Every finding on record at Penn Mar Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure the physician's order (PO) for facial X-ray (imaging test) was followed and carried out for one of two sampled residents (Resident 2). This deficient practice had the potential to result in serious health complications for Resident 2 following a physical altercation (incident involving physical contact or the use of force) with Resident 1 on 6/12/26 at 4:18 pm.Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including schizoaffective disorder bipolar type (a mental condition that causes both a loss of contact with reality [psychosis] and mood problems) and other psychoactive substance abuse with psychoactive substance induced anxiety disorder (a mental health condition characterized by intense, excessive, and persistent worry or fear about everyday situations). During a review of Resident 1's History and Physical (H&P) dated 6/4/26, the H&P indicated Resident 1 lacked the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 6/10/26, the MDS indicated Resident 1 was independent (resident completes the activity with no assistance from a helper) with eating, toileting, oral and personal hygiene, shower, upper and lower body dressing and putting on and taking off footwear. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including schizoaffective disorder bipolar type and generalized anxiety disorder. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was independent with cognitive skills (ability to understand) for daily decision making. The MDS indicated Resident 2 was independent with eating, toileting, oral and personal hygiene, shower, upper and lower body dressing and putting on and taking off footwear. During a review of Resident 2's Change of Condition Evaluation (COCE) dated 6/12/26 at 4:18 pm, the COCE indicated Resident 2's nose was swollen and discolored with episode of bleeding. During a review of Resident 2's PO dated 6/12/26 at 4:45 pm, the PO indicated facial x-ray one time only to rule out fracture. During a review of Resident 2's Interdisciplinary Team Notes (IDT) dated 6/12/26 at 9:41pm, the IDT notes indicated Resident 2 was involved in a resident-to-resident altercation on 6/12/26. During an interview with the facility's Administrator (Admin) on 6/24/26 at 9:30 am, the Admin stated on 6/12/26, Resident 1 and Resident 2 had a resident-to-resident altercation. The Admin stated Resident 1 struck Resident 2 and Resident 2 struck Resident 1 back causing Resident 2 to have a nosebleed. During a concurrent interview and record review (RR) of Resident 2's clinical record with the Admin on 6/24/26 at 11:30 am, the Admin stated there was an order for facial x-ray for Resident 2 on 6/12/26 (the day of the altercation between Resident 1 and Resident 2). The Admin stated the Admin was unsure if the x-ray was done in the facility or in the hospital where Resident 2 was transferred out to. During a concurrent interview and RR with the Admin on 6/24/26 at 12:45 pm, the Admin stated there was an x-ray ordered for Resident 2 on 6/12/26, but the x-ray was not done in the facility. The Admin stated Resident 2 was transferred out to the hospital but the x-ray was not done in the hospital either. The Admin stated there was no x-ray result indicating Resident 2 did not have a fracture from the altercation with Resident 1 on 6/12/26 because the x-ray order was not completed (carried out). During a review of the facility's Policy and Procedure (P&P) titled Resident Rights, dated 10/1/23, the P&P indicated the facility will promote and protect the rights of all residents at the facility. During a review of the facility's P&P titled, Violence Between Residents, dated 2/1/17, the P&P indicated the facility will protect the health and safety of residents by ensuring that altercations between residents are promptly reported, investigated and addressed by the facility. During a review of the facility's P&P titled, Physicians Orders dated 2/1/17, the P&P indicated the facility will ensure that all physician's orders are complete and accurate. The licensed nurse receiving the order will be responsible for documenting and implementing the order.

Based on observation, interview, and record review, the facility failed to provide supervision to one of eight sampled residents (Resident 1) in accordance with Resident 1's Care Plan. This failure resulted in Resident 1 hitting Resident 2 in the face on [DATE] at 3 pm. Resident 2 sustained a laceration (tear or cut in the skin) under Resident 2's left eye, a skin tear (traumatic wound caused by friction when the upper layer of the skin becomes torn from the underlying layers) on the left eyelid, and was transferred to the General Acute Care Hospital 1's (GACH 1's) Emergency Department (ED). Resident 2's Computed Tomography (CT scan - a detailed picture of the inside of the body using specialized imaging techniques and computer technology) results from GACH 1's ED, dated [DATE] and timed at 1:07 pm, indicated Resident 2 sustained a displaced fracture (a broken bone where the pieces have shifted out of their normal alignment, often breaking into two or more fragments) of the left nasal (relating to the nose) bone. Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included schizophrenia (severe mental disorder causing loss of touch with reality) and anxiety (persistent worries that disrupt daily life). During a review of Resident 1's History & Physical (H&P) dated [DATE], the H&P indicated Resident 1 did not have the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated [DATE], the MDS indicated Resident 1's was inattentive (not paying attention to something) and had disorganized thinking (thoughts do not have logical flow). During a review of Resident 1's untitled Care Plan Report (CPR), dated [DATE], the CPR indicated Resident 1 had schizophrenia which placed Resident 1 at risk (increased possibility of happening) for aggression, anxiety, and unsafe behaviors. The CPR indicated Resident 1 attempted to strike a male peer on [DATE] due to belief that the peer was talking about Resident 1. The CPR indicated Resident 1 struck a male peer [Resident 2] without provocation (action or speech that makes someone angry) due to paranoid ideation (persistent feelings of distrust and suspicion) on [DATE]. The CPR indicated on [DATE], while out on the patio, Resident 1 accused a male staff member (unknown) of talking about Resident 1 and wanted to engage in a physical fight with the male staff member. The CPR indicated on [DATE], while out on the patio, Resident 1 struck another resident [Resident 2] without provocation due to paranoid ideations. The CPR interventions initiated on [DATE] indicated Resident 1 will have Resident 1's meals in the dining room with assigned 1:1 supervision (providing dedicated, constant supervision for individual) while [Resident 2] will have [Resident 2's] meals in the patio area or the TV room; Resident 1 will be permitted in the patio area when Resident 1 was deemed psychiatrically stable (person is no longer an immediate danger to themselves or others), accompanied by Resident 1's 1:1 staff and only when the patio is not in use by others. The CPR also indicated Resident 1, and [Resident 2] have been informed of the [DATE] safety plan interventions and both residents understood the supervision protocols. The CPR did not indicate how long the [DATE] safety plan interventions were going to be in effect. The CPR safety plan interventions were updated on [DATE] and indicated Resident 1 will be closely monitored while on the patio, by assigned Certified Nursing Assistant (CNA); Resident 1 will have Resident 1's meals on a table alone until Resident 1 presents with further behavioral stability with no incidents of aggression for 2 weeks. The CPR did not indicate any changes to the safety plan interventions initiated on [DATE]. During a review of Resident 1's Interdisciplinary Team (IDT, a team of professionals from various disciplines who work in collaboration to address the resident's care) Note, dated [DATE] and timed 6:38 pm, the IDT Note indicated at 4 pm (on [DATE]), Resident 1 was observed by facility staff (unknown) struck another male peer [Resident 2] once to the back of [Resident 2's] head while [Resident 2] was getting water out of the water jug while out on the patio. The staff (unknown) separated Resident 1 and Resident 2 immediately, notified the Nurse Practitioner (NP- a nurse who is qualified to treat certain medical conditions without the direct supervision of a doctor), and received a Telephone Order (T.O.) to give Resident 1 an emergency intramuscular (IM- injecting directly into the muscle) of Haldol 10 milligrams (mg)/milliliter (ml) and Benadryl 50 mg/ml x1 STAT (immediately) and for Resident 1 to be placed in the Seclusion Room (room within facility used to decrease stimulation to calm resident) due to (d/t) delusional thoughts (false beliefs) and aggression as ordered. During a review of Resident 1's Change of Condition (COC, a sudden clinically important deviation in the resident's health or functioning that requires further assessments and interventions) Evaluation, dated [DATE] and time 4 pm, the COC indicated Resident 1 showed verbal and physical aggression towards another male peer [Resident 2]. During further review of Resident 1's medical record, no evidence of a behavioral evaluation or an IDT note addressing Resident 1's behavior and discontinuation of 1:1 supervision before [DATE] was found in Resident 1's medical record. b. During a review of Resident 2's AR, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included schizophrenia and anxiety. During a review of Resident 2's H&P, dated [DATE], the H&P indicated Resident 1 had the capacity to make medical decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was intact and Resident 2 was independent with mobility (the ability to move). During a review of Resident 2's COC, dated [DATE] and time 4 pm, the COC indicated Resident 2 was the victim involved in a resident-to-resident altercation (argument or disagreement) with Resident 1. Resident 2 sustained an abrasion (a surface or superficial wound where the skin was scraped off) to Resident 2's 4th/5th dorsal right medial phalanx (the top [back] surface of the middle bone in the right middle finger). Resident 2 complained of pain of 3/10 on a pain scale 0-10 (tool used to track and measure pain). During a review of Resident 2's COC, dated [DATE] and timed 1:53 pm, the COC indicated that Resident 2 was the victim involved in a resident-to-resident altercation with Resident 1. Resident 2 sustained a one-centimeter (cm, unit of measure) laceration (tear or cut in the skin) under Resident 2's left eye and a skin on Resident 2's eyelid. During a review of Resident 2's Nurses Notes (NN), dated [DATE] and timed 2:45 pm, the NN indicated at 12 pm on [DATE], Resident 2 was walking out of the building and Resident 1 struck Resident 2 without provocation and without warning. The NN indicated Resident 1, and Resident 2 were separated, and Resident 2 was transferred out of the facility to get Resident 2's wounds treated. Durin a review of Resident 2's NN, dated [DATE] and timed 8:44 pm, the NN indicated Resident 2 got back to the facility from GACH 1 on [DATE] at 4:10 pm. Then NN indicated Resident 2 complained of pain of 3/10 on a pain scale 0-10. During a review of Resident 2's CT scan results from GACH 1's ED, dated [DATE] and timed at 1:07 pm, the CT scan results indicated Resident 2 sustained a displaced fracture of the left nasal bone. During a review of Resident 2's GACH 1 Emergency Department Patient Discharge Instruction (EDPDI) dated [DATE], the EDPDI indicated Resident 2 had a nasal fracture and facial contusion (a bruise on the face from torn blood vessels). During a concurrent observation and interview on [DATE] at 1:14 p.m. with the Administrator (ADM), a facility surveillance video dated [DATE] was observed. Resident 1 was observed walking towards the entrance door into building from the outside recreation/patio area and struck Resident 2 in the upper facial area with no provocation by Resident 2. Resident 1 struck Resident 2 when Resident 2 exited the door to go out to the recreation area. The ADM stated, We (unknown facility staff) told Resident 1 to come and talk to us (any facility staff) when Resident 1 heard voices, but Resident 1 would not listen. The ADM stated, There was nothing we could do to prevent it. The ADM stated Resident 1 was no longer on 1:1 supervision and Resident 1's 1:1 supervision was discontinued based on staff discretion and did not require a Physician's Order (PO). During an interview on [DATE] at 3:39 pm with Mental Health Worker 1 (MHW 1), MHW 1 stated the incident between Residents 1 and 2 on [DATE] happened quickly, and when MHW 1 came out of the Activity Room, Resident 2 was already on the ground. MHW 1 stated MHW 1 observed Resident 2's face was red. MHW 1 stated Resident 1 had very little insight (understanding) into Resident 1's diagnosis and symptoms and Resident 1 was unable to distinguish if the voices Resident 1 heard were real. MHW 1 stated Resident 1 stated Resident 1 didn't know why Resident 1 struck Resident 2. MHW 1 stated Resident 1 had a history of (h/o) hearing voices and internal stimuli (internal voices/hallucinations). MHW 1 stated Resident 1 believed people were saying things to Resident 1. MHW 1 stated Resident 1 had previously stated to staff they're talking shit, it's okay but, they're talking shit. During a concurrent observation and interview on [DATE], at 4:23 pm with Resident 2, Resident 2 was alert and able to state person, place, and time. Resident 2 stated Resident 2 was attacked by one of the inmates for no reason. Resident 2 stated Resident 2 kicked Resident 1 off Resident 2 because Resident 1 knocked Resident 2 down when Resident 1 attacked Resident 2 by surprise. Resident 2 stated Resident 2 just walked past Resident 1. Resident 2 stated Resident 1 hit Resident 2 in the back of the head before, about six months prior, sometime in October, and Resident 2 had a bump. During an interview, on [DATE], at 4:36 pm with CNA 1, CNA 1 stated CNA 1 was currently providing 1:1 supervision to Resident 1. CNA 1 stated Resident 1 was unpredictable, and Resident 1 will swear and get angry unprovoked. CNA 1 stated Resident 1 was very paranoid (irrationally suspicious, fearful, or distrustful) and suspicious of others. CNA 1 stated sometimes Resident 1 could tell CNA 1 that Resident 1 was hearing voices and sometimes Resident 1 gets angry and unable to talk. During an interview, on [DATE], at 2:30 pm with the Social Services Director (SSD/SW), the SSD/SW stated Resident 1 was delusional (having fixed false beliefs that are based on an inaccurate interpretation of reality) and paranoid because Resident 1 reacts to the voices. The SSD/SW stated Resident 1 has had that for a long time and had a long history of aggressive/assaultive behavior (actions intended to harm, intimidate, or dominate others). The SSD/SW stated Resident 1 was unpredictable and had a long history of mental illness (health conditions involving changes in emotion, thinking, or behavior). During an interview, on [DATE], 2:51 pm with the ADM, the ADM stated there was an incident [which involved Resident 1 and Resident 2] on [DATE]. Resident 1 was the aggressor and Resident 2 was the victim. During an interview, on [DATE], at 4:37 pm with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 is an aggressive resident who doesn't have a particular trigger which facility staff have been able to identify. LVN 1 stated Resident 1 stayed away from peers mostly and stayed in Resident 1's room most of the time. LVN 1 stated Resident 1 had a history of cheeking (concealing a medication in the mouth) medication and had random aggression. A review of the facility's policy and procedure (P&P) titled, Care Planning, dated [DATE], the P&P indicated a Comprehensive Care Plan will be developed for each resident based on their individual assessed needs. The P&P indicated, Each resident's Comprehensive Care Plan will describe.services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The P&P indicated the IDT will revise the Comprehensive Care Plan as needed, as dictated by changes in the resident's condition and to address changes in behavior and care of the resident.

