Every finding on record at San Diego Post-Acute Center

Based on observation, interview and record review, the facility failed to ensure one of one resident (Resident 1) was free from sexual abuse when:Maintenance Personnel (MP) kissed Resident 1's forehead without consentMP made contact with Resident 1's upper extremities without consentMP pulled Resident 1's pants without consentMP sat on Resident 1's bed without consentAs a result, MP had continued access to Resident 1These failures to identify and report allegations of abuse did not protect Resident 1 Cross reference F600 F607 F609 F610Findings:On 5/11/2026 at 8 A.M. an unannounced onsite was conducted to investigate one facility reported incident of alleged abuse. On 5/19/2026 additional facility reported incident of alleged abuse for the same parties involved (MP to Resident 1). A review of the facility's Report of Suspected Dependent Adult/Elder Abuse (S0C 341, a report submitted to the State agency to report allegations of abuse) dated 4/29/26, indicated Resident 1 alleged MP inappropriately caressed her arm and sat on her bed in close proximity to her while she was seated in her wheelchair and reported type of abuse with check marked sexual. A review of the facility's Report of Suspected Dependent Adult/Elder Abuse dated 5/13/26 indicated .Reopened investigation due to employee admission /inconcistant[sic] statements regarding kissing a resident. During CDPH interview, employee admitted to kissing [Resident 1] on the forehead. Facility reported type of abuse with check marked sexual. A review of the facility's Midnight Census Report dated 5/12/26 indicated there were currently 220 residents in the facility. A review of the facility's Midnight Census Report dated 6/15/26 indicated there were currently 228 residents in the facility. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include functional quadriplegia (a profound loss of mobility on all four limbs). A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 4/8/26 , indicated 15 out of a possible 15 on the brief interview of mental status (which meant the resident was cognitively intact). A review of Resident 1's MDS related to functional abilities dated 4/8/26 indicated Resident 1 was dependent to a helper to do all of the effort to complete an activity related to personal hygiene, putting on and off footwear and upper and lower body dressing. A review of Resident 1's physician History and Physical Examination (H&P) date 8/21/25, indicated Resident 1 had the capacity to understand and make decisions. A review of the physician order summary active orders as of 4/30/26 indicated Resident 1 may have power wheelchair to use for mobility due to diagnosis of quadriplegia. A review of Resident 1's IDT (interdisciplinary team, a group of healthcare providers to collaborate, plan, provide and evaluate patient care) note dated 4/30/26, indicated .[Resident 1] alleged that facility staff member inappropriately caressed her arm and sat in her bed in close proximity. A review of the facility Work Order Request indicated 4/21/26 at 5:35 P.M. MP provided service for problem related to wheelchair missing parts on which solution indicated it was done to Resident 1's room. A review of Certified Nursing Assistant (CNA for April 2026 indicated CNA 1 was scheduled on 4/24/26 and 4/25/26 night shift (3 to 11 P.M.) while CNA 2 was scheduled on 4/26/26 and 4/27/26. A review of the facility Maintenance Schedule for 2026 indicated that MP was scheduled to work from Tuesdays to Saturdays during the night shift. On 5/13/26 at 4:10 P.M. a phone interview was conducted with MP with Assistant Director of Nursing (ADON) 2 present. MP stated he kissed Resident 1's forehead without asking Resident 1's permission. MP denied touching Resident 1's hands. MP denied pulling up Resident 1's pants. On 5/19/26 at 12:59 P.M., an interview with Director of Nursing (DON ) 1 was conducted. DON 1 stated MP kissing Resident 1's forehead should not have happened. DON 1 stated this goes against code of conduct of an employee. On 6/16/26 at 8:50 A.M., an observation and interview was conducted with Resident 1 while inside her room. Resident 1 stated the incident with the MP started when Resident 1 needed assistance to fix her wheelchair. Resident 1 stated the MP came to her room and fixed it for about 45 minutes. Resident 1 stated she had conversations with the MP during this time. Resident 1 stated the MP, who was seated on Resident 1's bed stood up, went to face Resident 1, who was seated on her wheelchair, the MP suddenly grabbed both Resident 1's cheeks and kissed Resident 1's forehead. Resident 1 stated MP did not ask Resident 1's consent before kissing Resident 1's forehead. Resident 1 stated MP came about three times that day but could not recall whether MP kissed Resident 1's forehead on the first or second time MP was in Resident 1's room. Resident 1 stated at that time she did not react, because this was the first time it had happened to her. Resident 1 stated she felt grossed because Resident 1 felt MP's wet lips on Resident 1's forehead and MP's dirty hands grabbed both Resident 1's cheeks and kissed Resident 1 in the forehead. Resident 1 stated MP came up until Saturday. Resident 1 stated MP was not scheduled to work on Sundays. Resident 1 stated her family member was here on Wednesday and MP attempted to see Resident 1 about two times that day. Resident 1 stated the first day, MP was lightly petting Resident 1's hand up until Thursday, where MP was