician's Order dated 2/23/2026 at 9:22 PM, The Physician's Order indicated an order for vitamin B12 (an essential nutrient that helped keep your body's nerves and blood cells healthy, boosted emergency, and aided in creating DNA [molecule that carried the genetic instructions for the development, functioning, growth, and reproduction of all known living organisms]) oral tablet 500 microgram (mcg, a unit of weight), give one tablet by mouth one time a day for supplement. During a review of Resident 9's Physician's Order dated 2/23/2026 at 9:33 PM, The Physician's Order indicated an order for Lasix (a powerful prescription diuretic or water pill used to remove excess fluid from the body) oral tablet 20 mg, give one tablet by mouth one time a day for hypertension (HTN, a chronic condition where the force of blood pushing against artery walls was consistently too high), hold if systolic blood pressure (SBP, the top or first number in a blood pressure reading) was less than 110. During a review of Resident 9's Physician's Order dated 2/23/2026 at 9:33 PM, The Physician's Order indicated an order for metoprolol tartrate (a beta-blocker medication that lowered blood pressure and heart rate, making the heart easier to pump blood) oral tablet 25 mg, give one tablet by mouth two times a day for HTN, hold if SBP less than 110 or heart rate was less than 60. During a review of Resident 9's Physician's Order dated 2/23/2026 at 9:37 PM, The Physician's Order indicated an order for folic acid (synthetic, man-made form of vitamin B9 used in supplements and fortified foods) oral tablet one mg, give on tablet one time a day for supplement. During a review of Resident 9's Physician's Order dated 2/27/2026 at 2:24 PM, The Physician's Order indicated an order for multivitamin-minerals (daily pill, capsule, or liquid containing a mix of essential vitamins and minerals designed to fill nutrient gaps in your diet) oral tablet, give one tablet by mouth one time a day for supplement. During a review of Resident 9's Physician's Order dated 2/27/2026 at 2:24 PM, The Physician's Order indicated an order for potassium chloride (KCL, salt-like mineral compound made of potassium and chlorine to treat low potassium levels in the body) tablet extended release 20 milliequivalent (MEQ, a unit used in medicine to measure the chemical activity of electrolytes in your body), give one tablet by mouth one time a day for supplement. During a review of Resident 9's Medication Administration Record (MAR) dated 3/1/2026 to 3/31/2026, the MAR indicated the resident received benztropine mesylate, Depakote, Keppra, vitamin B12, Lasix, metoprolol tartrate, folic acid, multivitamin-minerals, and potassium chloride's morning dose on 3/26/2026. During a medication observation on 3/26/2026 at 8:06 AM, Licensed Vocational Nurse (LVN) 4 was observed administering a medication to Resident 9. LVN 4 obtained the resident's blood pressure. LVN 4 sanitized hands and was checking each medication with the physician's order before placing the medication into a medicine cup. Upon gathering all medications, LVN 4 confirmed the residents name and date of birth and proceeded to hand the medication to the resident without explaining what the medications were or why the resident was receiving those medications. Resident 9 took the medication and LVN 4 checked the resident's mouth to ensure the resident swallowed all of the medication. During an interview on 3/26/2026 at 10:51 AM, LVN 4 stated when passing medication, she would inform the resident of each medication and why the resident was receiving the medication but forgot this morning. LVN 4 stated that if residents are not informed about the medications they are receiving, they would not know what they are taking or why, which could lead to confusion or anger. LVN 4 stated that the residents may have felt lost because staff were giving medications without explaining what the medications were or what they were for. During an interview on 3/27/2026 at 12:34 PM, the Director of Nursing (DON) stated that during medication pass, facility staff should be informing residents of their medications and providing a general explanation of what each medication is for. The DON stated that because of the resident population at the facility, informing the residents of the medication could trigger them so the staff were very careful in wording what the medications were. The DON stated the residents have the right to know what medications they were receiving and if they were not informed, the facility staff were not providing the residents with a choice. b. During a review of Resident 16's AR, the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder (a chronic mental health condition combining symptoms of schizophrenia [such as hallucinations, delusions, or disorganized thinking) with a major mood disorder [depression or mania]), bipolar disorder (a mental health condition characterized by severe, unpredicted shifts in mood, energy, and activity levels), and major depressive disorder (a serious mental health condition characterized by persistent, overwhelming sadness and a loss of interest in activities, lasting at least two weeks). During a review of Resident 16's H&P dated 12/10/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 16's MDS dated [DATE], the MDS indicated the resident had moderate cognitive impairment (a person was experiencing noticeable and significant difficulties with thinking, learning, remembering, and other cognitive skills that impacted their daily life). The MDS indicated the resident was receiving antipsychotic medications. During a review of Resident 16's Physician's Order dated 12/9/2025 at 11:40 AM, The Physician's Order indicated an order for divalproex sodium oral tablet delayed release 500 mg, give two tablet by mouth every morning and at bedtime for bipolar disorder m/b poor impulse control, easily getting agitated, two tablets equal 1000 mg. During a review of Resident 16's Physician's Order dated 12/9/2025 at 11:28 AM, The Physician's Order indicated an order for polyethylene glycol 3350 powder (also known as MiraLAX, a [NAME], over-the-counter white powder used to treat occasional constipation [having hard, dry bowel movements less than three times a week, or finding them difficult and painful to pass]), give 17 grams by mouth one time a day for bowel management, dissolve in four to eight ounces of beverage, hold for loose stools. During a review of Resident 16's Physician's Order dated 12/16/2025 at 11:36 AM, The Physician's Order indicated an order for gabapentin (a prescription medication primarily used to treat nerve pain and manage certain types of seizures) give 200 mg by mouth three times a day for neuropathic pain (pain caused by a direct lesion or disease affecting the somatosensory nervous system, either peripherally or centrally). During a review of Resident 16's Physician's Order dated 12/16/2025 at 11:36 AM, The Physician's Order indicated an order for multivitamin-minerals oral tablet, give one tablet by mouth one time a day for supplement. During a review of Resident 16's Physician's Order dated 1/26/2026 at 10:11 AM, The Physician's Order indicated an order for loxapine succinate (a conventional antipsychotic used primarily to treat schizophrenia by restoring balance to brain chemicals) oral capsule 25 mg, give three capsules by mouth every morning and at bedtime for schizoaffective disorder, bipolar type m/b responding to internal stimuli AEB mumbling to self, three capsules equal to 75 mg. During a review of Resident 16's Physician's Order dated 3/3/2026 at 1:27 PM, The Physician's Order indicated an order for Artane (a medication used to treat muscle stiffness, tremors, spasms, and poor muscle control) oral tablet two mg, give 0.5 tablet by mouth two times a day for EPS, give 0.5 tablet equals one mg. During a review of Resident 16's MAR dated 3/1/2026 to 3/31/2026, the MAR indicated the resident received divalproex sodium, polyethylene glycol 3350 powder, gabapentin, multivitamin-minerals, loxapine succinate, and Artane's morning dose on 3/26/2026. During an observation on 3/26/2026 at 8:21 AM, Licensed Vocational Nurse (LVN) 4 was observed giving medication to Resident 16. LVN 4 sanitized hands and was checking each medication with the physician's order before placing the medication into a medicine cup. Upon gathering all medication LVN 4 confirmed the residents name and date of birth and proceeded to hand the medication to the resident without explaining what the medications were or why the resident was receiving them. Resident 16 took the medication and LVN 4 checked the resident's mouth to ensure the resident swallowed all of the medication. During an interview on 3/26/2026 at 10:51 AM, LVN 4 stated when passing medication, she would inform the resident of each medication and why the resident was receiving the medication but forgot this morning. LVN 4 stated that if residents are not informed about their medications, they would not know what they were taking or why, which could lead to confusion or anger. LVN 4 stated the residents may have felt lost because they did not know what was happening, as staff were administering medications without explaining the purpose. During an interview on 3/27/2026 at 12:34 PM, the Director of Nursing (DON) stated during medication pass, the facility staff should have been informing the residents of their medication and roughly explain what each medication was. The DON stated that because of the resident population at the facility, informing the residents of the medication could trigger them so the staff were very careful in wording what the medications were. The DON stated the residents have the right to know what medications they are receiving, and if they were not informed, staff were not providing the residents with a choice. During a review of the facility's policy and procedure (P&P) titled Medication Administration dated 8/19/2025, the P&P indicated All medications shall be administered by licensed nursing staff according to physician's orders, current best practices, and federal and state regulations. The facility shall ensure residents receive the correct medications in a timely, safe, and documented manner. The P&P indicated Purpose: to establish standardized procedures for the safe, effective, and accurate administration of medications in compliance with state and federal regulations and best practice standards.