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, seven days a week from 11/1/2025 through 11/19/2025 for six out of 19 days. This deficient practice had the potential to affect the quality of nursing care provided to the residents.Findings: During a concurrent interview and record review on 11/19/2025 at 2:28 pm with the Director of Staff Development (DSD), the Nurse Staffing Sign-in Sheet for the month of November 2025 was reviewed. The Nurse Staffing Sign-in Sheet dated 11/1/2025 through 11/19/2025 did not indicate an RN was on duty for 6 days. The DSD stated the facility had no full time RN who worked eight hours per day, seven days a week since August 2025. The DSD stated a full time RN was important to oversee Licensed Vocational Nurses (LVNs) and Certified Nurse Assistants (CNAs) and to conduct residents' assessment and care in the facility daily. During a review of the facility's Assignment/Sign-In Sheet for all shifts, dated 11/1/2025, 11/2/2025, 11/8/2025, 11/9/2025, 11/15/2025 and 11/16/2025, the Sign-In Sheets indicated, there was no RN coverage for these six days. During an interview on 11/19/2025 at 3:12 pm with the Director of Nursing (DON), the DON stated there was no RN working on the weekends from 11/1/2025 up to date (11/19/2025). The DON stated the facility needed RN coverage for 8 consecutive hours for 7 days/week since the RN was responsible for overseeing the LVN's and CNA's in compliance with state regulations. The DON stated resident's initial assessment should be done by an RN. During a review of the facility's Policy and Procedure (P&P) titled, Nursing Department-Staffing, Scheduling & Postings, revised 10/1/2023, the P&P indicated To ensure an adequate number of nursing personnel are available to meet resident needs. The facility will employ sufficient Nursing Staff on a 24-hour basis that meets the appropriate competencies, skill set and required qualifications to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident.

Based on interview and record review the facility failed to obtain written informed consent for two of five sampled residents (Residents 6 and 9) by failing to:a. Obtain a written informed consent for the use of Lithium Carbonate (mood stabilizing medication to treat bipolar disorder [mental disorder characterized by periods of depression and of elevated mood]) for Resident 9.b. Ensure Resident 6 had written informed consents for the use of Clozapine (medication used to treat schizophrenia [mental disorder characterized by abnormal social behavior and failure to understand what is real]) and Fluvoxamine Maleate (medication used to treat depression [persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities]) before use. These deficient practices had the potential for the residents not to receive adequate or sufficient information regarding psychotropic medications (medication to treat mental disorders) necessary to make an informed health care decision.Findings: a. During a review of Resident 9's admission Record (AR), the AR indicated Resident 9 was admitted to the facility on [DATE] with diagnoses that included anxiety (emotion characterized by an unpleasant state of inner turmoil) and schizophrenia (a mental illness characterized by disturbances in thought). During a record review of Resident 9's Order Summary Report (OSR), dated 6/19/2025, the OSR indicated for licensed staff to administer Lithium Carbonate Oral Capsule 300 milligram (mg), two (2) capsules by mouth in the evening related to schizophrenia. During a review of Resident 9's Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 9/22/2025, the MDS indicated Resident 9 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 9 was independent for eating, oral hygiene, toileting hygiene, shower, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent interview and record review on 11/18/2025 at 1:27 pm with the Medical Records (MR) staff, of Resident 9's medical records (PointClickCare - PCC, a cloud-based software), the MR stated there was no informed consent obtained prior to administering Lithium Carbonate medication to Resident 9. During an interview on 11/18/2025 at 1:30 pm with Responsible Party 1 (RP 1), RP1 stated, I have not received a call from the facility when Resident 9 was admitted getting a consent for Lithium Carbonate use. No, I have not talked to the facility to give consent since Resident 9's admission. It's ok fwith me for the facility to call me. During a concurrent interview on 11/18/2025 at 1:45 pm with the facility's Director of Nursing (DON) and record review of Resident 9's PCC, the DON stated consent was not obtained prior to the use of Lithium Carbonate for Resident 9. The DON stated it was important to obtain informed consent for residents receiving psychotropic medications for the responsible party and residents to be aware of the risks and benefits as discussed by the physician and validated by Licensed Nurses. During a record review of the facility's Policy and Procedure (P&P) titled, Psychotherapeutic Drug Management, dated 10/1/2023, the P&P indicated, When obtaining consent for use of psychotherapeutic drugs, the resident will be informed of the risks and benefits for the use of these medications. When admitted with orders for psychotherapeutic drugs, licensed staff will verify with the resident that the risk and benefits have been explained to them prior to consent or use. The consent will remain in place until medication is discontinued or until consent is revoked by resident/responsible party. The P&P indicated, Licensed Nurse will not administer the psychotherapeutic medication until an informed consent form has been obtained and documented by the Attending Physician/Licensed Health Practitioner from the resident and/or surrogate decision maker unless it is an emergency situation. b. During a review of Resident 6's AR, the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses that included schizophrenia. During a review of Resident 6's History & Physical (H&P), dated 7/18/2025, the H&P indicated the resident had fluctuating capacity to make medical decisions. During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 was cognitively intact. During a review of Resident 6's OSR active as of 11/20/2025, the OSR indicated Resident 6 had active orders for: 1. Clozapine oral tablet 400 milligrams (mg- unit of measurement) to be given by mouth in the evening for thought disorganization related to schizophrenia, ordered on 7/17/2025. 2. Fluvoxamine Maleate oral tablet 25 mg to be given by mouth in the evening to augment Clozapine, ordered on 7/17/2025. During a review of Resident 6's Medication Administration Record (MAR) dated 11/1/2025 to 11/30/2025, the MAR indicated Resident 6 had been receiving Clozapine 400 mg and Fluvoxamine Maleate 25 mg in the evening from 11/1/2025 to 11/17/2025. During a concurrent interview and record review on 11/18/25 at 3:03 pm with Licensed Vocational Nurse 3 (LVN 3), Resident 6's medical record was reviewed. The medical record indicated there was no informed consent for Clozapine 400 mg and Fluvoxamine maleate 25 mg. LVN 3 stated, informed consents were needed for these psychotropic medications. LVN 3 stated the informed consent had to be completed to educate and inform the residents of the side effects and why they were taking the medication. LVN 3 stated the medications should not have been started before the facility received consent from the conservator and acknowledgment from the doctor. During an interview on 11/20/2025 at 10:13 am with the Director of Nursing (DON), the DON stated the licensed nurse needed to verify the informed consent was complete before administering the medication to the resident. The DON stated informed consents were done because the medications had long term side effects and to ensure the resident's quality of life. During a review of the facility's P&P titled, Informed Consent, dated 10/1/2023, the P&P indicated the purpose was to ensure that the facility respected the resident's rights to make an informed decision prior to deciding to undergo certain medical therapies and procedures. The P&P indicated the facility would have the Attending Physician/Licensed Healthcare Practitioner (LHP) determine when circumstances have changed so that an informed consent was required from the resident before providing treatment. The P&P indicated informed consent should be obtained from the resident or authorized representative before administration of a therapy or procedure that requires an informed consent. The P&P indicated informed consent should be done for psychotherapeutic drugs and should be documented and placed in the resident's medical record.

Based on interview and record review, the facility failed to ensure a copy of the Advance Directive (AD- a written statement of a person's wishes regarding medical treatment, made to ensure those wishes are carried out should the person be unable to communicate them) was not incomplete nor missing the conservator's signature, and readily available in the residents' medical chart for three of five sampled residents (Residents 5, 8 and 21) in accordance with the facility's Policy and Procedure (P&P) titled Advance Directives. These failures had the potential for the facility staff not knowing Residents 5, 8 and 21's specific wishes to follow and provide medical treatment and services against the will of the residents. Findings: a. During a review of Resident 5's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental condition that causes both a loss of contact with reality [psychosis] and mood problems) and major depressive disorder (persistent feeling of sadness and loss of interest). During a review of Resident 5's Order Summary Report (OSR) dated 6/26/2025, the OSR indicated, Legal Status: Conservatorship. During a review of Resident 5's History and Physical Examination (H&P), dated 6/29/2025, the H&P indicated Resident 5 did not have the capacity to understand and make decisions and currently under a temporary conservatorship (a legal arrangement where the court appoints a responsible person to manage the personal and/or financial affairs of another adult who was deemed unable to do so themselves). The H&P also indicated, Unable to obtain consent from patient, as patient lacks decision-making capacity. During a review of Resident 5's Minimum Data Set (MDS – a federally mandated resident assessment care screening tool) dated 10/6/2025, the MDS indicated Resident 5 was independent (resident completes the activity by themselves with no assistance from a helper) for eating, oral, toileting and personal hygiene. During a review of Resident 5's Advance Directive Acknowledgement (ADA) dated 6/30/2025, the ADA was signed by Resident 5 and a facility representative but was not signed by Resident 5's Responsible Party (RP) or Conservator. During an interview with the Minimum Data Set Coordinator (MDSC) on 11/20/2025 at 9:55 AM, the MDSC stated all consents including the AD should be filled out completely with name and date to confirm understanding between the conservator or the resident on what the facility offers and needs consent for resident treatments. During concurrent interview and record review with MDSC on 11/20/2025 at 10:00 AM, the MDSC stated Resident 5's AD should have been signed by Resident 5's conservator not the patient if the patient lacked decision making capacity. Per MDS, the AD was incomplete if it was missing a signature, date or the conservator or doctor's signature and if incomplete, the document was invalid. The MDSC stated it was very important for the forms to be completed and filled out by the right person and if the resident cannot provide a consent, it should be the conservator. During a review of the facility's P&P titled, Advance Directives dated 10/1/2023 indicated, the P&P indicated To provide residents with the opportunity to make decisions regarding their health care. If a resident is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she executed an Advance Directive, the facility may give Advance Directive information to the resident's representative in accordance with state law. During a review of the facility's P&P titled, Informed Consent dated 10/1/2023, the P&P indicated, To ensure that the facility respects the resident's right to make an informed decision prior to deciding to undergo certain medical therapies and procedures. B. The resident or representative must sign an informed consent prior to administration of treatment/procedure. Record Keeping: A. The facility will maintain documentation of verification of informed consent/Notice in the resident's medical record. b. During a review of Resident 8's AR, the AR indicated Resident 8 was admitted on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought) and depression (a mood disorder that may cause persistent sadness or loss of interest in activities). During a review of Resident 8's H&P dated 7/10/2025, the H&P indicated Resident 8 was unable to communicate and make decisions. During a review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8 was cognitively intact (ability to think). During a review of Resident 8's ADA dated 7/9/2025, the ADA did not indicate acknowledgement from the resident or responsible party (RP) of the following: being given written material and informed about rights to accept or refuse medical treatments, information of rights to formulate an AD, no obligation to formulate an AD, and if any AD was executed and it would be followed by the facility staff and it's attending physician. The ADA did not have the responsible party's (RP)/agent's signature. During an interview on 11/18/2025 at 10:32 am with Medical Records staff (MR), MR stated the ADA should be completed on admission. MR stated the ADA should be filled out and explained to the resident/responsible party and all consents should be completed on admission or within 72 hours of the resident's admission. During a concurrent interview and record review on 11/20/2025 at 9:38 am with MDSC, Resident 8's ADA dated 7/9/2025 was reviewed. The ADA did not have acknowledgments and responsible party's signature. The MDSC stated, Resident 8's ADA was an incomplete form. The MDS C stated the RP or conservator had the right to be informed. During a concurrent interview and record review on 11/20/2025 at 10:22 am with the Director of Nursing (DON), Resident 8's ADA dated 7/9/2025 was reviewed. The ADA did not have acknowledgments and responsible party's signature. The DON stated Resident 8's ADA was incomplete because it was missing the responsible party's signature and any checks or initials for the acknowledgment portion of the form. The DON stated the ADA was used to protect the residents' rights and verify if they had made an AD or not. During a review of the facility's P&P titled, Advance Directives, dated 10/1/2023, the P&P indicated, its purpose was to provide residents with the opportunity to make decisions regarding their health care. The P&P indicated, at the time of admission, admission staff or designee would inquire about the existence of an AD and the admission staff would inform and provide written information to residents concerning the right to accept or refuse medical treatment. The P&P indicated, upon admission, admission staff or designee would inform the resident of their right to execute an AD Form, if one does not already exist. The P&P indicated, if the resident was incapacitated at the time of admission and was unable to receive information or articulate whether or not he or she had executed an AD, the Facility may give AD information to the resident's representative in accordance with state law. The P&P indicated, each resident was informed that it was his/her choice to complete the AD. c. During a review of Resident 21's AR, the AR indicated the resident was initially admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 21's H&P dated 9/4/2025, the H&P indicated Resident 21 has the capacity to make medical decisions. During a record review on 11/18/2025 at 10:15 a.m. of Resident 21's chart, the ADA form was blank. The elements missing from the document were the resident's identification, treatment preferences, signature, date signed and witness signatures. During a concurrent interview and record review on 11/18/2025 at 10:30 a.m. with Medical Records (MR), the MR stated the Advance Directive Acknowledgment form was blank and should have been completed upon admission or within 72 hours. The MR stated an Advance Directive Acknowledgement form was signed by residents to show that the facility informed the residents about their rights to make decisions about their care. During a concurrent interview and record review on 11/19/2025 at 1:30 p.m. with [NAME] President of Clinical (VPC), Resident 21's medical record was reviewed. The VPC stated there was no Advance Directive Acknowledgement form. The VPC stated an Advance Directive Acknowledgement form offers as a guide for the care and wishes of Resident 21 and a blank form was an issue as the facility was unable to acknowledge Resident 21's preferences. During a review of the facility's policy and procedure titled Advance Directives, dated October 1, 2023, indicated, Upon admission, admission Staff or designee will inform the resident of their right to execute an Advance Directive form, if one does not already exist.Each resident is informed that it is his/her choice to complete the Advance Directive.