grabbing Resident 1's arm and MP was sitting at the edge of Resident 1's bed. Resident 1 stated that succeeding Thursday, MP kissed Resident 1's forehead again the same way where MP grabbed both Resident 1's cheeks and kissed Resident 1's forehead this time a little longer. Resident 1 stated MP did not asked Resident 1's consent before kissing Resident 1's forehead. Resident 1 stated at that point, she was not scared but she felt weird which meant that if this happened in the past, Resident 1 could walk before, Resident 1 stated she could defend herself. Resident 1 further stated, when MP did kiss her and touch her hands, she felt small. Resident 1 stated the succeeding Friday, she was sitting on her wheelchair wearing a shirt and baggy pants. Resident 1 stated her pants slid a few inches down. Resident 1 stated she felt MP look at me and look at my body like a pervert. Resident 1 stated MP pulled her pants up without asking her permission and MP stopped when she said no. Resident 1 stated that Friday, she asked CNA 1 to come to Resident 1's room when MP would come to Resident 1's room and pretend to do something. Resident 1 stated that same Friday, MP came to Resident 1's room and sat in Resident 1's bed. Resident 1 stated CNA 1 entered Resident 1's room and informed MP not to sit on Resident 1's bed. Resident 1 stated CNA 1 was made aware that MP kept coming to Resident 1's room, kissed Resident 1's forehead, pulled up Resident 1's pants. Resident 1 stated she did not report this incident and CNA 1 did not offer to report the incident but CNA 1 told Resident 1 she needed to speak up for herself. Resident 1 stated when her regular CNA (CNA2) returned to work, CNA was made aware that MP kissed Resident 1's forehead, pulled up Resident 1's pants, touching Resident 1 's arm, MP spending time with Resident 1 and CNA 1 defended her. Resident 1 stated she felt uncomfortable about what happened because this was not good, she knew right from wrong and there should be boundaries. Resident 1 stated an employee should not have done these things to her. Resident 1stated MP did not ask her consent. Resident 1 stated even if MP ask for her consent, Resident 1 would not allow MP to kiss her, touch, massage or rub her hand or pull her pants. On 6/16/2026 at 10: 30 A.M., an interview was conducted with Respiratory Therapist (RT) 1. RT 1 stated on 4/28/26 around 5 or 6 P.M., Resident 1 mentioned about a guy newly hired from maintenance where Resident 1 commented that MP was a weird vibe and creepy feel liked creepy weird. RT 1 stated on 4/29/2026, he was made aware of details MP did to Resident 1. RT 1 stated the newly hired MP kissed Resident 1's forehead, MP was massaging Resident 1's hands, MP was sitting on Resident 1's bed and MP pulled up Resident 1's pants. RT 1 stated on 4/28/2026 when Resident 1 commented weird vibe and creepy feel like creepy weird, he should have asked and elaborate that time. RT 1 stated this incident between Resident 1 and MP was a sexual abuse MP kissed Resident 1's forehead, neglect because he did not paid attention to Resident 1 was telling him and a physical abuse because MP touched Resident 1. On 6/16/26 at 10:56 A.M., an interview was conducted with CNA 2. CNA 2 stated she returned on Sunday which was 4/26/26. CNA 2 stated she was made aware the following day when Resident 1 informed her. CNA 2 stated Resident 1 started telling her MP caressed Resident 1's arm, MP kissed Resident 1's forehead, MP pulled up Resident 1's pants. CNA 2 stated Resident 1 needed one person assistance for her activities of daily living (ADLs). CNA 2 stated she did not witness the incident but she failed to report the incident when she was made aware. CNA 2 stated she should have reported this incident immediately to protect Resident 1. On 6/16/26 at 11:19 A.M., an interview was conducted with CNA 1. CNA 1 stated while she was charting on the computer, Resident 1 called her. CNA 1 stated computer was facing Resident 1's room. CNA 1 stated Resident 1 asked her to come inside Resident 1's room when the new guy from maintenance (MP) come to Resident 1's room. CNA 1 stated she asked Resident 1 which guy and Resident 1 informed her it was new guy from maintenance. CNA 1 stated she used to see the new maintenance guy (MP) coming to Resident 1's room. CNA 1 stated she was not made aware of the details of the incident the first time because Resident 1 asked her to come to her room when the MP entered Resident 1's room. CNA 1 stated she was made aware of incident including MP sitting on Resident 1's bed which she witnessed and MP touching Resident 1's hand which she did not witnessed. CNA 1 stated she did not report the incident when she was made aware and she should have reported the incident immediately. On 6/16/26 at 12: 44 P.M., an interview was conducted with ADON 1, ADON 2 and DON 2. ADON 1 stated the facility did not protect Resident 1 when the employees were made aware and failed to report the incident immediately. According to the facility policy entitled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised date April 2012, indicated .Residents have the right to be free from abuse, neglect.freedom from.sexual.abuse.1.) Protect residents from abuse, neglect.from a facility staff.2.implement polices and protocols to prevent and identify.a. abuse.8.Identify and investigate all possible incidents of abuse.9.Investigate and report any allegations within timeframes required by federal requirements.10.Protect residents form any further harm.