Based on observation, interview, and record review, the facility failed to ensure that staff provided assistance with dining in a manner that promoted and maintained resident dignity for one of one sampled resident (Resident 69) when Certified Nursing Assistant (CNA) 1 was observed feeding Resident 69 while standing, rather than sitting at eye level. This deficient practice did not promote a dignified, person-centered dining experience and had the potential to make Resident 69 feel rushed, disrespected, or less engaged during meals. Findings: During a review of Resident 69's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included schizophrenia (a mental illness that was characterized by disturbances in thought), anxiety disorder (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which could cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 69's History and Physical (H&P) dated 12/6/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 69's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 3/17/2026, the MDS indicated the resident had severe cognitive impairment (Problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident's active diagnoses included schizophrenia, anxiety disorder, and depression. During a review of Resident 69's Order Summary Report dated 3/6/2026, the Order Summary Report indicated the resident had a regular - standard portion diet, level 6 - soft and bit sized textured (consisted of soft, tender, and moist foods cut into small 1.5 centimeter (cm, metric unit of length) by 1.5 cm pieces), level zero thin consistency (or thin liquid, representing natural, unmodified liquids that flowed quickly and easily like water), may have soft bread, sandwiches, cookies, and cakes. During a review of Certified Nursing Assistant (CNA) 1's Providing Assistance with Eating Competency Validation dated 4/10/2025, the Competency indicated the procedure to assist a resident with eating included sitting in a chair and facing the resident during the feeding. The Competency indicated CNA 1 met the procedure by providing a return demonstration. During a review of the facility's Assistance with Feeding an Adult Procedure dated 2021, the Procedure indicated assisting the resident into a comfortable sitting position in a chair at the table and for the facility staff assisting the resident to place a chair next to the resident to assist the resident comfortably. During an observation in the Facility's Dining Room on 3/25/2026 at 12:35 PM, Resident 69 was observed sitting in a chair at a dining table with CNA 1 standing over the resident. CNA 1 was observed spoon feeding the resident two times before another facility staff member whispered into CNA 1's ear. CNA 1 thereafter did not feed Resident 69 anymore and instead prompted the resident to eat different items on the meal tray. CNA 1 was observed staying with the resident until the resident was done with her meal and was observed standing the entire time. During an interview on 3/25/2026 at 1:05 PM, CNA 1 stated she should have been sitting down with the resident and not standing over her. CNA 1 stated she respected the resident even though she was standing over the resident and would bend her body over to try and communicate with the resident, but the dining room was only for the residents to sit down and not the facility staff. During an interview on 3/26/2026 at 11:43 AM, Licensed Vocational Nurse (LVN) 1 stated when assisting or prompting residents during feeding, facility staff should be seated next to the resident at eye level and should not stand over the resident. LVN 1 stated facility staff assisting a resident during mealtimes should not stand over the resident because facility staff were not trained to feed the resident while standing up and standing while assisting a resident during mealtimes could make the resident feel rushed to eat. LVN 1 stated sitting with the resident and communicating with them to see their verbal cues or facial expressions would provide the resident with comfort. LVN 1 stated when facility staff stand over the resident while assisting with meals could make the resident feel uncomfortable if the spoon was too high when being fed or giving the resident a feeling of being rushed. During an interview on 3/27/2026 at 12:36 PM, the Director of Nursing (DON) stated when the facility staff assisted a resident during meals, the facility staff should be seated with the resident and not standing over them. The DON stated facility staff should not stand over resident's when feeding because of the resident's dignity and the resident might have felt like they were being hurried. During a review of the facility's policy and procedure (P&P) titled Resident Rights dated 1/1/2012, the P&P indicated, The Purpose: to promote and protect the rights of all residents at the facility. The P&P indicated, The Policy: Residents of skilled nursing facilities have a number of rights under state and federal law. The facility will promote and protect those rights. Residents have freedom of choice, as much as possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules and regulations and applicable state and federal laws governing the protection of resident health and safety. Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of resident's rights.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 75) was provided with written information regarding Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) upon admission in accordance with federal requirements and facility policy. This deficient practice had the potential for Resident 75 not to be informed about their rights to make an informed decision regarding their medical care.Findings: During a review of Resident 75's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included schizophrenia (a mental illness that was characterized by disturbances in thought), depression (constant feeling of sadness and loss of interest, which stopped you doing your normal activities), and cannabis use (a plant used for psychoactive effects which altered mood, perception, and consciousness). During a review of Resident 75's History and Physical (H&P) dated 3/22/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During an interview on 3/26/2026 at 3:41 PM, the Social Services Director (SSD) stated Resident 75 was admitted on [DATE] and the SSD provided the AD pamphlet on 3/26/2026 (six days after admission). The SSD stated the AD should have been provided to Resident 75 upon admission to the facility on 3/20/2026. During a concurrent interview and record review of the facility's policy and procedure (P&P) titled Advance Directive on 3/26/2026 at 3:55 PM, Admissions stated the facility was not following the policy that indicated written information regarding the AD should be provided upon admission. Admissions stated for Resident 75, if she did not have an AD, the facility staff would not know what the resident's wishes were in case there was a medical emergency. During an interview on 3/27/2026 at 10:47 AM, the SSD stated if a resident did not have capacity but was able to communicate, was verbal and able to read, the SSD would give an AD pamphlet to the resident. During a concurrent interview and record review of the facility's P&P titled Advance Directive on 3/27/2026 at 12:20 PM, the DON stated the facility staff were not following the facility's policy because the AD pamphlet was not provided to the resident upon admission. The DON stated the AD pamphlet should have been provided to the resident upon admission to the facility, so the resident was aware. The DON stated when a resident has an AD, the residents medical wishes would be provided, and the staff would be consistent and follow the residents' medical wishes. The DON stated without the AD pamphlet, the resident would not have the right to determine what they wanted in regard to medical care. During a review of the facility's P&P titled, Advance Directive dated 7/31/2024, the P&P indicated, Purpose: To include provisions to inform and provide written information to all adult residents concerning their right to accept or refuse medical and surgical treatment, and , at the resident's option, formulate an advance directive. The P&P indicated, Upon admission, the Admissions Staff or Designee will provide written information to the resident concerning his or her right to make decisions concerning medical care; including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. During the Social Service Assessment Process, the Director of Social Services or Designee will also ask the resident if they have a written advance directive.

Based on interview and record review, the facility failed to notify the physician of a resident exhibiting new behaviors of verbal threats for one of two sampled residents (Resident 35) when Licensed Vocational Nurse (LVN) 1 observed Resident 35 regularly saying, I want to hit you to staff but did not notify Resident 35's physician of this new behavior. On 3/24/26, Resident 35 was witnessed throwing coffee toward Resident 58 during activities and Resident 35 was transferred to a general acute care hospital (GACH) for medical and psychiatric evaluation. This failure to report Resident 35's new behavior of verbal threats toward others did not allow Resident 35's physician to evaluate Resident 35 and apply new interventions such as making changes to Resident 35's medications or ordering new nursing interventions. This had the potential for Resident 35 to escalate his behavior and physically attack staff or other residents. [Cross reference F656] Findings: During a review of Resident 35's admission Record, the record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and auditory hallucinations (perceptual experiences in which an individual hears sounds, often voices, with no external auditory stimulus present). During a review of Resident 35's Minimum Data Set (MDS- a resident assessment tool) dated 1/27/26, the MDS indicated Resident 35 had moderately impaired cognition (the mental process of how a person learns, remembers, understands, and uses information) and required supervision or touch assistance for most cares such as personal hygiene and toileting. The MDS also indicated Resident 35 did not exhibit verbal behavioral symptoms directed towards others such as threatening others, screaming at others, or cursing at others. During a review of Resident 35's care plan initiated on 1/21/26, the care plan indicated Resident 35 had a mood disorder with interventions to monitor/record/report to physician the risk of Resident 35 harming others: increased anger, labile mood or agitation, threatened by others or thoughts of harming someone. During a review of Resident 35's provider progress notes dated 2/9/26 at 4:02 PM and signed by NP 1, the notes indicated Resident 35 denied / expressed no suicidal ideations, homicidal ideations, and violent behavior. During a review of Resident 35's Change in Condition (CIC- a communication tool used by healthcare workers when there is a change of condition among the residents) Form dated 3/24/26 at 9:50 AM, the CIC indicated, During scheduled coffee social activities in the dining room, [Resident 35] started exhibiting physical aggression [related to] throwing coffee at another resident unprovoked. [Resident 35] was sitting down and stood up from his chair while speaking loudly. [Resident 35] threw a cup of coffee in the direction