Based on interview and record review the facility failed to develop and implement an individualized/person- centered care plan (CP) for two of two sampled residents (Residents 9 and 31) in accordance with facility's Policy and Procedure (P&P) titled Care Planning. These deficient practices had the potential for Residents 9 and 31 to not receive necessary treatment and specific care services. Findings: a. During a review of Resident 9's admission Record (AR), the AR indicated Resident 9 was admitted to the facility on [DATE] with diagnoses that included anxiety (emotion characterized by an unpleasant state of inner turmoil) and schizophrenia (a mental illness characterized by disturbances in thought). During a record review of Resident 9's Order Summary Report (OSR), dated 6/19/2025, the OSR indicated for licensed staff to administer Lithium Carbonate Oral Capsule 300 milligram (mg), two (2) capsules by mouth in the evening related to schizophrenia. During a review of Resident 9's OSR dated 6/19/2025, the OSR indicated for licensed staff to administer Benztropine Mesylate Oral Tablet one milligram (mg-unit of measurement) one tablet by mouth, two times a day related to schizophrenia. During a review of Resident 9's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/22/2025, the MDS indicated Resident 9 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 9 was independent for eating, oral hygiene, toileting hygiene, shower, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During an interview and concurrent record review on 11/19/2025 at 8:53 am with Licensed Vocational Nurse 1 (LVN 1) of Resident 9's medical records (PointClickCare - PCC, a cloud-based software), LVN 1 stated there was no clinical documentation that a CP was initiated/implemented for the management of Resident 9's use of Benztropine Mesylate Oral Tablet and Lithium Carbonate Oral Capsule. LVN 1 stated a person-centered CP should have been initiated and implemented for Resident 9's use of Benztropine Mesylate Oral Tablet and Lithium Carbonate Oral Capsule to guide the nurses on how to provide proper care and treatment to Resident 9. During an interview on 11/20/2025 at 11:14 am with the facility's Director of Nursing (DON), the DON stated a CP should have been initiated and implemented for Resident 9's use of Benztropine Mesylate Oral Tablet and Lithium Carbonate Oral Capsule. The DON stated the purpose of the CP was to provide staff guidance on how to provide care and treatment to the residents. b. During a review of Resident 31's AR, the AR indicated Resident 31 was admitted to the facility on [DATE] with diagnoses that included anxiety and schizophrenia. During a review of Resident 31's MDS dated [DATE], the MDS indicated Resident 31 had intact cognition for daily decision making. The MDS indicated Resident 31 was independent for eating, oral hygiene, toileting hygiene, shower, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent interview and record review on 11/20/2025 at 11:15 am with the Minimum Data Set Coordinator (MDS C), Resident 31's PCC was reviewed. The MDSC stated the CP for Seroquel use was not initiated and implemented for Resident 31 upon receiving the order from the physician. The MDSC stated the facility should have initiated the CP for Resident 31's use of Seroquel upon admission for staff to determine what were the specific interventions on how to take care of Resident 31. During a review of the facility's P&P titled, Care Planning, revised 10/2023, the P&P indicated to ensure that a comprehensive person-centered CP is developed for each resident based on their individual assessed needs. The P&P indicated the CP will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. The P&P indicated the comprehensive CP must be completed within 7 days after completion of the Comprehensive admission Assessment and must be periodically reviewed and revised by a team of qualified persons after each assessment.

Based on interview and record review, the facility failed to conduct competencies (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) for two of five staff (Licensed Vocational Nurse 2 [LVN 2] and Registered Nurse 1 [RN 1]). This deficient practice had the potential for residents not to receive appropriate nursing care and services. Findings: During a concurrent record review and interview on 11/20/2025 at 10:16 am with the Director of Staff and Development (DSD), LVN 2's employee file was reviewed. The DSD stated LVN 2 worked fulltime in the facility since 3/21/2025. The DSD stated the DON was the one conducting staff competency for all licensed nurses. During a concurrent record review and interview on 11/20/2025 at 10:27 am with the Bookkeeper (BK), RN 1's employee file was reviewed. BK stated RN 1 worked per diem in the facility since 12/10/2002. BK stated the DON was the one conducting staff competency for RNs. During an interview on 11/20/2025 at 10:47 am with the facility's DON, the DON stated she was the one responsible for doing skills competency for all Licensed Nurses. The DON stated she did not get to complete LVN 2's competency and did not get her to sign the skills competency. During an interview on 11/20/2025 at 10:56 am with the facility's DON, the DON stated there was no clinical documentation that competency was done for RN 1. The importance of competency was to make sure that licensed staff was providing proper care and treatment to the residents. The DON stated, I will get back to you with the policy and procedure for staffing competency. During an interview on 11/20/2025 at 1:34 pm with LVN 2, LVN 2 stated that she has not done with her skills competency. The LVN 2 stated, That would be good if they will do a skills competency for me, to show that there is a room for improvement. Since I started here (facility), they did not do my skills competency. During a review of the facility's policy and procedure (P&P), titled Nursing Department - Staffing, Scheduling, and Postings, dated 10/1/2023, the P&P indicated to ensure an adequate number of nursing personnel are available to meet residents needs, the facility will employ sufficient Nursing staff on a 24-hour basis that meets the appropriate competencies, skills set, and required qualifications to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident.

Based on observation, interview, and record review, the facility failed to follow proper food storage handling practices by failing to label and discard expired food items stored in two of two facility's refrigerators. Facility failed to ensure: 1. Two (2) Caesar salad containers, one (1) fruit salad container, four (4) ham sandwiches, and three (3) peanut butter and jelly sandwiches from the kitchen refrigerator had use by date.2. Four (4) meat sandwiches observed inside the refrigerator located in the nursing station, had use by date and the date when the sandwiches were made. These deficient practices have the potential to result in pathogen (germ) exposure to residents and place residents at risk for developing foodborne illness (food poisoning) which can lead to hospitalization.During initial kitchen observation and interview with the Dietary Supervisor (DS) on 11/18/2025 at 8:00 AM, observed a total of three (3) Caesar salads and one (1) fruit salad inside the kitchen refrigerator. One (1) Caesar salad was labeled with a date of 11/17/2025. Two Caesar salads were not labeled. DS stated the salads were from yesterday, but confirmed that two (2) Cesar salads and one (1) fruit salad were not labeled with a date of when they were made or best by date. DS stated if there's no label indicating the use by date or best by date, the food item should be tossed to make sure it's safe to eat and to make sure it's not expired. DS stated, This way staff will know when food items are expiring and when not to serve to the residents. Per DS, residents could get sick and could have stomach issues such as vomiting or diarrhea if given expired food, which could harm the residents. During the same kitchen observation and interview with the DS on 11/18/2025 at 8:09 AM, observed a container of four (4) ham and cheese sandwiches and a container of three (3) peanut butter and jelly sandwiches with a label indicating made date of 11/15/2025 and use by date of 11/17/2025. DS stated that according to the labels on the containers, the food items were expired and should have been thrown away. Per DS, expired items should be tossed to make sure they're not given to the residents by accident causing them to get sick. During an observation inside the nursing station on 11/20/2025 at 9:09 AM, a small refrigerator was observed containing a plastic bag with 4 (four) meat sandwiches that did not have the resident's name, room number, and the date of when the sandwiches were made or use by date. During an interview inside the nursing station with License Vocational Nurse (LVN1) on 11/20/2025 at 9:10 AM, LVN1 stated the refrigerator contained snacks for residents. LVN1 stated the plastic bag containing four meat sandwiches inside the refrigerator, did not have a use by date or date when the sandwiches were made. LVN1 stated, I don't know when they were made, they should be individually labeled in the bag. We do hand them out to the patients, but I shouldn't because they are not dated. I don't know if they are expired and if the sandwiches are given to the patients, it can make them sick. During an interview with LVN2 inside the nursing station on 11/20/2025 at 9:26 AM, LVN2 stated, The sandwiches inside the refrigerator are not dated, they are given to the residents, but the sandwiches should have a use by date or at least a date of when the sandwich was made. If the sandwiches are expired or past the use by date and the resident eats them, it can make them sick and give them a stomachache. These sandwiches should not be given to the residents; it is not safe. It can cause residents to have vomiting and diarrhea. During a concurrent kitchen observation and interview with the [NAME] (CK1) on 11/20/2025 at 11:45 AM, CK1 stated, Food items in the kitchen must be labeled indicating the date of when the food is made because everyone needs to know when the food item expires. We can't use expired food, it's not good for the residents, they can get sick. During a concurrent kitchen interview with DS on 11/20/25 at 12:09 PM, DS stated, Labels are used to identify when food is not to be used or is expired. It is very important not to give expired food to the residents since it can make them sick, causing stomach issues like stomach cramping, nausea, and vomiting. If there is food that is not labeled or expired inside the refrigerator, it should be tossed immediately. DS stated the sandwiches inside the refrigerator in the nursing station area should have a date. Per DS, if the sandwiches are not dated, then they should be thrown out and not given to the patients. DS further stated if there is no date on the sandwiches, then there is no way to know how long these sandwiches have been there and they might be expired. During an interview with the Activity Director (AD) on 11/21/2025 at 7:46 AM, AD stated there were no sandwiches or food from the kitchen in the Activity room for the patients. AD stated the snacks provided for the patients in the activity room are usually sealed and have an expiration or used by date. AD stated the snacks provided to the patients are cookies and coffee. Per AD, the kitchen staff makes the sandwiches for the residents and leave them in the nursing station with the nurses. AD stated all food items provided to the patients need to be labeled with a use by or expiration date because if residents eat expired food, it can make them sick. During a review of the facility's Policy and Procedures (P&P), titled Food Storage, implemented on October 1, 2023, the P&P indicated the purpose of this policy is to establish guidelines for storing, thawing, and preparing food. Storage Guidelines indicated to Label and date storage products. During a review of the facility's undated P&P, titled Labeling/Date Marking and Safe Storage of Refrigerated & Frozen Foods, the P&P's Guidelines section indicated, Foods held in refrigerated or other storage areas shall be covered. Liquids and food which are prepared and not served shall be tightly covered, stored appropriately, clearly labeled, and dated. A written procedure shall be established and followed for the safe use of leftover foods. Spoiled or contaminated food shall not be served. The P&P indicated, Practices to maintain safe refrigerated storage include labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable) or discarded. The P&P further indicated any foods removed from original container will be properly labeled as follows: - - The name of the food item being stored and the date the food was removed from its original container and stored.