Based on observation, interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when facility employees were made aware of allegations of abuse to one of one resident (Resident 1).As a result, facility failed to report in a timely manner and facility failed to protect Resident.Cross reference F600 F607 F609 F610Findings: According to the facility policy entitled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised date April 2012, indicated .Residents have the right to be free from abuse, neglect.freedom from.sexual.abuse.1.) Protect residents from abuse, neglect.from a facility staff.2.implement polices and protocols to prevent and identify.a. abuse.8.Identify and investigate all possible incidents of abuse.9.Investigate and report any allegations within timeframes required by federal requirements.10.Protect residents form any further harm.On 5/11/2026 at 8 A.M. an onsite was conducted to investigate one facility reported incident of alleged abuse. A review of the facility's Report of Suspected Dependent Adult/Elder Abuse (S0C 341, a report submitted to the State agency to report allegations of abuse) dated 4/29/26, indicated Resident 1 alleged MP inappropriately caressed her arm and sat on her bed in close proximity to her while she was seated in her wheelchair and reported type of abuse with check marked sexual. A review of the facility's Report of Suspected Dependent Adult/Elder Abuse dated 5/13/26 indicated .Reopened investigation due to employee admission /inconcistant[sic] statements regarding kissing a resident. During CDPH interview, employee admitted to kissing [Resident 1] on the forehead. Facility reported type of abuse with check marked sexual. A review of the facility's Midnight Census Report dated 5/12/26 indicated there were currently 220 residents in the facility. A review of the facility's Midnight Census Report dated 6/15/26 indicated there were currently 228 residents in the facility. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include functional quadriplegia (a profound loss of mobility on all four limbs). A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 4/8/26 , indicated 15 out of a possible 15 on the brief interview of mental status (which meant the resident was cognitively intact). A review of Resident 1's MDS related to functional abilities dated 4/8/26 indicated Resident 1 was dependent to a helper to do all of the effort to complete an activity related to personal hygiene, putting on and off footwear and upper and lower body dressing. A review of Resident 1's physician History and Physical Examination (H&P) date 8/21/25, indicated Resident 1 had the capacity to understand and make decisions. A review of the physician order summary active orders as of 4/30/26 indicated Resident 1 may have power wheelchair to use for mobility due to diagnosis of quadriplegia. A review of Resident 1's IDT (interdisciplinary team, a group of healthcare providers to collaborate, plan, provide and evaluate patient care) note dated 4/30/26, indicated .[Resident 1] alleged that facility staff member inappropriately caressed her arm and sat in her bed in close proximity. A review of the facility Work Order Request indicated 4/21/26 at 5:35 P.M. MP provided service for problem related to wheelchair missing parts on which the solution indicated it was done . A review of Certified Nursing Assistant (CNA for April 2026 indicated CNA 1 was scheduled on 4/24/26 and 4/25/26 night shift (3 to 11 P.M.) while CNA 2 was scheduled on 4/26/26 and 4/27/26. A review of the facility Maintenance Schedule for 2026 indicated that MP was scheduled to work from Tuesdays to Saturdays during the night shift. On 5/13/26 at 4:10 P.M. a phone interview was conducted with MP with Assistant Director of Nursing (ADON) 2 present. MP stated he kissed Resident 1's forehead without asking Resident 1's permission. MP denied touching Resident 1's hands. MP denied pulling up Resident 1's pants. On 5/19/26 at 12:59 P.M., an interview with Director of Nursing (DON) 1 was conducted. DON 1 stated MP kissing Resident 1's forehead should not have happened. DON 1 stated this goes against code of conduct of an employee. On 6/16/26 at 8:50 A.M., an observation and interview was conducted with Resident 1 while inside her room. Resident 1 stated the incident with the MP started when Resident 1 needed assistance to fix her wheelchair. Resident 1 stated the MP came to her room and fixed it for about 45 minutes. Resident 1 stated she had conversations with the MP during this time. Resident 1 stated the MP, who was seated on Resident 1's bed stood up, went to face Resident 1, who was seated on her wheelchair, the MP suddenly grabbed both Resident 1's cheeks and kissed Resident 1's forehead. Resident 1 stated MP did not ask Resident 1's consent before kissing Resident 1's forehead. Resident 1 stated MP came about three times that day but could not recall whether MP kissed Resident 1's forehead on the first or second time MP was in Resident 1's room. Resident 1 stated at that time she did not react, because this was the first time it had happened to her. Resident 1 stated she felt grossed because Resident 1 felt MP's wet lips on Resident 1's forehead and MP's dirty hands grabbed both Resident 1's cheeks and kissed Resident 1 in the forehead. Resident 1 stated MP came up until