of another resident. The CIC also indicated Nurse Practitioner (NP) 1 was notified of this incident and ordered to transfer Resident 35 to a GACH on a 5150 hold (a 72 hour hold for psychiatric evaluation when a resident is a danger to themselves, a danger to others, or are unable to care for their basic needs due to a mental health condition) for evaluation. During an interview with LVN 1 on 3/27/26 at 10:28 AM and concurrent record review of Resident 35's progress notes, CICs, and care plans from 1/2026 to 3/2026, LVN 1 stated there was no documentation of Resident 35 making verbal threats to staff. LVN 1 stated Resident 35 was known to easily be triggered when he did not get what he wanted and expressed his frustrations at staff by verbalizing, I want to hit you. LVN 1 further explained Resident 35's verbal threats to hit staff was new and he did not exhibit threatening behaviors until 2/2026, around a month after being admitted to the facility. LVN 1 stated she did not update Resident 35's care plan with Resident 35's verbal threats toward staff because Resident 35 was already known to be verbally aggressive and required frequent redirection. LVN 1 stated she should have created a CIC and notified Resident 35's physician of Resident 35's new behavior of making verbal threats to staff so that Resident 35 and his medications could have been reassessed by the physician. LVN 1 also stated that when residents stated they want to harm themselves or others, the facility's protocol is to place that resident on one-to-one supervision for safety to protect the resident or others from harm. During an interview with the Director of Registered Nursing (DON) on 3/27/26 at 11:20 AM, the DON stated she was not aware that Resident 35 was making verbal threats to hit staff. The DON stated that when a resident expressed verbal threats toward others such as, I want to hit you, staff should create a CIC to communicate the change in the resident's behavior to the rest of the staff, update the care plan to implement interventions, and notify the resident's physician in order to have the resident's medications reevaluated or sent to a GACH for further evaluation. The DON further explained that a CIC should have been created when Resident 35 first made verbal threats to harm others. During a review of the facility's Policy and Procedure (P&P) titled, Change in Condition and dated 8/25/22, the P&P indicated the licensed nurse will notify the resident's physician and legal representative when there is: An incident involving the resident A significant change in the residents' mental or psychosocial status

Based on interview, and record review, the facility failed to accurately document the administration of medication for one of one sampled resident (Resident 4.)This failure had the potential to cause severe hypoglycemia (low blood sugar), unconsciousness, and death to the resident.Findings: During a review of Resident 4's face sheet, the face sheet indicated Resident 4 was readmitted on [DATE] (original admission date 6/2/2008), with a diagnosis including but not limited to metabolic encephalopathy (a brain dysfunction caused by illness), schizophrenia (a mental disorder), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 4's order summary report (OSR), dated 3/25/2026, the order summary report indicated on 11/24/2025 to start administering pioglitazone (medication used to treat DM) 45 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) give one tablet orally (by mouth) one time a day for DM, hold if the blood sugar (BS) is less than 120 milligrams per deciliter (mg/dL). During a review of Resident 4's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated February 2026, the medication administration record indicated Resident 4 was administered pioglitazone 45mg by Licensed Vocational Nurse (LVN) 2 on 2/10/2026 at 9:00 a.m. by when Resident 4's BS was 89 mg/dL. During a review of Resident 4's MAR, dated February 2026, the medication administration record indicated Resident 4 was administered pioglitazone 45mg by Licensed Vocational Nurse (LVN) 3 on 2/22/2026) at 9:00 a.m. when Resident 4's BS was 110 mg/dL. During a review of Resident 4's MAR, dated February 2026, the medication administration record indicated Resident 4 was administered pioglitazone 45mg by LVN 2 on 2/27/2026) at 9:00 a.m. when Resident 4's BS was 77 mg/dL. During a review of Resident 4's MAR, dated March 2026, the medication administration record indicated Resident 4 was administered pioglitazone 45mg by LVN 2 on 3/10/2026) at 9:00 a.m. when Resident 4's BS was 84 mg/dL. During a review of Resident 4's MAR, dated March 2026, the medication administration record indicated Resident 4 was administered pioglitazone 45mg by LVN 2 on 3/13/2026) at 9:00 a.m. when Resident 4's BS was 114 mg/dL. During an interview on 3/25/2026 at 1:06 p.m., with LVN 2, LVN 2 stated on the Medication Administration Record (MAR), a check mark indicates a medication was administered, while a number indicates the medication was held, with the specific number identifying the reason for holding it. LVN 2 reported there was no way the medication was administered to Resident 4 on 3/10/2026 and stated the check mark on that date must have been a charting error on their part. LVN 2 confirmed they were fully aware of the order to hold pioglitazone HCL 45 mg if blood sugar (BS) is less than 120. LVN 2 stated -the BS documented for Resident 4 on 3/10/2026 was accurate and reiterated the check mark indicating administration was a mistake in charting. LVN 2 stated administering medications when a resident's BS is outside ordered parameters places the resident at risk for severely low blood sugar levels and potential hospitalization. During a review of the facility's policy and procedure (P&P) titled Completion and Correction medical records manual - general, dated 1/1/2012, the P&P indicated the facility will provide the highest quality and accuracy in documentation, and will make sure medical records are complete and correct. During a review of the facility's P&P titled, NP76 Medication Administration, dated 6/6/2025 the P&P indicated all medications must be administered by a licensed nurse according to physician's orders, and federal and state regulations.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals stored in Medication Cart A, for one of six sample residents (Resident 46) was properly labelled and reflected the correct dose and frequency as indicated on the active order's summary list. Resident 46's prescribed medication-Clozaril (Clozapine, an antipsychotic medication) Oral Tablet 25 milligrams (mg, unit of weight) medication label on the unit dose packaging (bubble pack or blister pack, an organization way to store and dispense pill medication). This failure had the potential to result in Resident 46 receiving the wrong dose and wrong frequency of Clozaril which may result in a medication error and compromise the safety of the resident. Findings: During a review of Resident 46's admission Record (AR), the facility admitted Resident 46 on 5/16/2024 and readmitted Resident 46 pm 9/8/2026 with diagnoses that include bipolar disorder (manic-depressive disorder; mood swings that range from lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar type schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 46's Letter of Conservatorship (legal order in which an appointed person makes decisions for another adult who cannot care for themselves) record, filed 12/29/2025, the record indicated that Resident 46 was gravely disabled due to a mental health disorder. During a review of Resident 46's Minimal Data Set (MDS, a resident's assessment), dated 2/20/2026, the MDS indicated that Resident 46's cognitive (a resident's thought process) skills were intact. The MDS indicated that Resident 46 had hallucinations (perceptual experiences in the absence of real external sensory stimuli). The MDS indicated that Resident 46's active diagnoses included anxiety disorder (mental health condition characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life), depression (mental health condition characterized by persistent sadness, loss of interest in activities, and low energy), bipolar disorder, psychotic disorder, and schizophrenia. The MDS indicated that Resident 46's routine medications included antipsychotics, antianxiety, and antidepressants. During a review of Resident 46's Order Summary Report the order, start date 3/2/2026, indicated that Resident 46 was taking Clozaril Oral Tablet (Clozapine) with instructions to give 37.5 mg by mouth one time a day for Schizophrenia manifested by the delusion that people was against him. During an interview on 3/26/2026 at 11:01 AM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated that if there was a medication order change such as an increase or decrease in the medication dose, it was important to remove the discontinued medication bubble pack from the medication cart, properly dispose the medication, and wait for the pharmacy to deliver the new medication bubble pack with new medication order label with the correct dose and frequency. LVN 3 stated, it was important to remove the discontinued medication bubble pack from the medication cart to prevent giving the resident the wrong order, wrong dose, or wrong frequency of the medication, which may result in a medication error. During a concurrent record review and interview on 3/26/2026 at 12:11 PM with LVN 3, Resident 3's Active Order List and current Clozaril medication bubble pack were reviewed. LVN 3 stated, the current order indicated Resident 46 was receiving Clozaril 37.5 mg with a frequency of once a day but the current Clozaril medication bubble pack's label indicated Resident 46 was receiving Clozaril 37.5mg twice a day. LVN 3 stated, the Clozaril's active order frequency and dose were not the same order frequency and dose on the medication's bubble pack label. LVN 3 stated, he did not know why the old medication bubble pack was not properly disposed of and replaced with a new bubble pack with the correct medication, correct dose, and correct frequency. LVN 3 stated, there no Change of Directions: See chart sticker on the current bubble pack to indicate the physician's change in directional use. During a review of the facility's policy and procedures (P&P) titled Medication Ordering and Receiving from Pharmacy: Medication Labels, dated 4/2014, the P&P indicated that each prescription medication label includes but not limited to: resident's name, specific direction for use, including route of administration, medication name, and strength of medication. During a review of the same P&P titled Medication Ordering and Receiving from Pharmacy: Medication Labels, dated 4/2014, the P&P indicated improperly or inaccurately labeled medications are rejected and returned to the dispensing pharmacy. During a review of the same P&P titled Medication Ordering and Receiving from Pharmacy: Medication Labels, dated 4/2014, the P&P indicated that if the physician's direction for use change or the label is inaccurate, the nurse may place a change of order label on the container indicating there is a change in directions for use, taking care not to cover important label information. The P&P indicated that when such a label appears on the container, the medication nurse checks the resident's MAR or the physician's order for current information.