Based on interview and record review, the facility failed to:a. Maintain clinical records in accordance with accepted professional standards and practices for one of one sampled resident (Resident 1) by failing to accurately document the monitoring of side effects from antipsychotic medications.b. Ensure medical records were accessible to staff for two of two sampled residents (Residents 26 and 33).These deficient practices had the potential to result in inappropriate care planning, unrecognized service needs, and failure to follow resident's treatment needs.Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and insomnia (trouble falling asleep or staying asleep). During a review of Resident 1's History and Physical (H&P), dated 9/25/2025, the H&P indicated the resident did not have the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS – a federally mandated resident assessment tool) assessment, dated 9/8/2025, the MDS indicated Resident 1 was cognitively intact (ability to think). During a review of Resident 1's Order Summary Report (OS), dated 11/20/2025, the OS indicated Resident 1 had an active order to: Monitor side effects of antipsychotic agent every shift. Chart 0 for None or use 1st letters: TCAP, T=Tardive Dyskinesia (facial tongue movement); C=Cognitive Impairment (decreased mental status); A=Akathisia (Inability to sit still); P=Parkinsonism (tremors, drooling, rigidity) with an order date of 4/23/2025. During a review of Resident 1's Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 11/1/2025 through 11/30/2025, the MAR indicated the Resident 1's order to monitor the side effects of the antipsychotic agent every shift was documented incorrectly on November 1, 2, 3, 4, 5, 7, 8, 9, 10, 14, 15, 16, 17, 18, and 19 across various (day, evening, and night) shifts with a dash in place of a zero or letter. During a concurrent interview and record review on 11/20/2025 9:13 am with Licensed Vocational Nurse 1 (LVN 1), Resident 1's antipsychotic side effect monitoring order in the November MAR was reviewed. LVN 1 stated Resident 1 was on multiple antipsychotics, and the monitoring was documented incorrectly. LVN 1 stated it should be charted zero or the letter indicated for the symptom, T-C-A-P (T - Tardive Dyskinesia, C - Cognitive Impairment, A- Akathisia, P - Parkinsonism). LVN 1 stated it was important to chart properly so staff would know if Resident 1 was experiencing any symptoms and if she was, they could contact the psychologist for treatment modifications. During a concurrent interview and record review on 11/20/2025 at 10:21 am with the Director of Nursing (DON), Resident 1's antipsychotic side effect monitoring order in the November MAR was reviewed. DON stated it was charted incorrectly and the nurses should follow the order's instructions. DON stated this was done for accurate charting and monitoring of the resident. During a review of the facility's policy and procedure (P&P), titled Documentation-Nursing, dated 10/1/2023, the P&P indicated nursing documentation would be concise, clear, pertinent, and accurate. The P&P indicated checklists, flow charts, and other documentation would be used as appropriate. The P&P indicated medication administration records and treatment administration records are completed with each medication or treatment completed. b. During a review of Resident 26's admission Records, the admission Records indicated Resident 26 was admitted on [DATE] to the facility with diagnoses of Schizophrenia (a mental illness that is characterized by disturbances in thoughts); other long term(current) drug therapy. During a review of Resident 26's Minimum Data Set [MDS) - a resident assessment tool) dated 11/3/25 revealed that the resident is able to make himself understood and is able to understand others. Resident 26 is independent (completes the activities by himself with no assistance from a helper) with eating, toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear. During a review of Resident 33's admission Records, the admission Records indicated Resident 33 was admitted on [DATE] to the facility with diagnoses of schizophrenia, other stimulant abuse, uncomplicated; essential (primary) hypertension (high blood pressure with no specific medical cause). During a review of Resident 33's MDS dated [DATE] indicated the resident has the ability to make himself understood and to understand others. Resident 33 is independent (completes the activities by himself with no assistance from a helper) with eating, toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear. During a concurrent interview and record review for Resident 26 on 11/19/25 at 3:10 pm with [NAME] President of Clinic (VP of Clinic). She stated everyone is a level II in facility. VP of Clinic stated that for Resident 26, (PASRR) level I and referral letter were found in chart but PASRR level II was not found in the chart. VP of Clinic stated that PASRR is important because it identifies needed services, and without it, required care may be missed. During a concurrent interview and record review for Resident 33's physical chart on 11/18/2025 at10:40 am with Medical Records (MR), MR stated all the consents for this resident were not signed including advance directive. During a concurrent interview and record review of Resident 33's physical chart on 11/18/25 at 3:00pm with Minimum Data Set Coordinator (MDSC), MDSC stated she does not see advance directive in the chart. She also stated it is Important to have an advanced directive, so they know what to do, how to treat resident, and resident's wishes. The advance directive still needs to be done even if they are full code. During a Concurrent interview and record review of Resident 33's Physical chart on 11/19/25 at 11:43am with Medical Social Worker (MSW), she stated she had some advance directives in a separate folder and Resident 33's advance directive was there. During a review of the facility's policy and procedure (P&P) titled, Pre-admission Screening and Resident Review (PASRR), dated 10/1/2023, the P&P indicated, The PASRR results are maintained in the resident's medical record. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated 10/1/2023, the P&P indicated, upon admission, admission Staff or designee will inform the resident of their right to execute an Advance Directive Form, if one does not already exist. The P&P indicated if the resident has an Advance Directive, admission Staff or designee will place a copy of the Advance Directive in the resident's medical record and will notify the Director of Social Services of the existence of the Advance Directive.

Based on interview and record review, the Quality Assurance Performance Improvement (QA/QAPI - Quality Assurance/Quality Assurance and Performance Improvement, a data driven proactive approach to improvement used to ensure services are meeting quality standards) committee did not fulfill the requirement to have the Medical Director (MD) participate in the QAPI Committee meetings. This failure had the potential to negatively impact resident care coordination and ensure that resident care policies were implemented appropriately.Findings:During a review of the QAPI committee information, undated, the committee information indicated the MD was a member who attended the monthly and quarterly QA meetings. During a review of the Quality Assurance/Risk Management Plan, undated, the plan indicated the Medical Director would have a joint responsibility with the Administrator for the operation of the QA/Risk Management Program. During a concurrent interview and record review on 11/21/2025 at 10:54 am with the Director of Nursing (DON), the QAPI meeting sign-in sheets from January 2025 to October 2025 were reviewed. The QAPI sign-in sheets indicated the MD was not in attendance at any of the meetings. DON verified they were not signed by the MD and stated that QAPI meetings were conducted monthly and quarterly. DON further stated the MD should be involved in the meetings and during her employment at the facility, the DON had not seen the MD in attendance during their QAPI committee meetings. During a review of the facility's policy and procedure (P&P), titled QAPI Program, dated 10/1/2023, the P&P indicated its purpose was to ensure all services provided by the facility to residents met quality standards and the facility implemented and maintained an ongoing, facility-wide Quality Assurance and Performance Improvement (QAA) Program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolve identified problems. The P&P indicated the governing body of the facility should be ultimately responsible for the QAPI Program. The P&P indicated the QAA committee met at least quarterly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 9)'s target behavior was monitored for the use of Lithium Carbonate Oral Capsule (medication that treats bipolar disorder (mental disorder with periods of depression and periods of elevated mood) and the indication for use of Benztropine Mesylate Oral Tablet (Cogentin, medication used to treat symptoms of Parkinson's disease, such as tremors and stiffness, as well as involuntary movements caused by certain antipsychotic drugs [antipsychotic medication - drugs that are used to treat symptoms of psychosis]) was accurate for one of five sampled residents (Resident 9) as indicated in the facility's Policy and Procedure (P&P) titled Psychotherapeutic Drug Management. This deficient practice had the potential to result in the use of unnecessary psychotropic drug, which may result in significant adverse (harmful) consequences to Resident 9.Findings: During a review of Resident 9's admission Record (AR), the AR indicated Resident 9 was admitted to the facility on [DATE] with diagnoses that included anxiety (emotion characterized by an unpleasant state of inner turmoil) and schizophrenia (a mental illness characterized by disturbances in thought). During a record review of Resident 9's Order Summary Report (OSR), dated 6/19/2025, the OSR indicated for licensed staff to administer Lithium Carbonate Oral Capsule 300 milligram (mg), two (2) capsules by mouth in the evening related to schizophrenia. During a review of Resident 9's OSR dated 6/19/2025, the OSR indicated for licensed staff to administer Benztropine Mesylate Oral Tablet one milligram (mg-unit of measurement) one tablet by mouth, two times a day related to schizophrenia. During a review of Resident 9's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/22/2025, the MDS indicated Resident 9 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 9 was independent for eating, oral hygiene, toileting hygiene, shower, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent interview and record review on 11/19/2025 at 8:40 am with Licensed Vocational Nurse 1 (LVN 1) of Resident 9's medical records (PointClickCare - PCC, a cloud-based software), the OSR did not indicate the specific target behavior and there was no documented monitoring for Resident 9's target behavior for the use of Lithium Carbonate since 6/19/2025. LVN 1 stated it was important to monitor the target behavior of the residents every shift to determine if the medication was effective or not. During a concurrent interview and record review on 11/19/2025 at 8:46 am with LVN 1 of Resident 9's PCC, LVN 1 stated the indication for the use of Benztropine Mesylate Oral Tablet was not accurate. LVN 1 stated We don't give Cogentin for schizophrenia. It (Cogentin) should be administered to manage the side effects caused by antipsychotic medications. During a concurrent interview and record review on 11/20/2025 at 11:14 am with the facility's Director of Nursing (DON) of Resident 9's PCC records, the DON stated the target behavior should have been indicated in the physician's order for any psychotropic medications. The DON stated, per regulation, psychotropic medications were administered to a correct/accurate diagnosis and specific behaviors. The DON stated staff needed to monitor the target behavior every shift to monitor how the residents responded to the medication therapy and to avoid unnecessary use of the medication. During a review of the facility's P&P titled, Psychotherapeutic Drug Management, dated 10/2023, the P&P indicated, The psychotherapeutic medication order will include the following information: Diagnosis for the medication, indications and manifestations of the disorder treated. The P&P indicated, Nursing Responsibility: Will monitor the presence of target behaviors on a daily basis charting by exception (i.e., charting only when the behaviors are present).

Based on interview and record review, the facility failed to ensure one of one sampled resident's (Resident 6) Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment related to medications was accurately documented to reflect the resident's use of an antidepressant (medication used to treat depression). This failure had the potential to negatively affect Resident 6's plan of care and delivery of necessary care and services.Findings: During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 6's History and Physical (H&P), dated 7/18/2025, the H&P indicated the resident had fluctuating capacity to make medical decisions. During a review of Resident 6's Minimum Data Set assessment, dated 10/22/2025, the MDS indicated Resident 6 was cognitively intact (ability to think) and was taking an antipsychotic medication (a type of medicine used to help manage symptoms of certain mental health conditions, such as schizophrenia), no antidepressants were indicated in use. During a review of Resident 6's Order Summary Report (OS), dated 11/20/2025, the OS indicated Resident 6 had an active order for fluvoxamine maleate (antidepressant medication) oral tablet 25 milligrams (mg, a unit of mass ) to be given by mouth in the evening to augment clozapine (an antipsychotic medication), ordered on 7/17/2025. During a review of Resident 6's Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 11/1/2025 through 11/30/2025, the MAR indicated Resident 6 received fluvoxamine maleate from 11/1/2025 to 11/19/2025 each evening. During a concurrent interview and record review on 11/20/2025 9:47 am with Minimum Data Set Coordinator (MDSC), Resident 6's MDS dated [DATE] was reviewed. MDS did not indicate Resident 6 was on an antidepressant. MDSC stated it was an error that it was not documented and it was important to document accurately for each resident's individual needs. MDSC stated MDS was used to provide care and services for the residents and when submitted to The Centers for Medicare and Medicaid Services (CMS), it should be coded as accurately as possible. During an interview on 11/20/2025 at 10:10 am with the Director of Nursing (DON), DON stated MDS was used for continuity of care to allow the resident's care to be reflected through their MDS. DON stated it needed to be coded accurately to reflect that resident's care in the facility. During a review of the facility's policy and procedure (P&P), titled Documentation-Nursing, dated 10/1/2023, the P&P indicated nursing documentation would be concise, clear, pertinent, and accurate. The P&P indicated MDS completion as per CMS and Medicare guidelines.

Based on interview and record review, the facility failed to ensure that medication regimen review (MRR, a comprehensive evaluation of a resident's medications by a pharmacist to ensure the drugs are appropriate, effective, and safe) irregularity identified by the facility's Pharmacy Consultant was acted upon for one of five sampled resident (Resident 31). This deficient practice had the potential for resident harm due to the missed opportunity by the physician and the licensed staff to act upon the reported irregularities. Findings: During a review of Resident 31's admission Record (AR), the AR indicated Resident 31 was admitted to the facility on [DATE] with diagnoses that included anxiety and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 31's History and Physical (H&P), dated 7/24/2025, the H&P indicated the resident had fluctuating capacity to make medical decisions. During a review of Resident 31's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/28/2025, the MDS indicated Resident 31 had intact cognition for daily decision making. The MDS indicated Resident 31 was independent for eating, oral hygiene, toileting hygiene, shower, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 31's Order Summary Report (OSR), dated 11/19/2025, the OSR indicated to administer Gabapentin Oral Capsule (used primarily to calm overactive nerves to treat certain types of nerve pain and seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) 600 milligram (mg, a unit of mass) one tablet by mouth three (3) times a day for anxiety/restlessness related to Schizophrenia with an order date of 9/24/2025. During a review of a facility document, titled Note to Attending Physician/Prescriber, dated 9/17/2025, completed by the facility's Pharmacy Consultant, the note indicated The resident (Resident 31) has Gabapentin 600 mg three times a day for schizophrenia, which is a non-FDA (Food and Drug Administration, a public health protector by ensuring that a wide range of products are safe and effective for public use) labeled use of this medication for this particular indication. According to CMS guidelines, this can be considered duplicate, unnecessary therapy. Please evaluate the risks/benefits of this medication for this resident to keep the facility in compliance with regulations. During an interview on 11/20/2025 at 11:18 am, with the facility's Director of Nursing (DON), the DON stated the MRR was a monthly recommendation that licensed nurses supposed to carry out once received from the pharmacy. The DON stated there was no other clinical documentation that the monthly recommendation for Resident 31 from the pharmacist dated 9/17/2025 was carried out. The DON stated the purpose of MRR was for the pharmacy to review if residents were receiving proper medications and to avoid unnecessary drug use. During a review of the facility's Policy and Procedure (P&P), titled Drug Regimen Review, dated 10/1/2023, the P&P indicated The pharmacist will review each resident's medication regimen at least once a month to identify irregularities and to identify clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications. The consulting Pharmacist will report any irregularities such as unnecessary drugs (which include but are not limited to excessive dosage, excessive duration, inadequate monitoring, inadequate indications for use or adverse consequences of use) to the Facility's Medical Director, Director of Nursing, and the Attending Physician. The report will be submitted within 3 business days if review unless the irregularity is an emergent issue requiring immediate action if the irregularity is emergent, the Attending Physician will be contacted as soon as practicable from the time the irregularity is identified.