Saturday. Resident 1 stated MP was not scheduled to work on Sundays. Resident 1 stated her family member was here on Wednesday and MP attempted to see Resident 1 about two times that day. Resident 1 stated the first day, MP was lightly petting Resident 1's hand up until Thursday, where MP was grabbing Resident 1's arm and MP was sitting at the edge of Resident 1's bed. Resident 1 stated that succeeding Thursday, MP kissed Resident 1's forehead again the same way where MP grabbed both Resident 1's cheeks and kissed Resident 1's forehead this time a little longer. Resident 1 stated MP did not asked Resident 1's consent before kissing Resident 1's forehead. Resident 1 stated at that point, she was not scared but she felt weird which meant that if this happened in the past, Resident 1 could walk before, Resident 1 stated she could defend herself. Resident 1 further stated, when MP did kiss her and touch her hands, she felt small. Resident 1 stated the succeeding Friday, she was sitting on her wheelchair wearing a shirt and baggy pants. Resident 1 stated her pants slid a few inches down. Resident 1 stated she felt MP look at me and look at my body like a pervert. Resident 1 stated MP pulled Resident 1's pants up without asking Resident 1's permission and MP stopped when she said no. Resident 1 stated that Friday, she asked CNA 1 to come to Resident 1's room when MP would come to Resident 1's room and pretend to do something. Resident 1 stated that same Friday, MP came to Resident 1's room and sat in Resident 1's bed. Resident 1 stated CNA 1 entered Resident 1's room and informed MP not to sit on Resident 1's bed. Resident 1 stated CNA 1 was made aware that MP kept coming to Resident 1's room, kissed Resident 1's forehead, and pulled up Resident 1's pants. Resident 1 stated she did not report this incident and CNA 1 did not offer to report the incident, but CNA 1 told Resident 1 she needed to speak up for herself. Resident 1 stated when her regular CNA (CNA2) returned to work, CNA was made aware that MP kissed Resident 1's forehead, pulled up Resident 1's pants, touching Resident 1 's arm, MP spending time with Resident 1 and CNA 1 defended her. Resident 1 stated she felt uncomfortable about what happened because this was not good, she knew right from wrong and there should be boundaries. Resident 1 stated an employee should not have done these things to her. Resident 1stated MP did not ask her consent. Resident 1 stated even if MP ask for her consent, Resident 1 would not allow MP to kiss her, touch, massage or rub her hand or pull her pants. On 6/16/2026 at 10: 30 A.M., an interview was conducted with Respiratory Therapist (RT) 1. RT 1 stated on 4/28/26 around 5 or 6 P.M., Resident 1 mentioned about a guy newly hired from maintenance where Resident 1 commented that MP was a weird vibe and creepy feel liked creepy weird. RT 1 stated on 4/29/2026, he was made aware of details MP did to Resident 1. RT 1 stated the newly hired MP kissed Resident 1's forehead, MP was massaging Resident 1's hands, MP was sitting on Resident 1's bed and MP pulled up Resident 1's pants. RT 1 stated on 4/28/2026 when Resident 1 commented weird vibe and creepy feel like creepy weird, he should have asked and elaborate that time. RT 1 stated this incident between Resident 1 and MP was a sexual abuse MP kissed Resident 1's forehead, neglect because he did not paid attention to Resident 1 was telling him and a physical abuse because MP touched Resident 1. On 6/16/26 at 10:56 A.M., an interview was conducted with CNA 2. CNA 2 stated she returned on Sunday which was 4/26/26. CNA 2 stated she was made aware the following day when Resident 1 informed her. CNA 2 stated Resident 1 started telling me MP caressed Resident 1's arm, MP kissed Resident 1's forehead, MP pulled up Resident 1's pants. CNA 2 stated Resident 1 needed one person assistance for her activities of daily living (ADLs). CNA 2 stated she did not witness the incident but she failed to report the incident when she was made aware. CNA 2 stated she should have reported this incident immediately CNA 2 to protect Resident 1. On 6/16/26 at 11:19 A.M., an interview was conducted with CNA 1. CNA 1 stated while she was charting on the computer, Resident 1 called her. CNA 1 stated computer facing Resident 1's room. CNA 1 stated Resident 1 asked her to come inside Resident 1's room when the new guy from maintenance (MP) come to Resident 1's room. CNA 1 stated she asked Resident 1 which guy and Resident 1 informed her it was new guy from maintenance. CNA 1 stated she used to see the new maintenance guy (MP) coming to Resident 1's room. CNA 1 stated she was not made aware of the details of the incident the first time because Resident 1 asked her to come to her room when the MP entered Resident 1's room. CNA 1 stated she was made aware of incident including MP sitting on Resident 1'ws bed which she witnessed and MP touching Resident 1's hand which she did not witnessed. CNA 1 stated she did not report the incident when she was made aware and she should have reported the incident immediately. On 6/16/26 at 12: 44 P.M., an interview was conducted with ADON 1, ADON 2 and DON 2. ADON 1 stated the facility did not protect Resident 1 when the employees were made aware and failed to follow the facility policy to report the incident immediately.