Based on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident for twelve (12) out of twenty-two (22) resident rooms (room [ROOM NUMBER], 2, 3, 4, 6, 9, 21, 26, 27, 28, 30, and 31). The 12 resident rooms consisted of 1 (one), twelve (12) bed capacity room, 1 (one), seven (7) bed capacity room, 2 (two), four (4) bed capacity rooms, 2 (two), three (3) bed capacity rooms, and 6 (six), two (2) bed capacity rooms. This deficient practice had the potential to negatively impact the quality-of-care and the ability to of the nursing care to safely provide care and privacy to the residents. Findings: During the entrance conference interview, the Administrator (ADM) on 3/24/2026 at 9:21 AM, the ADM stated multiple rooms in the facility did not have the required 80 square feet of space per resident, but the facility had a room waiver (a permit approved by Centers for Medicare & Medicaid Services for rooms that did not meet the regulation requirement) in place and would like to request an additional waiver this year. The ADM stated the room size had no impact on the care of the residents. During an interview on 3/27/2026 at 10 AM with Resident 4 in room [ROOM NUMBER], Resident 4 stated he was sharing room [ROOM NUMBER] with other residents. Resident 4 stated the room size was okay and stated that the wheelchair and other equipment were used for other residents without any restrictions. Resident 4 stated, he did not have any issue with the room size. During an interview on 3/27/2026 at 10:13 AM, certified nursing assistant (CNA) 5 stated residents do not complain of room size or having multiple roommates. CNA stated there was enough room for residents to move around with or without assistive devices like wheelchairs or walkers. During a concurrent observation and interview on 3/27/2026 at 10:17 AM with Resident 13 in room [ROOM NUMBER], Resident 13 was observed walking around with no restriction. Resident 13 stated she had no concern with resident's space in his room. During a review of the facility' s Client Accommodations Analysis form, dated 3/25/2026, indicated the facility had 12 rooms (room [ROOM NUMBER], 2, 3, 4, 6, 9, 21, 26, 27, 28, 30, and 31) that measured less than the required 80 square footage per resident in multiple bed capacity rooms. During a review of the facility's request for room waiver, dated 3/25/2026, indicated the arrangement of the rooms provided adequate space for nursing care, for wheelchair access, and did not adversely affect the health and safety of the residents. The request indicated the following resident bedrooms were: room [ROOM NUMBER] (12 beds) 8 residents 56x20 sq. ft., 79.1 sq. ft per resident. room [ROOM NUMBER] (2 beds) 2 residents 11x12 sq. ft., 63 sq. ft per resident. room [ROOM NUMBER] (2 beds) 2 residents 11x12 sq. ft., 63 sq. ft per resident. room [ROOM NUMBER] (2 beds) 2 residents 11x12 sq. ft., 63 sq. ft per resident. room [ROOM NUMBER] (2 beds) 2 residents 12x13 sq. ft., 75 sq. ft per resident. room [ROOM NUMBER] (2 beds) 2 residents 12x12 sq. ft., 70 sq. ft per resident. room [ROOM NUMBER] (4 beds) 4 residents 12x23 sq. ft., 67 sq. ft per resident. room [ROOM NUMBER] (7 beds) 7 residents 25x23 sq. ft., 79.8 sq. ft per resident. room [ROOM NUMBER] (2 beds) 2 residents 12x14 sq. ft., 66.5 sq. ft per resident. room [ROOM NUMBER] (4 beds) 4 residents 12x25 sq. ft., 72 sq. ft per resident. room [ROOM NUMBER] (3 beds) 3 residents 12x20 sq. ft., 78 sq. ft per resident. room [ROOM NUMBER] (3 beds) 3 residents 12x20 sq. ft., 78 sq. ft per resident. During the survey, from 3/24/2026 to 3/27/2026, there were no observed adverse effects as to the adequacy of space, nursing care, comfort, and privacy to the residents. The residents residing in the affected rooms (room [ROOM NUMBER], 2, 3, 4, 6, 9, 21, 26, 27, 28, 30, and 31) with an application for variance were observed to have enough space to move freely inside the rooms. Each resident inside the affected rooms had beds and lockers. There was adequate room for the operation and use of the wheelchairs, walkers, or canes. The room variance did not affect the care and services provided to the residents when nursing staff were observed providing care to the residents. During a review of the facility's Resident Census from the last Health Recertification Survey with exit date of 2/14/2025 indicated the residents that occupied Rooms 1, 2, 3, 4, 6, 9, 21, 26, 27, 28, 30 and 31 were not the same residents that occupies Rooms 1, 2, 3, 4, 6, 9, 21, 26, 27, 28, 30 and 31 during this current Health Recertification Survey from 3/24/2026 to 3/27/2026.

Based on observation, interview, and record review, the facility failed to ensure four (4) out of twenty-two (22) resident's rooms (room [ROOM NUMBER], 5, 20, and 26) accommodated no more than four residents in each room. The 4 resident rooms consisted of 2 (two) - twelve (12) bed capacity rooms, 1 (one), seven (7) bed capacity room, and 1 (one), six (6) bed capacity rooms. This deficient practice had the potential adversely affect the delivery of care, quality of life, safety and violate the resident's rights for privacy. Findings: During the entrance conference interview, the Administrator (ADM) on 3/24/2026 at 9:21 AM, the ADM stated there were four rooms in the facility that occupied more than four residents in each room, but the facility had a waiver (a permit approved by Centers for Medicare & Medicaid Services for rooms that did not meet the regulation requirement) in place and would like to request an additional waiver this year. The ADM stated the multiple beds per room had no impact on care of the residents. During a review of the facility ' s Client Accommodations Analysis form, dated 3/25/2026, indicated the facility had 4 rooms (room [ROOM NUMBER], 5, 20, and 26) that had more than four residents per room. During a review of the facility's request for additional room waiver dated 3/25/2026, indicated the arrangement of the rooms provided adequate space for nursing care, for wheelchair (a chair fitted with wheels for use as a means of transport by a person who is unable to walk as a result of illness, injury, or disability) access. The multiple beds per room and did not adversely affect the health and safety of the residents. The request indicated the following resident bedrooms were: room [ROOM NUMBER] (12 beds) 8 residents, 79.1 square (sq, unit of measure) feet (ft, unit of measure) per resident. room [ROOM NUMBER] (6 beds) 6 residents, 92.8 sq. ft per resident. room [ROOM NUMBER] (12 beds) 12 residents, 87.1 sq. ft per resident. room [ROOM NUMBER] (7 beds) 7 residents, 79.8 sq. ft per resident. During an interview on 3/27/2026 at 10 AM with Resident 4 in room [ROOM NUMBER], Resident 4 stated he was sharing room [ROOM NUMBER] with other residents. Resident 4 stated the room size was okay and stated that the wheelchair and other equipment were used for other residents without any restrictions. Resident 4 stated, he did not have any issue with the room size. During the survey, from 3/24/2026 to 3/27/2026, there were no observed adverse effects as to the adequacy of space, nursing care, comfort, and privacy to the residents. The residents residing in the affected rooms (Rooms 1, 5, 20, and 26) with an application for variance were observed to have enough space to move freely inside the rooms. Each resident inside the affected rooms had beds and lockers. There was adequate room for the operation and use of the wheelchairs, walkers, or canes. The room variance did not affect the care and services provided to the residents when nursing staff were observed providing care to the residents. During an interview on 3/27/2026 at 10:13 AM, certified nursing assistant (CNA) 5 stated residents do not complain of room size or having multiple roommates. CNA stated there was enough room for residents to move around with or without assistive devices like wheelchairs or walkers. During a review of the facility's Resident Census from the last Health Recertification Survey with exit date of 2/14/2025 indicated the residents that occupied Rooms 1, 5, 20, and 26 were not the same residents that occupies Rooms 1, 5, 20,and 26 during this current Health Recertification Survey from 3/24/2026 to 03/27/2026.

Based on observation, interviews, and record review, the facility failed to notify the physician (MD) of an accident involving a resident for one of two sampled residents (Resident 1) after Resident 1 was observed by staff walking head first into a door that resulted in a cut near his right eye during the nightshift on 3/7/26 around 3 AM. The facility's staff did not notify Resident 1's physician (MD) of the injury during the morning shift, on 3/7/26 at 9 AM, six (6) hours after the accident, when Resident 1 was sent to a general acute care hospital (GACH) for medical evaluation and treatment. This failure to notify Resident 1's physician at the time of Resident 1's accident delayed the MD from placing orders to evaluate Resident 1 for severe injury that potentially required medical intervention and to monitor Resident 1 for any change in condition and had the potential for Resident 1 to decline from his head injury.Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), lack of coordination, and abnormalities of gait (walking) and mobility. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 1/29/26, the MDS indicated Resident 1 had severe cognitive impairment (a profound decline in memory, orientation, reasoning, and daily functioning) and required supervision for most cares such as personal hygiene and dressing. During a review of Resident 1's Change in Condition Evaluation form (CIC- a communication tool used by healthcare workers when there is a change of condition among the residents) dated 3/7/26 at 8:45 AM, the CIC indicated, Resident [1] was seen in the shower room getting ready to shower when he started rubbing his right eyebrow and started bleeding. Upon further assessment noted resident with a 1.2 cm (centimeter- a unit of measurement) cut on his right eyebrow and discoloration on right upper eyelid. Resident might need to go to acute hospital for evaluation. The CIC also indicated that Resident 1 had a skin change of a right eyebrow cut and right eyelid discoloration. The CIC also indicated a neurological assessment was relevant to the change in condition. The CIC also indicated Resident 1's physician was notified of the CIC on 3/7/26 at 9 AM and recommended to transfer Resident 1 to a GACH for medical clearance related to the right eyebrow cut and discoloration on the right upper eyelid. During a review of the facility's Investigation Report dated 3/13/26, the report indicated that Resident 1 was investigated for an injury of unknown origin for a cut and mild discoloration to the right eye after the ADM was informed of Resident 1's injury on 3/7/26 at 8:56 AM. The investigation indicated Certified Nursing Assistant (CNA) 1 witnessed Resident 1 turned a corner in the hallway and bumped into an open door on 3/7/26 shortly before 3 AM. The report further indicated CNA 1 noticed a small cut above