Based on observation, interview, and record review, the facility failed to ensure an active, ongoing antibiotic stewardship program (ASP - promote appropriate use of antibiotics while optimizing the treatment of infections, and reduce possible adverse events associated with antibiotic use) with monitoring, tracking, reviewing antibiotic use, and implementing interventions to promote appropriate antibiotic prescribing for the 13 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 8, Resident 9, Resident 21, Resident 26, Resident 31, Resident 33, Resident 36, and Resident 37).This failure has the potential to result in residents receiving unnecessary or inappropriate antibiotics, delayed identification of antimicrobial resistance (bacteria stop responding to medicine), avoidable drug reactions, and compromised resident health outcomes.Findings:During an interview on 11/19/2025 at 9:09 a.m. with Director of Staff Development (DSD), the DSD stated the facility does not have an ASP. The DSD was unable to identify any antibiotics screening used to treat infections for residents. During an interview on 11/19/2025 at 1:20 p.m. with [NAME] President of Clinical (VPC), the VPC stated the facility does not have an ASP in place. During a review of the facility's Quality Assurance / Risk Management Committee (QAC) minutes for August 2025, September 2025, and October 2025, the QAC minutes did not include the facility's ASP as indicated by Medication Monitoring with no documentation. During a record review on 11/19/2025 of the facility's policy and procedure titled Antibiotic Stewardship, dated October 1, 2023, indicated The Facility's leadership team will identify and Infection Preventionist (IP) who will collaborate with the Medical Director to oversee the ASP (Antibiotic Stewardship Program) for the facility.The IP and Medical Director will set standards for the use of antibiotics after reviewing antibiotic trends from the previous quarter and outcome reports.The IP reports ICC recommendations to the QAC during monthly/quarterly QAC meetings.

Based on observation, interview, and record review, the facility failed to:a. Ensure education was provided about the benefits and risks of the COVID-19 (an illness caused by the coronavirus and affects the lungs and breathing, and can make other parts of the body sick) vaccine, maintain documentation of vaccine education, refusals, or acceptance, and follow their policy for ongoing COVID-19 immunization review for 13 of 13 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 8, Resident 9, Resident 21, Resident 26, Resident 31, Resident 33, Resident 36, and Resident 37). b. Ensure staff documentation contained complete information demonstrating each staff member had been screened, provided with COVID-19 vaccine education, was offered the vaccine and had their current vaccination status recorded.This failure had the potential to result in residents and staff remaining unprotected against COVID-19, increased risk of serious illness, delayed identification of vaccine status, and missed opportunities to prevent the spread of infection within the facility.Findings:a. During an interview on 11/19/2025 at 9:09 a.m. with the Director of Staff Development (DSD), the DSD stated the facility has not offered COVID-19 immunizations and has not offered education on COVID-19 immunization to residents since January 2025 based on a decision by the Quality Assurance / Risk Management Committee (QAC). The DSD stated the facility has not tracked COVID-19 immunizations given to residents by the facility since January 2025. The DSD stated she was one of two Infection Preventionists (IP- a nurse whose main job is to maintain and oversee infection control policies and procedures in a nursing home, hospital, or clinic) for the facility. During an interview on 11/19/2025 at 1:20 p.m. with [NAME] President of Clinical (VPC), the VPC stated the facility has not immunized residents with the COVID-19 vaccine based on a decision by the QAC. The VPC stated the decision was not based from the guidance of All Facility Letter (AFL- message by state health department to give important updates, rules or instructions), Quality, Safety, and Oversight [QSO- message from Centers for Medicare & Medicaid Services (CMS- government agency sets the rules and for nursing homes and healthcare facilities are safely providing care to patients) informing nursing homes the federal rules, new guidance, or changes in how surveys are done], or Health Officer Order (HOO- an official order from the County or State Health Officer that facilities must follow, usually during outbreaks, emergencies, or public health issues). The VPC stated the facility has not offered education and has not tracked COVID-19 immunizations since January 2025. During a record review on 11/19/2025 at 4:00 p.m. of Quality Assurance / Risk Management Committee (QAC) minutes for August 2025, September 2025, and October 2025, the QAC minutes did not include the tracking and administration of COVID-19 immunization in the minutes. During a record review on 11/19/2025 the facility's policy and procedure titled COVID-19 Vaccination, dated June 15, 2021, indicated, When the COVID-19 vaccine is available, the facility will offer each resident.the COVID-19 vaccine unless it is medically contraindicated, or the individual has already been fully vaccinated.The facility will provide education to .residents or resident representatives.on the risks, benefits and potential side effects of the COVID-19 vaccine.The Infection Preventionist, or designee, will ensure that the resident's medical record includes documentation that at a minimum, the resident and/or resident representative was provided education regarding the vaccine they were offered if they accepted and received the vaccine or the reason for refusal.b. During an interview on 11/19/2025 at 9:09 a.m. with the Director of Staff Development (DSD), the DSD stated the facility has not offered COVID-19 immunizations to staff and has not offered education on COVID-19 immunization to staff since January 2025 based on a decision by the Quality Assurance / Risk Management Committee (QAC). The DSD stated the facility has not tracked COVID-19 immunizations given to staff by the facility since January 2025. During a record review on 11/19/2025 at 4:00 p.m. of Quality Assurance / Risk Management Committee (QAC) minutes for August 2025, September 2025, and October 2025, the QAC minutes did not include the tracking and administration of COVID-19 immunization in the minutes. During a record review on 11/19/2025 of Centers for Disease Control and Prevention (CDC -the nation's leading science-based, data-driven, service organization that protects the public's health) CDC.gov website indicated, CDC recommends everyone ages 65 years and older, including people who live and work in LTC settings, get 2 doses of an updated COVID-19 vaccine 6 months apart.During a record review on 11/19/2025 the facility's policy and procedure titled COVID-19 Vaccination, dated June 15, 2021, indicated, When the COVID-19 vaccine is available, the facility will offer each staff.the COVID-19 vaccine unless it is medically contraindicated, or the individual has already been fully vaccinated.The facility will provide education to staff on the risks, benefits and potential side effects of the COVID-19 vaccine .Facility staff will complete COVID-19 Vaccine-Staff Consent/Declination.The Facility will maintain consent/declination forms in the medical record in the personnel file for facility staff.

Based on observation, interview, and record review, the facility failed to ensure five out of 11 resident bedrooms accommodated no more than four residents in Rooms 25, 27, 29, 31, and 33. This deficient practice had the potential to result in inadequate space for residents' mobility and staff provision of care to the residents in these rooms.Findings: During a review of the facility's Client Accommodation Analysis (CAA) form, dated 11/19/2025, the CAA form indicated that Rooms 25, 27, 29, 31, and 33 were occupied by five ambulatory residents to be used as a bedroom. During a review of the facility's letter for the room waiver request, dated 11/19/2025, the letter indicated the facility was requesting a room waiver for rooms 25, 27, 29, 31, and 33. The letter indicated all the rooms had the same measurement of 464.96 square feet and had five beds in each room. The letter further indicated that each of these rooms had ample space to accommodate wheelchairs and other medical equipment, as well as space for mobility and movement of ambulatory residents. The letter indicated that there was adequate space for nursing care, and the health and safety of residents occupying these rooms were not in jeopardy. During an observation on 11/20/2025 at 11:14 am, the five resident bedrooms for which a waiver was requested (Rooms 25, 27, 29, 31, and 33) had adequate space available for the residents' use and movement. There were no adverse effects as to the adequacy of the spaces for nursing care, comfort, and privacy to the residents. There were no residents who expressed any concerns about the room sizes. During an interview on 11/20/2025 1:25 pm with Administrator (ADM), ADM verified that Rooms 25, 27, 29, 31, and 33 were occupied by five residents in each room. ADM stated, these rooms had adequate space to provide care for each resident and will not adversely affect the residents' health and safety. During a review of the facility's policy and procedure (P&P), titled Resident Rooms and Environment, dated 10/1/2023, the P&P indicated the facility must ensure resident rooms do not accommodate more than four residents.

Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from physical abuse (aggressive or violent behavior with the intention to cause physical harm) as indicated in the facility's policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program.This failure resulted in Resident 2 hitting Resident 1 on 3/1/25, 4/12/25, 5/7/25, and on 6/27/25 and resulted in Resident 1 feeling unsafe in the facility.A. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and was independent with activities of daily living (ADLs) and with walking.During a review of Resident 1's Change in Condition (CIC) Evaluation, dated 4/12/25 and timed at 1:10 pm, the CIC indicated Resident 1 was hit once in the face by another resident.During a review of Resident 1's Nurses Notes (NN), dated 4/12/25 and timed at 4:16 pm, the NN indicated Resident 1 informed the charge nurse (unknown) that another resident hit Resident 1 on the patio on 4/11/25.During a review of Resident 1's IDT note, dated 4/15/25 and timed at 10:39 am, the IDT note indicated Resident 2 hit Resident 1 in the face during supervised patio activities.During a review of Resident 1's CIC, dated 5/7/25 and timed at 12:35 pm, the CIC indicated Resident 1 came out of Resident 1's room and stated another resident came to Resident 1's room and hit Resident 1 once in the face.During a review of Resident 1's IDT note, dated 6/27/25 and timed at 9 pm, the IDT note indicated Resident 1 was struck by a male peer who was experiencing a psychotic break (a period where a person loses touch with reality). The IDT note indicated the incident was unprovoked by Resident 1.During a review of Resident 1's Physician's Progress Note (PPN), dated 6/27/25 and timed at 11:57 pm, the PPN indicated Nurse Practitioner (NP) 1 received a report from nursing staff (unknown) that Resident 2 hit Resident 1 while Resident 1 was in bed.During a review of Resident 1's Census List (CL), the CL indicated Resident 2 had been in room [ROOM NUMBER]-C since 3/18/25.B. During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and was independent with activities of daily living (ADLs) and with walking.During a review of Resident 2's untitled Care Plan (CP) Report, initiated on 3/1/25 and revised on 4/12/25 and revised on 5/7/25, the CP indicated Resident 2 punched a male peer in the nose on 3/1/25, punched a male peer in the face on 4/1/25, and punched a peer on the face on 5/7/25. The CP indicated the CP interventions were not revised after Resident 2 punched a male peer in the face on 4/12/25.During a review of Resident 2's untitled CP Report, initiated on 5/7/25 and revised on 6/7/25, the CP indicated Resident 2 hears voices which contributes to Resident 2's physical aggression. The CP indicated Resident 2 heard voices that peer had urinated in Resident 2's food so Resident 2 went to male peer's room and struck male peer. The CP indicated Resident 2 heard voices which led to an unprovoked assault on a male peer on 6/27/25. The CP interventions indicated Resident 2 was placed on one-to-one supervision for 24 hours on 5/8/25.During a review of Resident 2's IDT note, dated 5/7/25 and timed at 4 pm, the IDT indicated, on 5/7/25, Resident 2 heard voices that peer had urinated in Resident 2's food so Resident 2 went to male peer's room and struck male peer. The IDT indicated Resident 2 was placed on one-to-one supervision for 24 hours.During a review of Resident 2's Interdisciplinary Team (IDT, a team of professionals from various disciplines who work in collaboration to address the resident's care) note, dated 6/27/25 and timed at 9 pm, the IDT note indicated Resident 2 had an episode of physical aggression towards a male peer and Resident 2 was placed on one-to-one (1:1, one staff supervising 1 resident) supervision to ensure the safety of other residents.During a review of Resident 2's Change in Condition (CIC) Evaluation, dated 6/27/25 and timed at 11:45 pm, the CIC indicated Resident 2 was physically aggressive to Resident 1 while inside Resident 1's room.During a review of Resident 2's Nurses Notes (NN), dated 6/27/25 and timed at 11:57 pm, the NN indicated, on 6/27/25, Resident 2 was witnessed by Licensed Vocational Nurse (LVN) 2 inside Resident 1's room holding on to Resident 1's back while Resident 1 was in bed. The NN indicated Resident 2 was restraining Resident 1 and was not allowing (Resident 1) to move or get away.During a review of Resident 2's Physician's Progress Note (PPN), dated 6/27/25 and timed at 11:57 pm, the PPN indicated Nurse Practitioner (NP) 1 received a report from the nursing staff (unidentified) that Resident 2 hit Resident 1 while Resident 1 was in bed. The PPN indicated NP 1 ordered an antipsychotic (used to treat symptoms of psychosis, such as hallucinations, delusions, and disorganized thinking) medication to be given to Resident 2 every bedtime and for Resident 2 to be on one-to-one supervision. The PPN also indicated NP 1 ordered an emergency antipsychotic injection to be given to Resident 2 due to Resident 2's aggression and Resident 2 being a danger to others. During a review of Resident 2's Census List (CL), the CL indicated Resident 2 had been in room [ROOM NUMBER]-A since admission. During an interview on 7/8/25 at 1:45 pm with Resident 1, Resident 1 stated Resident 2 had hit Resident 1 two times prior to 6/27/25. Resident 1 stated on 6/27/25, Resident 1 was asleep in bed when Resident 2 hit Resident 1 for no reason. Resident 1 stated there was another incident which happened on another day (date unknown) when Resident 2 went inside Resident 1's room and hit Resident 1. Resident 1 stated there was another incident which happened two months ago (date unknown) when Resident 1 was watching television in the patio and Resident 2 hit Resident 1 unprovoked. Resident 1 stated Resident 1 did not feel safe in the facility and did not want to be in the facility. During an interview on 7/8/25 at 3:15 pm with the Director of Staff Development (DSD), the DSD stated there had been no room changes for Resident 1 and Resident 2 as indicated on the Census List. The DSD reviewed Resident 2's care plans which addressed Resident 2's incidences of physical aggression towards Resident 1 on 3/1/25, on 4/12/25, on 5/7/25, and on 6/27/25. The DSD stated the CP interventions did not include room changes and only placed Resident 2 on one-to-one supervision 24 hours after each incident. The DSD stated the CP interventions were not revised after Resident 2 punched a male peer in the face on 4/12/25. During an interview on 7/9/25 at 12:02 pm with Licensed Vocational Nurse (LVN) 1, LVN 1 stated staff (in general) redirect residents and try to keep Resident 1 and Resident 2 away from each other but the facility only has one hallway. LVN 1 stated if Resident 1 and or Resident 2 were on one-to-one supervision, it would be easier to keep the residents from each other.During an interview on 7/9/25 at 1 pm with the Director of Nursing (DON), the DON stated Resident 2 was not on one-to-one supervision before Resident 2 hit Resident 1 on 6/27/25. The DON reviewed Resident 2's care plans which addressed Resident 2's incidences of physical aggression towards Resident 1 and stated the facility should have implemented other interventions like removing Resident 1 from Resident 2's line of sight. The DON reviewed the facility's P&P titled, Abuse Prevention and Prohibition Program, dated 7/9/24. The DON stated the facility did not keep Resident 2 from hitting Resident 1 and should have placed Resident 2 on one-to-one supervision indefinitely to prevent Resident 2 from hitting others. The DON stated Resident 2 also refuses to take Resident 2's antipsychotic medication and Resident 2's responsible party (RP) did not give consent for Resident 2 to receive the antipsychotic medication as an injection which made it difficult to manage Resident 2's behavior. The DON stated the facility will now place Resident 2 on one-to-one supervision until the facility finds another solution to Resident 2's physical aggression towards Resident 1.During a review of the facility's P&P titled, Abuse Prevention and Prohibition Program, dated 7/9/24, the P&P indicated each resident has the right to be free from abuse and the facility is committed to protecting the residents from abuse by anyone. The P&P indicated, The facility conducts an ongoing review and analysis of abuse incidents and implements corrective actions to prevent future occurrences of abuse. Resident assessments and care planning are performed to monitor resident needs and address behaviors that may lead to conflict.