Based on observation, interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when facility employees were made aware of allegations of abuse to one of one resident (Resident 1).As a result, facility failed to report in a timely manner and facility failed to protect Resident.Cross reference F600 F607 F609 F610Findings:On 5/11/2026 at 8 A.M. an onsite was conducted to investigate one facility reported incident of alleged abuse. A review of the facility's Report of Suspected Dependent Adult/Elder Abuse (S0C 341, a report submitted to the State agency to report allegations of abuse) dated 4/29/26, indicated Resident 1 alleged MP inappropriately caressed her arm and sat on her bed in close proximity to her while she was seated in her wheelchair and reported type of abuse with check marked sexual. A review of Resident 1's IDT (interdisciplinary team, a group of healthcare providers to collaborate, plan, provide and evaluate patient care) note dated 4/30/26, indicated .[Resident 1] alleged that facility staff member inappropriately caressed her arm and sat in her bed in close proximity. A review of Certified Nursing Assistant (CNA for April 2026 indicated CNA 1 was scheduled on 4/24/26 and 4/25/26 night shift (3 to 11 P.M.) while CNA 2 was scheduled on 4/26/26 and 4/27/26. A review of the facility Maintenance Schedule for 2026 indicated that MP was scheduled to work from Tuesdays to Saturdays during the night shift. On 5/13/26 at 4:10 P.M. a phone interview was conducted with MP with Assistant Director of Nursing (ADON) 2 present. MP stated he kissed Resident 1's forehead without asking Resident 1's permission. MP denied touching Resident 1's hands. MP denied pulling up Resident 1's pants. On 5/19/26 at 12:59 P.M., an interview with Director of Nursing (DON) 1 was conducted. DON 1 stated MP kissing Resident 1's forehead should not have happened. DON 1 stated this goes against code of conduct of an employee. On 6/16/26 at 8:50 A.M., an observation and interview was conducted with Resident 1 while inside her room. Resident 1 stated the incident with the MP started when Resident 1 needed assistance to fix her wheelchair. Resident 1 stated the MP came to her room and fixed it for about 45 minutes. Resident 1 stated she had conversations with the MP during this time. Resident 1 stated the MP, who was seated on Resident 1's bed stood up, went to face Resident 1, who was seated on her wheelchair, the MP suddenly grabbed both Resident 1's cheeks and kissed Resident 1's forehead. Resident 1 stated MP did not ask Resident 1's consent before kissing Resident 1's forehead. Resident 1 stated MP came about three times that day but could not recall whether MP kissed Resident 1's forehead on the first or second time MP was in Resident 1's room. Resident 1 stated at that time she did not react, because this was the first time it had happened to her. Resident 1 stated she felt grossed because Resident 1 felt MP's wet lips on Resident 1's forehead and MP's dirty hands grabbed both Resident 1's cheeks and kissed Resident 1 in the forehead. Resident 1 stated MP came up until Saturday. Resident 1 stated MP was not scheduled to work on Sundays. Resident 1 stated her family member was here on Wednesday and MP attempted to see Resident 1 about two times that day. Resident 1 stated the first day, MP was lightly petting Resident 1's hand up until Thursday, where MP was grabbing Resident 1's arm and MP was sitting at the edge of Resident 1's bed. Resident 1 stated that succeeding Thursday, MP kissed Resident 1's forehead again the same way where MP grabbed both Resident 1's cheeks and kissed Resident 1's forehead this time a little longer. Resident 1 stated MP did not asked Resident 1's consent before kissing Resident 1's forehead. Resident 1 stated at that point, she was not scared but she felt weird which meant that if this happened in the past, Resident 1 could walk before, Resident 1 stated she could defend herself. Resident 1 further stated, when MP did kissed her and touch her hands, she felt small. Resident 1 stated the succeeding Friday, she was sitting on her wheelchair wearing a shirt and baggy pants. Resident 1 stated her pants slid a few inches down. Resident 1 stated she felt MP look at me and look at my body like a pervert. Resident 1 stated MP pulled Resident 1's pants up without asking Resident 1's permission and MP stopped when she said no. Resident 1 stated that Friday, she asked CNA 1 to come to Resident 1's room