Resident 1's right eye after he bumped into the door and Licensed Vocational Nurse (LVN) 1 and Registered Nurse (RN) 1 assessed Resident 1's cut and rendered first aid. During an interview with the ADM and concurrent observation on 3/20/26 at 8:45 AM of Resident 1, Resident 1 was observed walking and shuffling his feet with short strides and leaning forward with his head down as he walked. The ADM stated that Resident 1 sometimes did not watch where he was walking and could bump into things as he walked. During another interview with the ADM and concurrent observation on 3/20/26 at 9 AM, the door to the facility's room [ROOM NUMBER] was observed. The door to room [ROOM NUMBER] was opened and stuck out approximately 10 inches into the hallway. The ADM stated that Certified Nursing Assistant (CNA) 1 observed Resident 1 turn the corner of the hallway and bump into the edge of the door with his face. The ADM also stated the licensed nurses assessed Resident 1 and provided first aid and deemed [Resident 1] was fine. During a telephone interview with CNA 1 on 3/20/26 at 11:24 AM, CNA 1 stated that, on 3/7/26 around 3 AM, he observed Resident 1 turning a corner and then hit the end edge of the door to room [ROOM NUMBER] with his face. CNA 1 stated he noticed a cut on Resident 1's eyebrow with blood on his face and hand. CNA 1 further stated that he brought Resident 1 to the nurses station where LVN 1 and RN 1 cleaned Resident 1's wound. During an interview with the DON on 3/20/26 at 12:05 PM, the DON stated that Resident 1's right eye injury was initially considered an injury of unknown origin because no one during the day shift (7 AM to 3 PM) knew how Resident 1 got the injury. After further investigation by the facility, it was discovered that Resident 1 received the injury after bumping into the edge of a door during night shift (11 PM to 7 AM) around 3 AM on 3/7/26. The DON stated LVN 1 and RN 1 did not initiate a CIC to communicate to the rest of the facility how Resident 1 received his injury to the right eye. The DON stated LVN 1 and RN 1 should have initiated a CIC and notified Resident 1's MD of the accident so that the MD could place orders for proper interventions for Resident 1 such as medical evaluation from a GACH and monitoring. The DON stated she looked through Resident 1's Progress Notes and CIC documentation and did not see any documentation related to Resident 1's accident on 3/7/26 at 3 AM. During a review of the facility's policy and procedure (P&P) titled Change in Condition dated 8/25/22, the P&P indicated a licensed nurse will notify the resident's physician and legal representative or an appropriate family member when:There is an incident/accident involving the residentAn accident involving the resident which results in injury and has the potential for requiring physician intervention

Based on interview and record review the facility failed to ensure the licensed staff verified Resident 1 ' s admission orders from the facility, by reviewing Resident 1 ' s medical history and general acute care hospital (GACH 1) discharge orders upon readmission to the facility on [DATE], for one of two sampled residents (Resident 1), when it failed to: As a result of this deficient practice, Resident 1 had the potential to not receive the care and services, and correct medications needed for the resident ' s diagnosis while in the facility. Findings: During a review of facility ' s Admission Record indicated Resident 1 was initially admitted on [DATE] but readmitted back to the facility from GACH 1 on 3/12/2025, with diagnoses that included Schizophrenia (a disorder that affects a person ability to think, feel and behave clearly), Bipolar disorder (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs). During a review of Resident 1 ' s History and Physical (H&P), dated 2/23/2025, indicated the resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s GACH 1 Patient ' s Home Medication on discharge date d 3/12/2025 indicated continue taking the following medications 1.Quetapine (a medication used for Schizophrenia) 150 milligrams oral tablet 1 tab orally 2 times a day During a review of Resident 1 ' s GACH 1 Telemetry-Clinical Summary Report dated 3/11/2025 indicated the following medication: 1. Quetiapine give 100 milligrams tablet oral at bedtime, the report indicated the status as active. During a review of a facility document titled Order Summary report dated March 13,2025, indicated an order for the following medication: 1. Seroquel (Quetiapine) oral tablet 100 milligrams, give 1 tablet by mouth at bedtime for Schizophrenia manifested by paranoid delusion thinking everyone is against him. During a review of an SMS (short Message Service, refers to standard text messages sent using a cellular signal) sent by Registered Nurse 1 to Physician 1 on 3/12/2025 timed at 10:20 pm, the SMS message indicated 7 images containing Resident 1 ' s face sheet and Facility ' s Order Summary Report with an active order date of 3/13/2025 and a message addressed to Physician 1 stating This is RN 1 from (Facility), Resident 1 is readmitted to the facility, attached is the resident ' s medication list the message showed a read notification of yesterday (3/12/2025) under the message. During a telephone interview with RN 1 on 3/13/2025 at 2:35 PM, RN 1 stated she was the nurse who completed Resident 1 ' s admission orders to the facility on [DATE]. RN 1 stated she reviewed Resident 1 ' s GACH Telemetry-Clinical Summary Report based on the medication on the report that indicated active, RN 1 stated she input the medications into Resident 1 ' s facility admission orders. RN 1 stated she did not verbally speak to Physician 1. RN 1 stated that once she completed Resident 1 ' s admission orders she sent Physician 1 an SMS- text message from her personal phone to inform him of Resident 1 ' s admission and medication orders. RN 1 stated this was the common practice at the facility to inform Physician 1. RN 1 stated if Physician 1 did not respond to the message, but the message indicated it was read, it was understood Physician 1 agreed to the medication orders texted to him. RN 1 stated she did not see Resident 1 ' s GACH Patient ' s Home Medication on Discharge documents and only went based on Resident 1 ' s GACH Telemetry-Clinical Summary Report and Resident 1 ' s previous medication while at the facility to input Resident 1 ' s readmission orders. During an interview with on 3/13/2025 at 3:18 AM with the Director of Nursing (DON), the DON stated that during admission and readmission, licensed nurses should be going over the discharge summary list from the originating GACH to the physician. The DON stated sometimes physicians would ask the facility some questions regarding the residents ' GACH stay and the facility ' s admitting nurse will then go over all hospital medications and physicians would tell the licensed nurses what to continue and discontinue. The DON stated all admitting nurses should be calling and verbally talking to the admitting physicians, to ensure the admitting physician agrees with the resident ' s admission orders. A review of facility ' s policy titled Admission and Orientation of Residents with a revision date of October 2017, indicated 3. Upon admission, the residents attending Physician will provide the following information to the admissions office: an order for skilled nursing care, the type of diet the resident requires, Medication orders, including medical condition or problems associated with each medication

Based on observation, interview, and record review, the facility failed to prevent two of two residents (Residents 1 and 2) who were assessed at high risk for elopement (an act of leaving a care facility or safe area independently without notifying anyone) from leaving the facility in accordance with the facility's policy for elopement and residents' plan of care by failing to: 1. Provide adequate monitoring and supervision to ensure Resident I, who had fluctuating capacity to understand and make decisions, and was assessed at risk for elopement with diagnoses of suicidal ideation (thinking about killing yourself) did not elope from the facility on 9/10/2024 during a change of shift [evening shift and night shift) at 11 PM from Patio I. 2. Provide adequate monitoring and supervision to ensure Resident 2, who had no capacity to understand and make decisions, assessed at risk for elopement and with diagnoses of suicidal ideations, did not elope from the facility, on 9/17/2024, during change of shift [night shift and morning shift] at 7 AM from Patio I. 3. Ensure the facility thoroughly investigated on how Resident 1 eloped from the facility and provided interventions to prevent another resident, Resident 2, eloping from the same location in Patio I. 4. Ensure Patio 1, that is in the front patio, and Patio 2 that is in the back patio, were equally monitored and supervised to prevent residents from elopement. 5. Ensure Certified Nursing Assistant (CNA) 5 immediately informed staff that he saw someone climbing the roof near Patio 1. As a result of these deficient practices, Resident 1 climbed the roof by the facility's main/front patio (Patio I], jumped from the roof out to the facility's parking lot and climbed over the fence. On 9/11/2024, Resident 1 was located and transferred to the hospital for behavior management. On 9/17/2024 (6 days after Resident I eloped from the same facility patio] Resident 2 climbed over the same roof by Patio I, and jumped over the fence of the facility's parking lot. Resident 2 has not been found as of 9/19/2024. The deficient practice had the potential for Resident's 1 & 2 to sustain fall and injury when climbing the roof and struck by motor vehicles. Resident 1 had the potential to be exposed to extreme weather, malnutrition (lack of proper nutrition) and a psychiatric emergency due to a history of suicidal ideations that could lead to death. Resident 2 missed his daily medications including psychotropic medications (medications that affects mood and behavior) that were necessary to ensure he was not a danger to self and others. On 9/19/24 at 1:23 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance [not following rules] with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility's failure to provide adequate supervision to the residents in Patio 1. The survey team notified the Administrator (ADM) and the Director of Nursing (DON) of the IJ situation on 9/19/24 at 1:23 PM, regarding the facility's lack of supervision of the residents in Patio 1 that resulted to the elopement of Residents 1 and 2 from the facility on 9/10/24 and 9/17/24 respectively. On 9/20/24 at 6:34 PM, the ADM provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On 9/20/24 at 7:45 PM, while onsite and after the surveyor verified/confirmed the facility's full implementation of the IJ Removal Plan through observation, interview, record review, and determined that the IJ situation was no longer present, the IJ was removed onsite in the presence of the ADM and the DON. The IJ Removal Plan dated 9/20/24 included the following: The facility's immediate action to correct noncompliance that has caused or is likely to cause serious injury, serious harm, serious impairment, or death to Resident 1, who eloped on 9/10/24, but found immediately, and Resident 2 who eloped on 9/17/24 continued to be missing as of 9/19/24. The facility placed a system in place to ensure: 1. Residents were monitored and supervised when in Patio 1 at all times, in all three shifts. 