Based on interview and record review, the facility failed to ensure annual performance evaluations were completed for three of four Certified Nursing Assistants (CNAs) as indicated in the facility's policy and procedure (P&P) titled, Performance Evaluations. This failure had the potential to result in unrecognized skill deficiencies, placing residents at risk for receiving subpar care from staff. Findings: During an interview on 5/14/2025 at 2:20 PM with the Director of Staff Development (DSD), the DSD stated that CNA skills evaluations had not been completed consecutively or annually as required. The DSD stated, I just started last week and haven't had a chance to review everyone's (performance) evaluations. I know they haven't been done consistently. The DSD stated that performance evaluations were essential to identify gaps in understanding and ensure staff were competent to provide quality care. During a review of the personnel files for the following CNAs on 5/14/2025 indicated: 1. CNA 2 had no performance evaluation completed or 2024. 2. CNA 4 had no performance evaluations completed for 2022, 2023, and 2024. 3. CNA 5 had no performance evaluations completed for 2023 and 2024. During a review of the facility's P&P titled, Performance Evaluations, revised August 2010, the P&P indicated, The job performance of each employee shall be reviewed and evaluated at least annually.

Based on observation, interview, and record review, the facility failed to perform neurological (of, relating to, or affecting the functioning of the brain, spine or nerves) assessments for two of three sampled residents (Residents 5 and 6) following an incident with potential head trauma per facility's policy and procedure (P&P) titled, Neurological Assessments. This failure had the potential to result in delayed identification and treatment of neurological changes, placing Resident 5 and Resident 6 at risk for harm. Findings: 1. During a review of Resident 5's Admission Record (AR), the AR indicated the facility admitted Resident 5 on 3/28/2025, with diagnoses including Schizophrenia (chronic mental health condition characterized primarily by symptoms of hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression) and seizures (a sudden, temporary disturbance of the brain's electrical activity, leading to involuntary movements, changes in awareness, or sensory experiences). During a review of Resident 5's History and Physical (H&P), dated 3/29/2025, the H&P indicated Resident 5 had the mental capacity to make medical decisions. During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool), dated 4/4/2025, the MDS indicated Resident 5's cognitive (the ability to think and process information) skills for daily decisions making was intact. The MDS indicated Resident 5 was independent with activities of daily living. During a review of Resident 5's Progress Notes (PN) dated 5/12/2025, timed at 8 PM, the PN indicated at about 7:30 PM, on 5/12/2025, Resident 5 had a physical altercation with Resident 6 on the facility patio. The PN indicated Resident 5 and Resident 6 were in fist fight after verbal confrontation. The PN indicated Resident 5 was noted with minor cuts on the right hand and bruised right cheek. The PN indicated both parties were separated immediately. During a review of Resident 5's medical record on 5/14/2025, there was no documentation of neurological checks (neuro checks- evaluates brain and nervous system [network of cells, tissues, and organs that controls and coordinates bodily functions]) performed every 15 minutes for the first hour as required by the facility's policy. Resident 5's medical record indicated neuro checks were performed every hour for the 72 hours post incident. 2. During a review of Resident 6's AR, the AR indicated the facility admitted Resident 6 on 12/27/2024, with diagnoses including Schizophrenia (and insomnia (having trouble sleeping at night, staying asleep, or both). During a review of Resident 6's H&P, dated 12/28/2024, the H&P indicated Resident 6 lacked the mental capacity to make medical decisions. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive kills for daily decisions making was intact. The MDS indicated Resident 6 was independent with activities of daily living. During a review of Resident 6's PN dated 5/12/2025, timed at 8 PM, the PN indicated at about 7:30 PM, on 5/12/2025, Resident 6 had a physical altercation with Resident 5 on the facility patio. The PN indicated Resident 5 and Resident 6 were in fist fight after verbal confrontation. The PN indicated Resident 6 had no physical marks. The PN indicated both parties were separated immediately. During a review of Resident 6's medical chart on 5/14/2025, there was no documentation of neuro checks performed every 15 minutes for the first hour as required by the facility's policy. Resident 6's medical record indicated neuro checks were performed every hour for the 72 hours post incident. During a concurrent interview and record review on 05/14/2025 at 2:45 PM with the Director of Nursing (DON), Resident 5's and Resident 6's medical records were reviewed. The DON stated that neurological checks should be completed per facility policy when there was potential for head injury. The DON stated that neuro checks for both residents were done every 1 hour instead of every 15 minutes during the first hour, which did not meet the facility's policy requirements. During a review of the facility's P&P titled, Neurological Assessments, revised August 1, 2014, the P&P indicated, Neurological checks will be performed as follows or as otherwise ordered by the Attending Physician: a. Every 15 minutes for 1 hour, then; b. Every 30 minutes for 1 hour, then; c. Every hour for 2 hours, then; d. Every 4 hours for a total of 72 hours.

Based on observation, interview, and record review, the facility failed to post daily nurse staffing information in a prominent and accessible location as indicated in the facility's policy and procedure (P&P) titled, Nursing Department - Staffing, Scheduling & Postings. This failure had the potential to result in a lack of transparency regarding nurse staffing levels, affecting residents, families, and regulatory oversight. Findings: During an observation on 5/14/2025, at 9:45 AM, the daily nurse staffing posting was not posted outside the nursing station or anywhere in the facility. During an interview on 5/14/2025 at 2:20 PM with the Director of Staff Development (DSD), the DSD stated the DSD had not updated the required nurse staffing information since 5/1/2025. The DSD stated, I overlooked it. I just started last week and didn't realize it hadn't been updated. It should be posted daily. The DSD acknowledged that the lack of nurse staffing information posting reflected poorly on the facility's compliance and that posting daily Nursing Hours Per Patient Day (NHPPD- refers to the actual hours of work performed per patient day by a direct caregiver) was necessary for transparency and to demonstrate quality of care. During a review of the facility's nurse staffing posting log on 5/14/2025, no updates were documented after 5/1/2025. The facility's nurse staffing posting log confirmed that staffing data had not been posted for 13 consecutive days. During a review of the facility's P&P titled, Nursing Department - Staffing, Scheduling & Postings, dated October 1 2023, the P&P indicated, The Facility will post the nurse staffing data . on a daily basis at the beginning of each shift. Data must be posted in a clear and readable format and in a prominent place readily accessible to residents and visitors.