when MP would come to Resident 1's room and pretend to do something. Resident 1 stated that same Friday, MP came to Resident 1's room and sat in Resident 1's bed. Resident 1 stated CNA 1 entered Resident 1's room and informed MP not to sit on Resident 1's bed. Resident 1 stated CNA 1 was made aware that MP kept coming to Resident 1's room, kissed Resident 1's forehead, and pulled up Resident 1's pants. Resident 1 stated she did not report this incident and CNA 1 did not offer to report the incident, but CNA 1 told Resident 1 she needed to speak up for herself. Resident 1 stated when her regular CNA (CNA 2) returned to work, CNA 2 was made aware that MP kissed Resident 1's forehead, pulled up Resident 1's pants, touching Resident 1 's arm, MP spending time with Resident 1 and CNA 1 defended her. Resident 1 stated she felt uncomfortable about what happened because this was not good, she knew right from wrong and there should be boundaries. Resident 1 stated an employee should not have done these things to her. Resident 1stated MP did not ask her consent. Resident 1 stated even if MP ask for her consent, Resident 1 would not allow MP to kiss her, touch, massage or rub her hand or pull her pants. On 6/16/2026 at 10: 30 A.M., an interview was conducted with Respiratory Therapist (RT) 1. RT 1 stated on 4/28/26 around 5 or 6 P.M., Resident 1 mentioned about a guy newly hired from maintenance where Resident 1 commented that MP was a weird vibe and creepy feel liked creepy weird. RT 1 stated on 4/29/2026, he was made aware of details MP did to Resident 1. RT 1 stated the newly hired MP kissed Resident 1's forehead, MP was massaging Resident 1's hands, MP was sitting on Resident 1's bed and MP pulled up Resident 1's pants. RT 1 stated on 4/28/2026 when Resident 1 commented weird vibe and creepy feel like creepy weird, he should have asked and elaborate that time. RT 1 stated this incident between Resident 1 and MP was a sexual abuse MP kissed Resident 1's forehead, neglect because he did not paid attention to Resident 1 was telling him and a physical abuse because MP touched Resident 1. On 6/16/26 at 10:56 A.M., an interview was conducted with CNA 2. CNA 2 stated she returned on Sunday which was 4/26/26. CNA 2 stated she was made aware the following day when Resident 1 informed her. CNA 2 stated Resident 1 started telling me MP caressed Resident 1's arm, MP kissed Resident 1's forehead, MP pulled up Resident 1's pants. CNA 2 stated Resident 1 needed one person assistance for her activities of daily living (ADLs). CNA 2 stated she did not witness the incident but she failed to report the incident when she was made aware. CNA 2 stated she should have reported this incident immediately CNA 2 to protect Resident 1. On 6/16/26 at 11:19 A.M., an interview was conducted with CNA 1. CNA 1 stated while she was charting on the computer, Resident 1 called her. CNA 1 stated computer facing Resident 1's room. CNA 1 stated Resident 1 asked her to come inside Resident 1's room when the new guy from maintenance (MP) come to Resident 1's room. CNA 1 stated she asked Resident 1 which guy and Resident 1 informed her it was new guy from maintenance. CNA 1 stated she used to see the new maintenance guy (MP) coming to Resident 1's room. CNA 1 stated she was not made aware of the details of the incident the first time because Resident 1 asked her to come to her room when the MP entered Resident 1's room. CNA 1 stated she was made aware of incident including MP sitting on Resident 1'ws bed which she witnessed and MP touching Resident 1's hand which she did not witnessed. CNA 1 stated she did not report the incident when she was made aware and she should have reported the incident immediately. On 6/16/26 at 12: 44 P.M., an interview was conducted with ADON 1, ADON 2 and DON 2. ADON 1 stated the facility did not protect Resident 1 when the employees were made aware and failed to report the incident immediately. According to the facility policy entitled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised date April 2012, indicated .Residents have the right to be free from abuse, neglect.freedom from.sexual.abuse.1.) Protect residents from abuse, neglect.from a facility staff.2.implement polices and protocols to prevent and identify.a. abuse.8.Identify and investigate all possible incidents of abuse.9.Investigate and report any allegations within timeframes required by federal requirements.10.Protect residents form any further harm.