2. Heightened awareness on security and oversight of all facility exit doors for all three shifts. 3. Residents at risk for elopement are frequently monitored and their whereabouts are always accounted for. 4. Staff were in-serviced on how to care for residents at risk for elopement. 5. Measures are in place to prevent residents from leaving the facility unsupervised for 22 residents at risk for elopement. What corrective actions(s) will be accomplished for those residents found to have been affected by the deficient practice: As of 9/19/24, Resident 1 is currently out of the facility (in the hospital) with anticipated return. As of 9/17/24, Resident 2 is currently out of the facility and has not returned (not found). Police notified on 9/17/2024, and missing person's report filed. Facility contacted local hospitals during every shift to locate the resident. On 9/19/24, the Maintenance Staff removed clutter/items in Patio 1 that may potentially be used by the residents to gain access to climbing over the roof. On 9/17/24, Patio 1 was assigned 24-hour monitoring to ensure residents are monitored and supervised and for are to be on the outer perimeter of Patio 1 on all three shifts when in Patio 1. Outgoing staff monitoring patio stays in Patio 1 until incoming staff to patio monitor arrives. During shift change, incoming and outgoing staff that monitors patio are to position themselves in a spot where they have clear vision of Patio 1 while they are endorsing to other staff. When the staff monitoring patio goes on break, a staff is assigned to relieve them prior to leaving Patio 1. On 9/19/24, the Administrator contacted security agency to secure a contract for unarmed security to provide heightened awareness for security oversight of all facility exit doors and facility egress (the action of going out of or leaving a place) for all three shifts including supervision and monitoring of resident areas. This will begin as soon as the company contracted signs the agreement and will continue until at least 30 days and will be reevaluated for further need based on the Facility's assessment of effectiveness of the implementations for additional monitoring systems. On 9/19/24, the Administrator secured a quote for fencing. The contractor is arriving on 9/19/24 to evaluate the area of concern on the identified area of fencing. A work order will be completed by 9/19/24. Corporate policy committee will be consulted regarding a more updated Elopement policy. How the facility will identify other residents having the potential to be affected by the same deficient practice and the corrective action will be taken: On 9/17 /24, the DON/Designees conducted an audit of the Elopement Binder (the binder used by the facility that list the names of the residents at risk for elopement) to ensure that current residents that are at risk for elopement were included and had a photo identifier unless they refused to have their photo taken. There are currently 21 residents identified to be at risk for elopement. The Elopement Binder was updated to ensure all identified residents are included in the binder. On 9/19/24, the Administrator/designee conducted an observation of the patio area (Patio 1) during the shift change between 7-3 and 3-11 to ensure that the patio is monitored, and residents were always supervised by the staff. No concerns were noted during observation. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: On 9/19/24, the Administrator and DON initiated an in - service education to RNs, Licensed Vocational Nurses (LVNs), CNAs, Rehabilitation and Activity staffs, Activities, Business Office, Dietary, Housekeeping, Laundry, Maintenance, Receptionist, Social Services, Medical Records staff. regarding the facility's policy and procedures for Wandering and Elopement, with emphasis on the importance of having the patio area always supervised in all three shifts, caring for residents at risk for elopement, and recognizing changes in condition that may potentially increase the risk of residents leaving the facility unsupervised. This in-service will be completed by 9/20/24. Staff on leave or unscheduled will receive education upon return to work. On 9/19/24, DON initiated an in-service to the nursing staff regarding hourly monitoring of residents who are at risk for elopement. This will be documented on the 'Residents who are at Risk for Elopement Monitoring' form. This in-service will be completed by 9/20/24. Staff on leave or unscheduled will receive education upon return to work. CNAs will conduct room rounds hourly every shift to ascertain all residents are accounted for. The Elopement Binder is placed at each Nurses Station and are reviewed with staff during shift change for any concerns, changes, or new admissions. These binders are updated by the DON/Designee as needed. The ADM will be responsible for monitoring and sustaining compliance. Findings: 1. A review of Resident 2's Admission Record indicated the facility admitted the resident on 8/1/24 and readmitted the resident on 8/14/24 with diagnoses that included schizophrenia (a serious mental health condition that affects how people think, feel, and behave, with paranoia [mistrust of other people] as one of its most dominant symptoms) and suicidal ideations. A review of Resident 2's History and Physical, dated 8/2024 indicated the resident does not have the capacity to understand and make decisions. A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 5/23/2024, indicated that the resident's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was intact. The MDS indicated that Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance (a type of assistance where a caregiver places one or two hands on a patient's body to help with balance while the patient performs a task) as resident completes activity and assistance may be provided throughout the activity or intermittently) when performing activities of daily living (ADL) such as eating, toileting, showering, and when performing oral hygiene. A review of Resident 2's care plan, initiated on 8/14/2024, indicated Resident 2 was at risk for wandering and elopement, to ensure the resident does not leave the facility unattended, the interventions included identifying triggers for wandering/elopement attempts, identify if there are patterns and purpose of wandering and monitor the resident's location every hour. A review of Resident 2's Elopement Evaluation (EE) dated 9/11/24 indicated that the resident was recently readmitted (within the past 30 days). Resident 2 also verbally expressed the desire to go home, packed belongings to go home, or stayed near an exit door. During a facility tour on 9/18/24 at 11:30 AM, the ADM demonstrated how Resident 2 climbed the roof from the patio to the other side of the building. The building that the residents in the facility occupied had six red doors that led to Patio 1. The patio had a screen fence approximately 12 feet high, with a door equipped with an alarm system, that led to the office of the ADM in another building. During a concurrent interview with the ADM, 9/18/24 at 11:30 AM she stated Resident 2 used the water pipes attached to the wall of the building to climb to the roof and jumped to the other side of the building to escape the facility. The ADM stated that the six red doors that led to Patio 1 remain unlocked 24 hours a day to enable the residents to freely go to the patio whenever they desired. All the doors and leading to the Patio are supposed to be supervised by staff that monitors the Patio 1. During an interview and concurrent record review with Director of Staff Development (DSD) on 9/18/24 at 2:30 PM, she stated on the night shift (11-7 AM), the staff monitoring the breezeway (an architectural feature similar to a hallway that allows the passage of a breeze) also monitors the patio simultaneously. The ADM stated Patio 1 does not have a dedicated staff to monitor the patio (Patio 1) area between 11 PM and 7AM. A review of the Nursing Staff Assignment dated 9/16/24, 11-7 AM shift, indicated that there was no dedicated staff assigned to monitor Patio 1 during the night shift (11-7 AM). During an interview with CNA 5 on 9/18/2024 at 3 PM, he stated he was assigned to monitor the breezeway on 9/17/24 from 7-3 PM. CNA 5 stated that on 9/17/24 between 7:15 - 7:20 AM, he observed a person from the breezeway climbing the roof in Patio 1 and simultaneously heard a Code [NAME] (an emergency code used by the facility to alert the facility staffs that a resident was missing or eloped [leaving the facility without permission or informing the facility] from the facility's paging system. CNA 5 stated he immediately stepped out of the building from the breezeway to confirm what he saw, but the person was not there anymore. CNA 5 stated he did not report to anyone immediately that he observed someone climbing the roof rather, rather he returned to his post while the rest of the staff looked for Resident 2. CNA 5 stated he learned later on from the other staffs that Resident 2 eloped and was missing. During a concurrent interview and observation on 9/18/2024 at 3 PM with CNA 5, CNA 5 stated he was assigned to monitor Patio 1 and the breezeway. CNA 5 stated the location from where he stood along the breezeway did not have a full and clear view. During an interview with Licensed Vocational Nurse (LVN) 4 on 9/19/24 at 12:20 PM, LVN 4 stated during breakfast on 9/17/24 at around 7:15 AM, she found a food tray in the food cart that belonged to Resident 2. LVN 4 stated she looked for Resident 2 everywhere in the building and was unable to locate the resident. LVN 4 then stated she immediately paged Code [NAME] on 9/17/24 at around 7:18 AM. During an observation on 9/19/24 at 3:35 PM, the Maintenance Supervisor (MS) measured the distance from the breezeway where the staff stood to monitor Patio 1 simultaneously. The distance from where the staff stood in the Breezeway to the wall where Resident 2 allegedly climbed to the roof was approximately 97 feet away and the height of the wall was approximately 11 feet and 2 inches. A review of the facility investigation report sent to CDPH, dated 9/23/24, indicated on 9/17/24 during a routine hourly head counts in the morning shift change, Resident 2 was not in his room. The staff informed the licensed nurse, and a Code [NAME] was immediately called at around 7:18 AM that initiated the search for Resident 2. During the search, a member of the search team saw Resident 2 making his way through the football field at the high school adjacent to the facility. The facility called the police on 9/17/24 at 7:27 AM but the resident was nowhere to be found. During an observation of a photo taken at the breeze way from the middle/back position of Patio 1 on 9/19/24 at 12:40 PM indicated the breeze way door frame was blocking full visual of Patio 1. A review of the facility's closed-circuit television (CCTV, also known as video surveillance, is the use of closed-circuit television cameras to transmit a signal to a specific place, on a limited set of monitors) on 9/19/24 at 12:45 PM showed the camera in Patio 1 only captured one side of the patio. The camera does not show side of the patio where Resident 2 climbed to get to the roof of the building. 