Based on interview and record review, the facility failed to protect residents' rights to be free from emotional abuse (non-physical behaviors that were meant to control, isolate, or frighten) and physical abuse (any intentional act causing injury or trauma to another person) for three of seven sampled residents (Residents 3, 4 and 7) when: a. Resident 3 punched Resident 4 in the face on 5/29/2024 in the patio.Resident 4 punched Resident 3 in the mouth on 5/29/2024 in the patio. This deficient practice resulted in Resident 3 and Resident 4 being subjected to emotional and physical abuse. Resident 4 became upset and punched Resident 3 on the mouth. Resident 3 sustained superficial cut (cuts that do not involve fat or muscle tissue and not bleeding heavily) measured approximately 0.5 centimeter (cm-unit of measurement) to right lower lip with slight bleeding. b. Resident 8 punched Resident 7 in the face on 6/3/2024 and Resident 8's care plan was not updated and/or revised after hitting another resident on 3/1/2024, 3/23/2024, 4/8/2024, 4/29/2024, and 6/3/2024.These failures had the potential for Resident 8 to hit other residents. Findings: a. During an interview on 6/3/2024 at 9:22 AM with Resident 3, in the activity room, Resident 3 stated Resident 4 called him (Resident 3) a name (to address a person with a name that is intended to be offensive) while they (Resident 3 and Resident 4) were at the patio (unable to recall date). Resident 3 stated in consequence, he messed (to deal with someone in a way that may cause anger or violence) with Resident 4. Resident 3 stated he tried to punch Resident 4, then Resident 4 punched him on the mouth, and he (Resident 3) sustained a cut on his right lower lip. During an interview on 6/3/2024 at 3:08 PM, Registered Nurse (RN 1) stated on 5/29/2024, he was in the patio and saw Resident 4 asking Resident 3 for chips. RN 1 stated Resident 3 refused to give away chips and told Resident 4 to leave him (Resident 3) alone. RN 1 stated he saw both residents (Resident 3 and Resident 4) walked away from each other. RN 1 stated he (RN 1) turned his back and went to the restroom, then when he returned, he heard a chant, Fight, fight, fight from the patio. RN 1 stated the residents (Resident 3 and Resident 4) were separated when he (RN 1) arrived in the patio. During the interview on 6/3/2024 at 3:08 PM, RN 1 stated he saw Resident 3 and Resident 4 in the patio with both arms up in the air (indicated to stop an activity or effort and admit that one cannot do anything to make a situation better). RN 1 stated he saw blood coming from Resident 3's lip, and RN 1 provided Neosporin (a first aid antibiotic to prevent infections caused by bacteria in minor cuts, scrapes, or burns on the skin) to Resident 3's right lower lip. RN 1 stated there was no other staff present in the patio when Resident 3 and 4 started fighting. During a concurrent interview and video review on 6/3/2024 at 3:30 PM with the Administrator (ADM), a video recording taken at the patio on 5/29/2024 at 5:02 PM was reviewed. The ADM stated the residents fighting on the video were Resident 3 and Resident 4. The video showed Resident 4 approached Resident 3 then Resident 3 hit Resident 4 on the face. Resident 4 punched Resident 3 in the mouth. No staff was seen in the video footage when Resident 3 and Resident 4 started fighting. The video showed RN 1 ran to Resident 3 and Resident 4 after Resident 3 and Resident 4 were separated. During the interview on 6/3/2024 at 3:30 PM, the ADM stated on 5/29/2024, he heard a scream, Fight coming from the courtyard (patio). The ADM stated he ran to the courtyard (patio) and witnessed RN 1 separating Resident 3 and Resident 4. The ADM stated RN 1 informed him that Resident 4 asked Resident 3 for chips, and he (Resident 4) stepped back and started being verbally aggressive towards Resident 3. The ADM stated Resident 3 had a cut and blood in the lip after Resident 3 and Resident 4 had physical fight. A review of Resident 3's Admission Record, indicated the facility admitted Resident 3 to the facility on [DATE], with diagnoses including anxiety (feelings of fear, dread, and uneasiness that might occur as a reaction to stress), insomnia (trouble falling or staying asleep), major depressive disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest), and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 3's Practitioner (any individual licensed to practice medicine) Progress Note (a written record that captures the details of a patient's health status, treatment progress, and any changes in their condition over time), dated 8/4/2023, indicated Resident 3 was alert and oriented (person's level of awareness) to person. A review of Resident 3's care plan for post trauma response (the state of an individual experiencing a sustained painful response to an overwhelming traumatic event), date initiated 11/15/2023 indicated Resident 3's care plan goal included Resident 3 will recognize and verbalized increased feelings of safety and will seek out support from staff members. A review of Resident 3's Minimum Data Set ([MDS]- a standardized resident assessment and care screening tool), dated 4/12/2024, indicated Resident 3's cognitive (the ability to think and process information) skills for daily decisions making was intact. The MDS indicated Resident 3 had serious mental illness (health conditions involving changes in emotion, thinking or behavior) and had put others at significant (serious) risk of physical injury. The MDS indicated Resident 3 had no impairment on all extremities, was independent with mobility, and does not require assistance from a helper in walking. A review of Resident 3's progress note, dated 5/29/2024 at 6:31 PM, indicated Resident 10 reported to RN 1 that Resident 4 punched Resident 3 in the mouth at the patio around 5 PM (on 5/29/2024). The progress note indicated Resident 3 got up from his seat and fought Resident 4 because Resident 4 was talking trash (to talk in an insulting way) to Resident 3. The progress note indicated Resident 3 sustained superficial cut to right lower lip with slight bleeding. A review of Resident 3's Skin Observation Checks, dated 5/29/2024 at 8:06 P.M., indicated Resident 3 had right lower lip superficial laceration (cut) approximately 0.5 centimeter (cm-unit of measurement) with no active bleeding. A review of Resident 3's Order Summary Report, dated 6/3/2024 indicated the following active orders: - Assaultive (violent physical actions which were likely to cause immediate physical harm or danger to an individual or others) precautions for Resident 3, ordered on 4/4/2023. - Suicidal precautions (placing the client in the least restrictive, safe, and monitored environment that allowed for the necessary level of observation) for Resident 3, ordered on 4/4/2023. - Behavioral monitoring (a proactive approach used to detect threats by establishing a system behavior baseline and checking for abnormalities) for episodes of aggressive behaviors for Resident 3, ordered on 3/13/2024. - Apply Neosporin to Resident 3's right lower lip topically (applied directly to the skin) one time a day for five (5) days, ordered on 5/29/2024. A review of Resident 4's Admission Record, indicated the facility admitted Resident 4 to the facility on [DATE], with diagnoses including anxiety, insomnia, and stimulant (a drug that increases bodily activity) abuse. A review of Resident 4's physician order, date ordered 3/20/2024, indicated an order for behavioral monitoring for aggressive behaviors. A review of Resident 4's MDS, dated [DATE], indicated Resident 4's cognitive skills for daily decisions making was intact. The MDS indicated Resident 4 had a serious mental illness. The MDS indicated Resident 4 had no impairment on all extremities, was independent with mobility and does not require assistance from a helper in walking. A review of Resident 4's Practitioner Progress Note, dated 4/14/2024, indicated Resident 4 was alert and oriented (person's level of awareness) to person. A review of Resident 4's progress note, dated 5/26/2024 at 7:19 PM, indicated Resident 4 was gesturing with his (Resident 4) fists towards a peer (unidentified) at the patio. A review of Resident 4's progress note, dated 5/28/2024, indicated Resident 4 has been provoking peers (unidentified) and being a bully (a person who habitually seeks to harm or intimidate those whom they perceive as vulnerable) with other residents. A review of Resident 4's progress note, dated 5/29/2024 at 2:16 PM, indicated Resident 4 had been trying to annoy (irritate, disturb, or bother) and provoke (to anger, enrage, exasperate) other (unidentified) residents. A review of Resident 4's progress note, dated 5/29/2024 at 5:45 PM, indicated Resident 4 was talking Crap (nonsense or lie) to Resident 3 in the patio around 5 PM, and Resident 3 got up from his chair to fight Resident 4. The progress note indicated Resident 4 punched Resident 3 on his (Resident 3) mouth at the patio. A review of Resident 4's Social Service progress note, dated 5/30/2024 at 1:52 PM, indicated Resident 4 informed Social Service (SS) 1 that Resident 3 tried to hit him (Resident 4) first. A review of Resident 4's care plan, titled Resident to Resident Altercation, created on 5/29/2024, indicated an intervention for staffs to intervene as needed to protect the rights and safety of others. A review of Resident 4's progress note, dated 6/2/2024 at 3:58 PM, indicated Resident 4 had been threatening peers on the patio. A review of facility's policy and procedure (P&P) titled Abuse Prevention and Prohibition Program, revised on 10/1/2023, indicated each resident has the right to be free from abuse. The facility has zero-tolerance (a policy of not allowing any violations of a rule or law) for abuse. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse. The P&P indicated signs and symptoms of physical abuse included abrasions or lacerations. 34273 b. During a review of Resident 7's Admission Record (AR), the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions, and relate to others) and depression (persistent feelings of sadness and loss of interest). During a review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/15/2024, the MDS indicated Resident 7's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and Resident 7 walked independently with steady gait. The MDS indicated Resident 7 was independent with oral hygiene, toileting hygiene, personal hygiene, and with upper and lower body dressing. During a review of Resident 7's Change in Condition Evaluation (CICE), dated 6/3/2024, the CIC indicated a Certified Nursing Assistant (CNA) reported to the charge nurse Resident 7 was punched in the face and Resident 7 had a nose bleed (blood vessels in the lining of the nose bursts). The CIC did not indicate who hit Resident 7. During a review of Resident 7's untitled care plan dated 6/3/2024, the care plan indicated Resident 7 was punched in the face by a male peer. During a review of Resident 8's AR, the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental condition that causes both a loss of contact with reality (psychosis) and mood problems). During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 had some difficulty with decision making in new situations only and walked independently with steady gait. The MDS indicated Resident 8 was independent with oral hygiene, toileting hygiene, personal hygiene, and with upper and lower body dressing. During a review of Resident 8's CICE, dated 6/3/2024, the CICE indicated a CNA reported to the charge nurse Resident 8 punched a male peer in the face. During a review of Resident 8's untitled care plan initiated on 11/13/2023, the care plan indicated Resident 8 was yelling in the patio, defiant towards staff, name calling, disruptive in the hallway and non-redirectable on 3/2/2024. The care indicated Resident 8 demanded breakfast, yelling and shouting in a fighting stance on 3/9/2024. The care indicated Resident 8 attempted to spit at male peer on 3/16/2024. The care plan indicated Resident 8 attempted to punch male peer behind the head on 3/27/2024. The care plan indicated Resident 8 hit staff member on the nose on 4/17/2024. The care plan indicated Resident 8 spit on a staff on 5/2/2024. The care plan indicated Resident 8 hit a resident in the face on 6/3/2024. The care plan interventions initiated on 11/13/2023 included to Assist the client in examining alternatives to acting out behavior, discuss and speak with patient the effectiveness and side effects of medications twice a week and encourage participation in community and coping skills groups twice a week. The care plan interventions also included the use of PRN (as needed) medications if he client's level of agitation is high, assess the client's behavior that indicates agitation is increasing and encourage verbalization of feelings rather than acting out and for staff to maintain a calm, nonthreatening manner for the Resident 8. The care plan was not revised and/or updated after Resident 8's behaviors on 3/2/2024, 3/9/2024, 3/16/2024, 3/27/2024, 4/17/2024, 5/2/2024, and 6/3/2024. During a review of Resident 8's untitled care plan initiated on 2/23/2024, the care plan indicated Resident 8 hit a male peer on the back of the neck on 2/23/2024. The care plan indicated Resident 8 hit a male peer on the right ear on 3/1/2024. The care plan indicated Resident 8 slapped a male peer on the face on 3/23/2024. The care plan indicated Resident 8 hit a male peer on the head on 4/8/2024. The care plan indicated Resident 8 slapped a male peer on the right side of the head on 4/11/2024. The care plan indicated Resident 8 hit a peer on the back of the head on 4/29/2024. The care plan indicated Resident 8 punched a peer in the face on 6/3/2024. The care plan interventions initiated on 2/23/2024 included to Administer and monitor the effectiveness of medications, evaluate for side effects of medications and intervene as needed to protect the rights and safety of others. The care plan interventions also included to approach in a calm manner, divert attention, remove from situation, and take to another location. The care plan interventions also included to monitor and modify environment for external contributors to behavior, monitor/document/report to the MD (medical doctor) of danger to self and others and Psychiatrist/psychologist consult as indicated. The care plan intervention initiated on 4/11/2024 included for the resident to check in with Activity Coordinator for activities inside the room and with Mental Health Worker for groups in the patio. The care plan was not revised and/or updated after Resident 7 hit another resident on 3/1/2024, 3/23/2024, 4/8/2024, 4/29/2024, and 6/3/2024. During an interview on 6/4/2024 at 11:58 am with Resident 7, Resident 7 stated Resident 7 had seen Resident 8 fought with other residents and staff before. During an interview on 6/4/2024 at 12:15 pm with the Director of Staff Development (DSD), the DSD stated on 6/3/2024, CNA 5 reported Resident 8 hit Resident 7 in the face. The DSD stated Resident 7 had a nose bleed after Resident 8 hit Resident 7. The DSD stated Resident 7 was calm and did not get into fights with other residents. The DSD stated Resident 8 was unpredictable and would all of a sudden hit (other) people. During an interview on 6/4/2024 at 12:32 pm with Mental Health Worker 1 (MHW 1), MHW 1 stated Resident 7 was calm. MHW 1 stated Resident 7 has not had any arguments or fights with other residents or staff before. MHW 1 stated Resident 8 was unpredictable. Resident 8 could suddenly change from a good mood to being agitated, mad, and throwing punches. MHW 1 stated Resident 8 had been involved in multiple fights and arguments with other residents and staff. During an interview of 6/4/2024 at 12:43 pm with Social Worker 1 (SW 1), SW 1 stated Resident 8 was impulsive, and Resident 8's behavior made it challenging to find placement for Resident 8. During an interview on 6/4/2024 at 12:58 pm with CNA 5, CNA 5 stated he was doing a head count on 6/3/2024 and walked towards the patio door where Resident 8 was standing. Resident 7 was walking out to the patio to get coffee, and when Resident 7 passed Resident 8, Resident 8 turned around and hit Resident 7 in the face. CNA 5 stated Resident 7 sustained a nose bleed. CNA 5 stated Resident 8 fought with residents and staff all the time. During a concurrent interview and record review on 6/4/2024 at 1:55 pm with the Director of Nursing (DON), the DON reviewed Resident 8's care plans. The DON stated every time Resident 8 was involved in an altercation, Resident 8's care plan needed to be revised. The DON stated care plans needed to be revised for any change in condition (CIC). The DON stated any altercation and/or behavior was considered a CIC. The DON stated it was important to determine a specific and individualized plan of care appropriate for the resident. During a review of the facility's Policy and Procedure (P&P) titled Abuse Prevention and Prohibition Program, dated 10/1/2023, the P&P indicated, Each resident has the right to be free from abuse . The Facility has zero-tolerance for abuse .The Facility promptly and thoroughly investigates reports of resident abuse . The Facility will reassess the resident following the investigation to determine if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences have changed as a result of the incident and initiate or update the care plan .