Based on observation, interview and record review, the facility failed to thoroughly investigate two facility reported incidents of sexual abuse. As a result of this deficient practice, there was the potential for continued employee access to residents in the building. Cross reference F600 F607 F609 F610Findings:On 5/11/2026 at 8 A.M. an onsite was conducted to investigate one facility reported incident of alleged abuse. A review of the facility's Report of Suspected Dependent Adult/Elder Abuse (S0C 341, a report submitted to the State agency to report allegations of abuse) dated 4/29/26, indicated Resident 1 alleged MP inappropriately caressed her arm and sat on her bed in close proximity to her while she was seated in her wheelchair and reported type of abuse with check marked sexual. A review of the facility's Report of Suspected Dependent Adult/Elder Abuse dated 5/13/26 indicated .Reopened investigation due to employee admission /inconcistant[sic] statements regarding kissing a resident. During CDPH interview, employee admitted to kissing [Resident 1] on the forehead. Facility reported type of abuse with check marked sexual. A review of Certified Nurse Assistant (CNA) 1's written statement which has, no time and no job title of the employee who wrote the statement indicated .he is seatting[sic] on my bed.and touching my hand. According to the Assistance Director of Nursing (ADON) 1 this was written by CNA 1. A review of CNA 2's written statement which has no date , no time, name and job title of the employee who wrote the statement indicated .'then all of a sudden he came to my room and sat on my bed really close.'.'then he caressed my arm and kissed my forehead and also helped pull my pants up.'.' According to the Assistance Director of Nursing (ADON) 1 this was written by CNA2 2. On 5/13/26 at 11;35 A.M. an interview and record review was conducted with Assistant Director of Nursing (ADON) 2. ADON 2 stated facility investigation did not include the following:The facility investigation did not include a timeline of the incident from the time the facility was made awareDid not include all the allegations in the SOC 341 that were indicated on the employees' written statements. In addition, employee-written statements did not included either name of the employee who wrote the statement, an official job title, date or time the written statement was completedResident interview record did not include details specific to the actual investigation in addition, there was no date and timeThe alleged employees date of birth did not match alleged employees background checkDuring this interview and record review, ADON 2 stated timeline in the facility investigation would show compliance of timely reporting and how facility protected the resident. ADON 2 stated facility investigations should have dates, times, name of employee who wrote the statements and official job title and have allegation details to make sure facility investigation was thorough and resident was safe. On 5/19/26 at 12: 43 P.M., an interview was conducted with ADON 1. ADON 1 stated it was important to indicate employee name and job tile, date and time to identify the employee and how much interaction between the employee and resident occurred. On 5/19/26 at 12:59 P.M., an interview was conducted with Director of Nursing (DON)1. DON 1 stated the employees should have immediately reported the incident. DON 1 stated the facility investigation was not thorough. DON 1 stated the facility should have caught the alleged employee date of birth did not matched alleged employee's background check. DON 1 stated resident interview record should have details including date, time specific to the investigation to show facility have done a thorough investigation. DON 1 stated all allegations should have been identified and investigated to show facility did a through investigations. According to the facility policy entitled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised date April 2012, indicated .Residents have the right to be free from abuse, neglect.freedom from.sexual.abuse.1.) Protect residents from abuse, neglect.from a facility staff.2.implement polices and protocols to prevent and identify.a. abuse.8.Identify and investigate all possible incidents of abuse.9.Investigate and report any allegations within timeframes required by federal requirements.10.Protect residents form any further harm.

Based on interview and record review, the facility failed to ensure three of 16 Registered Nurses (RNs 1, 11, 16) were trained and competent to administer an intravenous (IV-the administration of fluids, medications, or nutrients directly into the bloodstream through a needle or tube inserted into a vein) medication administration using a Medicine Ball infusion system (balloon-like reservoir filled with medication that relies on its own elastic walls to generate steady, continuous pressure, slowly pushing fluid into a patient's vein) to residents receiving an IV treatment. In addition, one of 19 sampled Certified Nursing Assistants (CNAs) (CNA 1) connected an IV antibiotic (medicines used to treat and prevent bacterial infections) to Resident 1's Gastrointestinal Tube (GT- medical device inserted directly through the abdominal wall into the stomach, providing a direct route to deliver liquid nutrition, fluids, and medications). As a result, Resident 1 was sent out to the hospital for evaluation. These failures could cause serious harm to Resident 1 or other residents receiving IV medications, which may lead to adverse reactions, or even death. Findings: 1. A review of the admission Record for Resident 1 indicated he was admitted [DATE] and readmitted on [DATE] for diagnoses which included: Cerebral Infarction (when a blood vessel in the brain is blocked or severely narrowed, cutting off blood supply), and Sudden Cardiac Arrest (when the heart abruptly stops beating).A review of Minimum Data Set (MDS) for Resident 1 Section C, dated 3/13/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS - evaluates a patient's temporal orientation and immediate/delayed recall to track cognitive function and decline) Score of 0, which indicated severe cognitive (thinking processes) impairment. A review of Physician Orders, dated 5/20/26, indicated Piperacillin Sod-Tazobactam (Zosyn-an antibiotic) So Intravenous Solution .Use 100 ml (milliliter) intravenously every 6 hours for PNA (Pneumonia-an infection of one or both lungs that causes the lungs to