46779 2. During a review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 9/3/2021 and readmitted on [DATE] with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and suicidal ideations (preoccupied thought of hurting or killing self). During a review of a MDS, dated [DATE], indicated Resident 1's had intact cognition (ability to understand and make decisions) and skills for daily decision making. The MDS indicated Resident 1 exhibited little interest or pleasure in doing things and trouble concentrating on things, such as reading the newspaper or watching television on half or more of the day. The MDS indicated Resident 1 also exhibited feeling down, depressed, (severe sadness and hopelessness) and bad about self or being a failure or let self or the family down nearly every day. The MDS indicated Resident 1 was independent with eating, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, walk 150 feet. A review of the plan of care dated 9/8/2024, indicated Resident 1 was at risk for elopement and wandering with the goal to ensure Resident 1 does not leave the facility unattended. The interventions included the facility will monitor resident's whereabout every hour and will involve resident in purposeful activity. During an interview on 9/18/24 at 3:35 PM, with Licensed Vocational Nurse (LVN) 3, LVN 3 stated she worked at the Station A on 9/10/2024 from 3 PM to 11 PM. LVN 3 stated she was inside East Nursing Station's main building around 11 PM on 9/10/2024, when she heard a noise coming from the Patio 1, but she did not see anyone on the ground of Patio 1 when she stepped out to the patio. LVN 3 stated, she heard a noise coming from the roof on the East wing building and she saw Resident 1 on top of the roof. During an observation on 9/19/2024 at 12 PM, Certified Nursing Assistant (CNA) 3 was observed standing in the breezeway. In a concurrent interview, CNA 3 stated all the red colored painted doors in the main building opens to Patio 1 that were never locked so that residents have 24 hours access to Patio 1. CNA 3 stated a staff was assigned to monitor only the Breeze way from 7 AM- 11PM, and another staff was assigned to monitor the Patio 1 from 7 AM to 11 PM. CNA 3 stated from 11 PM-7AM only one staff was assigned to monitor the Breeze way, Patio 1 and the Patio 2 (total three areas). CNA 3 stated she does not have a full visualization of Patio 1 when standing inside the Breeze way because the walls and the front door of the Breeze way blocks the views in certain areas of Patio 1. CNA 3 stated she had to put her head out or step out of the Breeze way to get a full visualization of Patio 1 and Patio 2. During an interview on 9/19/2024 at 1:54 PM, with Registered Nurse (RN) 1, RN 1 stated on 9/10/24 she worked from 3 PM to 11 PM. RN 1 stated at around 11:05 PM, she was in the main building near Patio 1 when LVN 3 from another station notified her that she saw someone on the roof near the Patio 1. RN 1 stated she activated Code [NAME] through the overhead paging system (an audio system that allows for one-way communication to a large audience) and when she ran out of the facility, she found Resident 1 on the driveway of the facility. RN 1 stated in the past she has observed Resident 1 always pacing (walk aimlessly) in the hallways and in Patio 1 during the evenings. During an interview on 9/19/2024 at 2:43 PM, CNA 1 stated Resident 1 always walks around in Patio 1. CNA 1 stated he was assigned to monitor Patio 1 from 3 PM to 11 PM on 9/10/2024 and did not see anyone in Patio 1 before he left in the end of his shift. CNA 1 stated he informed the charge nurse that he was leaving the facility and that there was no staff monitoring Patio 1 when he left the faciity on [DATE] between 11: 03 PM and 11:04 PM. CNA 1 stated he did not report to an incoming CNAs before he left the facility because he did not know if any staff was assigned to monitor Patio 1. CNA 1 stated he did not witness Resident 1 eloped from the facility on 9/10/2024. During a concurrent observation and interview on 9/19/24 at 3:45 PM, with the Assistant Director of Nursing (ADON), the ADON stated a facility staff assigned to monitor the breezeway from 11 PM to 7 AM, was supposed to stay inside the breezeway to monitor the residents. In an observation of the breezeway with the surveyor, the ADON explained, the staff monitoring the breezeway does not have a full view of Patio 1 if staff are monitoring the breezeway. During an interview on 9/20/24 at 9:07 AM, with LVN 1, LVN 1 stated on 9/10/24 at 11PM until 7 AM on 9/11/24 she was the staff assigned to monitor the Breeze way, Patio 1 and Patio 2. LVN 1 stated the staff monitoring the Breeze way usually stayed inside of the Breeze way, but if there was a resident in Patio 1, the staff goes outside to monitor the resident. LVN 1 stated she did not see anyone in Patio 1 when CNA 1 informed her that he was leaving which was around 11 PM on 9/10/2024. LVN 1 stated she did not see how Resident 1 went on top of the roof of the building. LVN 1 stated Resident 1 eloped because she thought no one would pay attention to her since the staff were busy during the change of the shift at 11 PM on 9/10/2024. LVN 1 stated there were blind spots from the Breeze way to the patio which blocks the view in Patio 1 where Resident 1 eloped from. LVN 1 stated she would not be able to see what was going-on in the patio due to the blind spots to Patio 1. During an observation and interview on 9/20/24 at 9:27 AM, Receptionist 1 stated the facility only had one surveillance camera monitoring Patio 1, but the camera could not capture the view of Patio 1 that was close to the main building where Resident 1 and Resident 2 eloped from. Receptionist 1 stated there was no staff assigned to the front office during the night from 11 PM to 7 AM to monitor the residents leaving from the facility in the front lobby or in Patio 1. During an interview on 9/20/2024 at 11:16 AM, LVN 2 stated when the facility readmitted Resident 1 in 8/2024, Family Member (FM) 1 called and stated Resident 1 had a history of eloping from home and was at high risk for elopement. LVN 2 stated she did not add this information to the nursing progress notes and care plan and did not inform any other staff of the resident's behavior of eloping from home. During a concurrent interview and record review on 9/20/24 at 12PM, with the ADON, Resident 1's Elopement Evaluation (EE), dated 8/9/24 indicated Resident 1 had a history of elopement and an attempted elopement while at home and in the facility. The EE also indicated Resident 1 verbally expressed the desire to go home, packed belongings to go home and stayed near an exit door. The EE indicated Resident 1 wandered aimlessly and likely to affect the privacy of others. The ADON stated based on the EE, dated 8/9/24, Resident 1 was at risk for elopement. A review of the EE, dated 9/3/24, indicated Resident 1 did not have a history of elopement or attempted to elope while at home and in the facility, and was not at risk for elopement. The ADON stated the EE, dated 9/3/24, was not answered correctly. The ADON stated the licensed nurse might have overlooked the facility's documents of Resident 1 when licensed nurse completed the elopement assessment on 9/3/24. The ADON stated the licensed nurses must review a resident's documents and assess the resident's current condition thoroughly and document the actual condition and assessment of the resident accurately. During a concurrent interview and record review on 9/20/24 at 3 PM, with the Administrator (ADM), the Facility Investigation Report, dated 9/11/24, was reviewed. The ADM stated the staff did not see Resident 1 get up to the roof on 9/10/24, and Resident 1 did not tell anyone how and where exactly she climbed up to get to the roof. The ADM stated based on the time and location the noise heard by the charge nurse on 9/10/24 at around 11:05 PM, Resident 1 may have eloped from Patio 1. During a concurrent interview and record review on 9/20/24 at 3:10 PM, with the ADM, Nursing Staff Assignments, dated from 9/10/24 to 9/17/24, the ADM stated only one staff assigned from 11 PM to 7 AM to monitor the breezeway, Patio 1 and Patio 2. During an interview on 9/20/24 at 3:15 PM, the ADM stated resident are kept away from Patio 1 at around 7AM, because the staff washes and cleans the grounds of the patio at the time. The ADM stated the grounds were wet and the facility discourages residents from going out to the Patio 1 to prevent fall and injury. During a concurrent interview and record review on 9/20/24 at 5:20 PM, with the Director of Nursing (DON), the DON stated the Elopement Evaluation of Resident 1 on 8/9/24 and 9/3/24, was not correctly assessed. Residents were supposed to be evaluated as high risk for elopement, and that affected the care of Resident 1 and 2 regarding the risk of elopement. During a concurrent interview and record review on 9/20/24 at 5:25 PM, with the DON, the facility's policy and procedure (P&P) titled, Wandering & Elopement, dated 7/2017, and Resident Safety, dated 4/15/21, were reviewed. The DON stated both versions of the P&P were the most current P&P that the facility followed. The DON stated the accurate assessment and documentation on residents' elopement risk was important so that the appropriate care plan and the intervention could be developed and implemented to prevent elopements. The DON stated providing additional supervision would be the fast and effective way to prevent residents' elopements in the secured facility, including by adding more staff to monitor the front patio and more frequent checking on the residents. A review of the facility's policy and procedure, titled Wandering & Elopement, dated 7/2017,indicated to enhance the safety of residents in the facility, the facility will identify residents at risk of elopement and minimize the possible injury as a result of elopement by ensuring the licensed nurse, in collaboration with the Interdisciplinary Team (IDT- a group of facility staff that help develop the plan of care for the residents) will assess residents upon admission, readmission, quarterly and upon identification of a significant change in condition. The residents at risk of elopement, preventative measures will be documented in the resident's clinical records and will be reviewed and re-evaluated by the IDT. The IDT will develop a plan of care considering the individual's risk factors.