Based on observation, interviews and record review, the facility failed to ensure the resident environment is free of hazards as possible and ensure its residents, who have mental illness and behavioral problems, receive care and services t o prevent injuries from resident-to-resident altercations for one of three sampled residents (Resident 1), including: 1. Failure to ensure Certified Nursing Assistant 2 (CNA 2) provided the necessary supervision to the residents when they gathered in the patio, including Residents 1 and 2, to prevent Resident 2 from physically assaulting Resident 1. 2. Failure to implement the facility's policy on Monitoring of Residents in the Patio, by not providing continuous supervision of the residents to ensure the residents' health, welfare, and safety. 3. Failure to implement the facility's policy on Maintenance Services, by not maintaining the chairs' armrests in good condition to protect the health and safety of the residents. As a result, on 10/19/18 at 10 p.m., while CNA 2 was playing chess with Resident 3 instead of monitoring residents in the patio , Resident 2 attacked Resident 1 with a piece of wood he took from a loose armrest of a chair in the television (TV) room, hit Resident 2 in the head and the body. Resident 1 sustained skull fractures (broken bones) and was transferred to General Acute Care Hospital 1 (GACH 1) by the paramedics (911 - emergency transportation). Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - standardized assessment and care planning tool), dated 3/21/18, indicated Resident 1 had no memory problems and was able to walk, eat, dress, and use the toilet without staff assistance. A review of the Admission Record indicated Resident 2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of Psychosocial Admission assessment dated [DATE], indicated Resident 2 had a history of [REDACTED]. A review of the MDS assessment, dated 9/19/18, indicated Resident 2 had no memory problems and was able to walk, eat, dress, and use the toilet without staff assistance. A review of the Plan of Care developed for Resident 2's danger to others related to the assault of a peer on 10/18/18, indicated as a goal, for Resident 2 to decrease assaults toward others. The intervention included assessing for signs and symptoms of assaultive behavior and encouraging the resident to vent feelings before striking out occurs. A review of the Interdisciplinary Progress Notes, dated 10/19/18, indicated Resident 2 struck Resident 1 on the back and the right side of the head with a piece of wood from a chair. Resident 1 was on the ground with blood coming out of the right ear and the resident was taken to GACH 1 by paramedics. A review of GACH 1's ENT (Ear - Nose - Throat) Consultation, dated 10/20/18, indicated Resident 1 had a Computerized Tomography scan (CT scan - series of x-ray images taken from different angles around the body and uses computer processing to create cross-section (slices) images), and the results indicated: 1. Right temporal bone (sides and base of the skull - head bone) fracture involving mastoid, tympanic and petrous segment (different section of the temporal bone) with possible extension to the right carotid canal (passageway in the temporal bone through which the internal carotid artery (blood vessel) in the neck). 2. Trace extra-axial hemorrhage (small amount of bleeding that occurs within the skull but outside of the brain tissue), and trace pneumocephalus (small amount of air or gas within the cranial cavity) underlying the right temporal bone fracture. 3. Non-displaced [MEDICAL CONDITION] occipital bone (bone located on the back of the skull). 4. Right temporal soft tissue contusion (a collection of blood outside a blood vessel). A review GACH 1's Discharge Instructions, dated 10/20/18, indicated Resident 1 had a [MEDICATION NAME] head trauma (physical head injury) and the resident was discharged back to the facility with [MEDICATION NAME]-[MEDICATION NAME] (antibiotic for the ear). A review of the Interdisciplinary Progress Notes, dated 10/21/18, indicated Resident 1 had a red stain on his pillow and staff noted blood was coming out of the resident's right ear. Resident 1 felt like passing out and the Physician ordered to send Resident 1 back to GACH 1 for further evaluation. A review of GACH 1's Discharge Instructions, dated 10/21/18, indicated Resident 1 was bleeding from the right ear. The discharge instructions indicated for staff to continue with the antibiotic eardrops, follow with the ENT specialist in two to three weeks, and return to the emergency department if Resident 1 experience any new or worsening symptoms. A review of the facility's Abuse Investigation Reporting form, dated 10/22/18, indicated on 10/19/18 at 10:20 p.m., Resident 2 hit Resident 1 on the right side of the face and ear with a piece of wood. Resident 2 was placed in a restraint (a measure to keep someone under control or within limit). During an observation on 10/30/18 at 2:25 p.m., there were five residents watching television (TV) in the TV Room, and there was no staff supervising the residents. During an observation 10/30/18 at 3:25 p.m., Resident 1's right lower peri-orbital (surrounding area of the eye) area had an uneven purplish discoloration and dry, scratches. Resident 1's right lower part of the sclera (white portion of the eye) was red. During a concurrent interview, Resident 1 stated his right ear was painful to touch and when he slept on his right side. Resident 1 explained he was watching Resident 3 playing chess with CNA 2 and after that he could not recall anything. During an interview on 10/30/18 at 3:40 p.m., CNA 1 stated she was assigned to monitor the patio with CNA 2. CNA 1 stated CNA 2 was playing chess with Resident 3 and five other residents were around them. CNA 1 stated Resident 1 was seated next to Resident 3. CNA 1 stated she heard Resident 4 screaming and saw both Residents 1 and 2 on the ground. Resident 2 had a wood stick in his right hand. During an interview on 10/30/18 at 4:05 p.m., Licensed Psychiatric Technician 1 (LPT 1) stated it was not appropriate for CNA 2 to be playing chess with Resident 3 and CNA 2 main responsibility was to supervise/monitor residents. During an interview on 10/30/18 at 4:32 p.m., the Director of Nursing (DON) stated CNA 2 should not play with residents. During an interview on 10/30/18 at 4:42 p.m., CNA 2 stated on 10/19/18, at 10 p.m., he was assigned to monitor the residents in the patio area. Resident 2 came from nowhere with a piece of wood and started hitting Resident 1 on the head and body. Resident 2 got the wood from the armrest of a chair in the TV Room. During an observation on 10/30/18 at 4:47 p.m., a similar piece of wood (as the one used by Resident 2) was on the armrest of a chair in the TV room which measured 58 centimeters (cm) in length by 3 cm in height by 6.5 cm in width. During an interview on 10/31/18 at 3:35 p.m., Resident 3 stated he witnessed Resident 2 beating Resident 1's head and body, then CNA 2 subdued (restrained) Resident 2 to the ground and he (Resident 3) held Resident 1's head off the ground because Resident 1 was bleeding a lot from the head. During an interview on 10/31/18 at 4:33 p.m., CNA 3 stated after the incident occurred, he found three more Wobbly (loose) armrests, and he could easily remove a piece of wood from the armrest. During a telephone interview on 11/19/18 at 8:46 a.m., Maintenance 1 stated he checked the furniture on a weekly basis but could not provide documentation because he did not have a repair log. A review of the facility's undated policy and procedure, titled Monitoring of Residents in the Patio, indicated to provide continuous supervision of residents to ensure resident's health, welfare, and safety. A review of policy titled, Maintenance Services, dated 2/01/17 indicated its purpose was to protect the health and safety of the residents, visitors, and facility staff and The Maintenance Department maintains all areas of the building, grounds, and equipment.

Based on observation, interview, and record review, the facility failed to protect the facility's residents from possible abuse, neglect, and/or mistreatment by failing to: Implement their policy and procedure to perform background checks for the facility's employees (EMP) before they got hired. Five of five employee files reviewed (EMP 1, 2, 3, 4, and 5), out of 86, did not have a background check before they were hired. This failure had the potential to expose residents to employees who might have had history of abuse, neglect, and/or mistreatment of [REDACTED]. As a result of the facility's failure to prevent abuse and protect the residents from possible abuse, neglect, and/or mistreatment by not checking the background screenings for all the facility's employees, an immediate jeopardy (IJ, a situation which may cause or is likely to cause serious injury, serious harm, serious impairment, or death and needs immediate correction) was called on 3/18/17, at 7:23 p.m. The administrator and director of nursing (DON) were notified of the immediate jeopardy findings. On 3/20/17, at 9 a.m., the facility submitted an acceptable plan of correction and the IJ was abated (lifted) on 3/21/17, at 12:10 p.m., for the following reasons: (a) Live scan (a system where an applicant's criminal history is checked using his/her scanned fingerprints) or other form of background check will be required for new employees. Applicants need to submit a live scan before they can get hired. All existing 86 employees were being screened using a live scan or other background check method. Findings: During a record review during offsite preparation (survey team meeting, prior to entering the facility, to review reports and other related documents), on 3/16/16 at 4:30 p.m., there was an entity reported incident (ERI, unusual incidents reported by the facility to the Ombudsman (resident's advocate), local law enforcement (police), and state licensing agency (DPH, department of public health)) that was received 07/11/16 by DPH indicating that on 07/03/16 at 9:35 p.m., in the hallway next to the utility room, a resident, while in a medication line (residents forming a line to wait for their turn to receive and take their medication/s), suddenly punched a certified nursing assistant (CNA) in the face with his fist because he did not want to take his medication. The report also indicated that the resident had an abrasion on the bridge of his nose, and that on 07/04/16 the DON received a report from one of the staff members, who witnessed the incident, that the CNA who was hit by the resident also struck back at the resident in the face and abdomen. Videotape recordings were reviewed and were able to confirm the incident and that CNA struck the resident. The CNA according to the report was terminated effective 7/11/16. During an interview with the director of staff development (DSD), on 3/16/17 at 4:20 p.m., she stated she does not screen the criminal backgrounds of all the employees that the facility hires. The DSD stated if they are a licensed staff such as a registered nurse (RN), licensed vocational nurse (LVN), licensed psychiatric technicians (LPT), or CNA, she will check their license or certificate to see if there is a record on the state licensing boards. For non-licensed staff in housekeeping, maintenance, dietary, and activities department, the DSD stated that she would only check their professional and/or personal reference. During an interview, on 3/18/17 at 3 p.m., with the DON, she stated she was unaware that all staff should have a background check when they are hired. During a record review of the employee files for EMP 1 who was hired on 10/17/16 as a LPT, there was no background screening done. For EMP 2 who was hired on 10/17/16 as a CNA, there was no background screening done. For EMP 3 who was hired on 11/7/16 as a CNA, there was no background screening done. For EMP 4 who was hired on 11/7/16 as a CNA, there was no background screening done. For EMP 5 who was hired on 11/28/16 as a CNA, there was no background screening done. During observations throughout the survey, interactions between the residents and the RNs, LVNs, LPTs, and CNA were observed, and there was no abuse and/or mistreatment seen throughout the survey. A record review of the facility's undated policy and procedure titled, Background Screening Investigations, indicated the facility conducts employment background screening checks, reference checks on individuals making application for employment with the facility. The staff development director, or designee, will conduct employment background checks, reference checks on persons making application for employment with this facility. Such investigations will be initiated within three days of employment or offer of employment.

Based on observation, interview and record review the facility failed to have accessibility and training to all of their staff in case of the emergency. 1. The dietary staffs were the only ones aware of where the key was located to open the dry food storage area where the emergency food was stored. 2. The facility's staffs were unaware where the emergency menu was located in case of an emergency. 3. The facility's staffs were unaware of how to get the water out of the hot boiler tanks (a water tank used for storing hot water for space heating or domestic use) and purify it in case of an emergency. As a result of the facility's failure to protect all residents in case of an emergency by not training and having accessibility to the emergency food supply, an immediate jeopardy (IJ, a situation in which the facility's non-compliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called on 3/18/17, at 7:23 p.m. The administrator and director of nursing (DON) were notified of the immediate jeopardy findings. On 3/20/17, at 9 a.m., the facility submitted an acceptable plan of correction and the IJ was abated (lifted) on 3/20/17, at 11:23 a.m., for the following reasons: (a). The keys for the storage room, freezers, and refrigerators will be available to all staff. It will be located on top of the dietary desk. An open key box will be installed 3/19/17. (b). An in-service (training given to employees during the course of employment) will be given to all staff starting, 3/18/17 at 10 p.m. about the location of the keys to the food storage, freezer, and refrigerators including the 3 day emergency menu with instructions. A copy of the 3 day emergency menu will be provided to all the staff. (c). All emergency water bottles will be located in a separate room labeled Emergency storage Area at the staff lounge. An in-service will be given to all staff starting 3/19/17. Findings: 1. During an observation of the initial kitchen tour, on 3/16/17 at 7:30 p.m. with registered nurse (RN 1), the door to get in the kitchen and the dry food storage, and the six door fridge inside the kitchen was locked and nobody knew where the keys were. RN 1 was unaware to where the key was located to get inside. During an interview, on 3/16/17 at 8:20 p.m., with the Administrator (ADM) she stated she had to get a hold of someone in the dietary department to find out where the keys where located to open the kitchen and the dry food storage area and the six door fridge. The ADM stated she did not know where the keys where located. The ADM stated there was theft in the kitchen that is why they lock everything up at night. During an observation with the ADM, on 3/16/17 at 8:20 p.m., the dry food storage room housed the emergency food supply. The food was being stored on metal racks in the back towards the left side of the storage room. During an interview with the dietary dishwasher (DW), on 3/16/17 at 8:40 a.m., she stated she knew where the keys where located for the dry food storage area and for the six door fridge. She said they keep the keys on top of the stove's hood. The DW stated the dietary staffs are the only ones that know where the keys are located. During an interview on 3/18/17 at 7:05 p.m., with the dietary supervisor (DS), she stated there is only one copy of the keys for the dry storage area and it is kept on top of the stove's hood inside the kitchen. During an interview, on 3/18/17 at 7:09 p.m., with the ADM she stated the kitchen staffs were the only ones that knew where the key was located for the kitchen and the dry storage area. The ADM stated maybe the key should be accessible to everyone and she will ask her dietary consultant for some guidance. The ADM stated maybe we would notify the charge nurses on the floor to where the kitchen and dry storage room key is located. A review of the facility's Disaster and Preparedness Plan Tool dated 3/17/17 indicated the emergency food supplies are stored in the dietary storage room area. 2. During an observation with the ADM in the dry storage room on 3/16/17 at 8:20 p.m., the Food for Disaster Menu was posted on a bulletin board in the dry storage room. During an interview with the DS on 3/18/17 at 6:50 p.m., she stated she did not think any other staff knew where the disaster menu was located. The DS stated she might be the only one who knew where it is located. During another interview, on 3/18/17 at 7:10 p.m., with the ADM she was unaware where the emergency menu was located. The ADM stated the food menu for a disaster should be available to all staff. 3. During an initial tour of the facility with a registered nurse (RN 1), on 3/16/17 at 6:35 p.m., RN 1 stated that the emergency water supply was in the facility's staff break room and stored against the wall on the water bottle racks. RN 1 confirmed that there were some bottles that were empty four of 27 five gallon bottles). RN 1 stated that stuff must be drinking from the supply. During an interview, on 3/17/17 at 8:25 p.m., a certified nursing assistant (CNA 1) stated that the emergency water supply was located in the employee break room and has not had a disaster drill in a while. CNA 1 also stated that staff use the water from the emergency water supply. During another interview, on 3/18/17 at 2:45 p.m., CNA 2 stated that the emergency water supply was in the break room and the staff drink from the same supply. During an observation and interview, on 3/18/17 at 6:50 p.m., the dietary supervisor (DS) stated that the facility had two boilers outside by the kitchen. The DS stated she was never trained on how to get the water out of the boiler in an emergency disaster situation. The DS did not know if she would have to purify the water from the boiler tank before drinking. The DS stated she did not see the instructions that were posted on one of the boiler tanks and did not know where the items needed to get the water out of the boiler were located. Next to the boiler with the instructions was a five gallon bucket with a lid. Upon opening the bucket there was tubing inside for syphoning. There was no chemical for treatment of [REDACTED]. During an interview, on 3/18/17 at 8:05 p.m., the maintenance assistant (MA) stated that he did not know how much water needed to be kept aside for emergency water supplies. The MA stated he did not know how many people he needed to keep on site in case of an emergency. The MA stated he was not trained for emergency preparedness with regards to the water supply and that he would drink the water straight from the boiler tank before any purification was completed.