Based on observation, interview and record review, the facility failed to provide adequate supervision for residents with special needs to prevent resident-to-resident altercations and/or falls for five of 15 sampled residents (Residents 2, 3, 4, 5 and 15). a. For Resident 2, the Fall Risk Prevention and Management Care Plan for providing a safe environment by having sufficient supervision was not implemented. On 9/7/17 Resident 2 fell from her wheelchair, while in the front patio, and sustained a laceration to the left eye brow and redness to the right knee. b. For Residents 4, 5, and 15, the Facility's Abuse-Prevention Program Policy and Procedures to maintain adequate staffing on all shifts, to ensure that the needs of each resident are met, was not implemented. The facility failed to provide adequate supervision during a smoking break on 9/17/17 at 4:15 p.m., which resulted to a resident to resident altercations. Resident 15 lost a tooth and sustained a lip laceration that needed stitches. c. For Resident 3, the Facility's Abuse-Prevention Program Policy and Procedures to maintain adequate staffing on all shifts, to ensure that the needs of each resident are met, was not implemented. On 9/16/17 at 4:05 a.m., there was in-adequate supervision in the hallways to prevent a resident-to-resident altercation between Resident 3 and Resident 15. Findings: a. During initial tour on 10/3/17 at 11:22 a.m., Resident 2 was in her wheelchair with a lap buddy (cushion used to restrain the person from rising from the wheelchair) and a wheelchair tab alarm attached to the back of her shirt. A dark discoloration was noticeable around the left eye. When asked what happened, Resident 2 stated she fell . A review of Resident 2's Admission Record indicated Resident 2 was admitted to facility on 7/21/17 and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 2's fall history indicated Resident 2 had a fall on 8/12/17, in her bedroom with no injury, and a second fall on 9/7/17 in the front patio and sustained a laceration to the left upper eye and right knee abrasion. A review of Resident 2's History and Physical dated 9/6/17 indicated Resident 2 did have the capacity to understand and make decisions. A review of Resident 2's Minimum Data Set (MDS), a comprehensive assessment and care screening tool, dated 7/28/17, indicated Resident 2 had a brief interview for mental status (BIMS) score of 8 (8-12 indicates moderately impaired cognition), required extensive assistance with bed mobility, transfer, dressing, personal hygiene and bathing. Resident 2 did not require a mobility device (wheelchair) during the assessment period. During an interview with the MDS Nurse (MDSN), on 10/4/17 at 1:01 p.m., she stated Resident 2 started using a wheelchair two weeks after her admission on 7/28/17. MDSN further stated a wheelchair was provided because Resident 2 would hold on to the hallway siderails. A review of Resident 2's Fall Risk Evaluation, dated 9/5/17 indicated Resident 2 had a fall risk scale score of 13. A score of 10 and above indicated high risk for falls. A review of Resident 2's Fall Risk Prevention and Management care plan r/t (related to) risk and actual falls, dated 9/5/17 indicated Resident 2 will be provided a safe environment to minimize complications associated with falls. A Situation/Background/Appearance/Review (SBAR) Communication Form, dated 9/7/17 indicated Resident 2 fell forward from her wheelchair while wheeling herself in the front patio. Resident 2 sustained a left eye brow laceration 1 centimeter (cm) by 0.5 cm, and complained of pain to the left knee. During an observation on 10/4/17 at 8:02 a.m., Resident 2 was on a wheelchair being pushed by Certified Nursing Assistant 6 (CNA 6) to the East Wing television (TV) area. CNA 6 left Resident 2 in the TV area and Resident 2 closed her eyes and began to lean forward in her wheelchair. During an interview on 10/4/17 at 8:04 a.m., with Resident 2's routine CNA, she stated Resident 2 has a behavior of rocking in her wheelchair when she is upset. The day of the fall, she stated, Resident 2 asked staff to leave her in the patio and she was rocking when she fell . During an observation on 10/5/17 at 8:20 a.m., there were three residents in the front patio with no staff to supervise the residents. One resident was ambulating with unsteady gait while pushing his wheelchair. The Director of Staff Development (DSD 1) was opening the front door gate when asked for the staffing assignment for the front patio. The DSD 1 verified there was no staff monitoring the resident and further stated one staff should always be supervising the patio. During a subsequent observation on 10/6/17 at 6:00 a.m., there were a total of five residents in the front patio with no staff to supervise the residents. There were three residents smoking and two ambulating around in the patio. During a concurrent interview and review of the facility's incident investigative report with the Administrator on 10/6/17 at 1:00 p.m., she verified based on her investigation that there was no staff supervising the front patio to prevent Resident 2's fall. According to the Centers for Medicare & Medicaid Services (CMS) State Operation Manual revised version 168, page 355, indicates Supervision/Adequate Supervision refers to an intervention and means of mitigating (ability to lessen the severity) the risk of an accident. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf b. An entity reported incident (ERI) indicated Resident 15 spat on Resident 4 and 5. Resident 4 did not like Resident 15's action and punched him in the mouth. Resident 15 sustained a laceration to the lower lip. A review of the Transfer Form, dated 9/17/17 at 6:00 p.m., indicated Resident 15 was transferred to the General Acute Care Hospital (GACH) for lower lip injury and one broken tooth. The GACH notes, dated 9/17/17 at 8:22 p.m., indicated Resident 15 received stitches (medical thread used to close a cut or wound on the skin). A review of Resident 15's Admission Record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a Smoking care plan dated 8/11/17, indicated Resident 15 was safe to smoke with supervision. The intervention was to supervise resident per Facility policy while smoking. A review of the Incident Investigation dated 9/18/17, indicated on 9/17/17, at 4:15 p.m., the certified nursing assistant (CNA) supervising the back patio heard yelling and rushed to separate the residents. The report further indicates Resident 15 got upset with Resident 5 and spat at her. Resident 4 was upset about Resident 15's action and hit him on the lip. A Situation/Background/Appearance/Review (SBAR) Communication Form, dated 9/17/17 indicated Resident 15 was in the back patio before smoke break when Resident 15 spat at Resident 5 and Resident 4 did not like what Resident 15 did and punched him on the mouth. Resident 15 sustained a laceration to the middle right side of his lip and lost a central lower incisor (lower front tooth). During a smoking break observation, on 10/5/17 at 2:15 p.m., there were a total of 26 residents in the back patio with two staff providing aprons, cigarettes and lighter. Then three additional staff came to the back patio. During a subsequent observation on 10/6/17 at 6:00 a.m., there were a total of five residents in the front patio with no supervision. There were three residents smoking and two ambulating around in the patio. During an interview with CNA 4, on 10/6/17 at 9:06 a.m., he stated the day of the incident he had stayed over because the facility was short in staff. When asked about the incident he stated there were over 20 residents in the smoking patio and he was the only staff supervising the residents during the smoking break. CNA 4 further stated he was busy passing the cigarettes when he heard the altercation. CNA 4 was busy with performing a task and was not able to prevent the altercation between the resident that resulted in injury. A review of the facility Smoking by Residents Policy and Procedure, dated 1/17, indicated the facility would develop a smoking schedule to ensure a safe environment and residents who require assistance and monitoring while smoking are not allowed to smoke unaccompanied. c. An entity reported incident (ERI) indicated Resident 3 pushed Resident 15 to the floor, by the east wing nursing station. A review of Resident 3's Admission Record indicated the resident was admitted to the facility on [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 9/7/17, indicated a score of 11 on the Brief Interview for Mental Status (BIMS - a BIMS score of 8-12 means moderate cognitive impairment) and required limited assistance in activities of daily living. The MDS further indicated the resident had delusion (misconception or belief that are firmly held, contrary to reality). A review of Behavioral/Psychotropic Medication care plan dated 8/31/17, indicated Resident 3's manifested behaviors were of threatening and aggressive behavior. The listed nursing interventions included to determine triggers and use de-escalation techniques. A review of the Incident Investigation dated 9/18/17, indicated on 9/16/17, at 4:05 a.m., Resident 3 and Resident 15 had an incident in the East Nursing Station. The charge nurse was inside the nursing station when Resident 3 walked by the nursing station and yelled at Resident 15 to get out of the way and suddenly pushed him. Resident 15 fell to the floor and sustained no injury. During an observation on 10/4/17, at 8:58 a.m., Resident 3 was observed walking by the East Nursing Station stating there is no space in the hallway when the nurses are passing the medications. Resident 3 went into his room, which is located next to the nursing station, then came out of his room and went out to the patio. A few seconds later Resident 3 returned to his room upset from the patio stating he cannot go outside because the gate is locked. During an interview with Resident 3, on 10/5/17 at 7:56 a.m., Resident 3 stated the facility had a Health and Safety issue for smoking break and medication pass. Resident 3 further stated that all the residents line up in a crowd and the lines bother him because it covers his bedroom door. During an observation on 10/5/17 at 7:50 a.m. and 8:17 a.m., there were residents in front of Resident 3's bedroom door. For the two observations Resident 3 came out of his room stating loudly that the crowd in front of his room should not be there. During an interview with LVN 3 on 10/6/17 at 6:35 a.m., she stated Resident 3 is very protective towards other residents. For the incident between Resident 3 and Resident 15 she remembers she was inside the nursing station with the gate locked and was busy charting when she heard the altercation between Resident 3 and Resident 15. LVN 3 further stated Resident 3 used his chest to push Resident 15. LVN 3 stated she was busy with a nursing task and the Certified Nursing Assistant that was assigned to monitor the hallway was not there to prevent the altercation.