become inflamed and fill with fluid or pus) .To infuse100ml over an hour.On 5/22/26 at 12:10 P.M., an interview was conducted with RN 2. RN 2 stated she RN 2 stated she worked the morning shift on Long Term Care (LTC- a dedicated section for individuals requiring extended medical supervision and custodial assistance because they can no longer live independently) Unit 2 on 5/21/26. RN 2 stated that morning, the night nurse (RN 1) was running late in administering Resident 1's 6 A.M. Zosyn IV medicine ball dose. Because RN 1 had never been trained on medicine ball infusions, she asked RN 2 to administer the dose with her. RN 2 stated the Zosyn IV medicine ball had to be taken out of the refrigerator to warm up to room temperature and could not administer the medicine until 8 A.M. RN 2 stated RN 1 did not know how to administer the Zosyn IV Medicine ball. RN 2 stated she had to show RN 1 how to prime the lines (the process of running a fluid through an empty tube or hose to completely fill it and push out all trapped air before it is put into use), clean the port of the hub, flush, and connect the IV to the Peripherally Inserted Central Catheter (PICC- line is a long, thin, flexible tube inserted into a vein in your upper arm that acts as a durable, long-term IV line). RN 2 stated during this time, RN 1 discovered an empty Zosyn IV medicine ball was connected to Resident 1's GT balloon port (used to inflate balloon that keeps GT in place). RN 2 stated that IV medication given through the GT could have caused Resident 1 harm, because it was not given by the right route. RN 2 reported to the day Charge Nurse (CN 1) found Zosyn IV medicine ball. RN 2 stated when they removed the found Zosyn IV medicine ball from the balloon port, RN 2 aspirated (removed) 10 ml of fluid with a syringe but could not aspirate more fluid after the 10ml. On 5/22/26 at 2:09 P.M., an interview with RN 1 was conducted by phone. RN 1 stated she worked the night shift of 5/20/26 on LTC Unit 2, into the morning of 5/21/26 and Resident 1 was her resident that night. RN 1 stated she gave the 12 A.M. dose of Zosyn IV medicine ball with the supervision of RN 3, through Resident 1's left-arm PICC line. RN 1 stated she then administered the 6 A.M., dose with RN 2 at about 8 A.M. on 5/21/26. RN 1 stated she later discovered an empty IV bag of Zosyn connected to the balloon port of Resident 1's GT, which had been covered by a blanket. RN 1 stated she did not give Resident 1 any medications through the GT that night, so she did not see the IV bag connected to the balloon port until the end of her shift. RN 1 stated she was with RN 2 at time of the discovery. RN 1 stated she reported the incident to CN 1, the charge nurse for morning shift. RN 1 stated CN 1 assessed the situation and reported the incident to the Director of Nursing (DON). RN 1 stated the facility did not provide her with training on medicine ball IV administration prior to working on the floor, and she never completed any return demonstrations for the medicine ball IV administration with a preceptor or training staff.On 5/22/26 at 3:15 P.M., an interview was conducted with charge nurse (CN) 2, the charge nurse for the Subacute Unit (a specialized, short-term wing designed for patients who no longer need hospital care but are too medically fragile to return home). CN 2 stated that IV training on the Subacute Unit was .conducted at the bedside with the orienting nurse, watch one time, then a return demonstration. CN 2 stated she trained all RNs who work to the Subacute Unit, and the DON was responsible for the other RNs on other units. RN 5 stated the medicine ball training was conducted bedside with a return demonstration with Subacute nurses; no classroom instruction was conducted with RNs. On 5/22/26 at 4:15 P.M., an interview with CNA 1 was conducted. CNA 1 stated on the evening of 5/20/26, Resident 1 was one of his assigned residents for LTC Unit 2. CNA 1 stated at about 10 P.M., he noticed Resident 1 was wet, and he changed the resident's brief and linens. CNA 1 stated when he turned Resident 1 on his back, he saw that the Zosyn IV medicine ball was in the bed next to Resident 1's stomach. CNA 1 stated Resident 1 had a towel on his stomach, and the medicine ball was lying by his left arm but not connected. I connected the IV to the port on his GT but did not screw it in. CNA 1 stated that touching the IV and GT was outside his scope of practice as a CNA.On 5/26/26 at 10:50 A.M., an interview with CN 1 was conducted. CN 1 stated she was the charge nurse for LTC Unit 2 on 5/21/26. CN 1 stated RN 1 reported that an IV was found attached to Resident 1's GT. CN 1 stated because she was a Licensed Vocational Nurse (LVN) she could not touch the IV set-up and handle IVs. CN 1 stated she reported the incident immediately to the Director of Nursing (DON) at 7:50 A.M. (on 5/21/26). CN 1 stated the DON came to the bedside to assess the resident and took over responsibility for the incident. A review of the facility document titled Job Description: Certified Nursing Assistant dated 2-2024, indicated The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with resident's assessment and care plan, and as may be directed by supervisors.Report all changes in the resident's condition to Nurse Supervisor/Charge Nurse as soon as practical.Report all accidents and incidents you observe on the shift that they occur. Perform only those nursing care procedures that you have been trained to do.A review of the facility's policy titled Staffing, Sufficient and Competent Nursing dated 2001 indicated .4. Licensed nurses and nursing assistants are trained and must demonstrated competency in identifying, documenting, and reporting resident changes of condition consistent with their scope of practice and responsibilities.2. On 5/22/26 at 2:09 P.M., an interview with RN 1 was conducted by phone. RN 1 stated the facility did not provide her with IV training on the Medicine Ball Infusion system prior to being on the floor, and she did not complete any return demonstrations for Medicine Ball IV administration with a preceptor or training staff. On 5/22/26 at 3 P.M., an interview with RN 11 was conducted who stated she had not received training for the Medicine Ball IV infusion. RN 11 stated she only received a verbal in-service with no actual administration or a return demonstration. On 5/22/26 at 3:13 P.M., an interview with RN 16 was conducted. RN 16 stated, I believe I wasn't trained. RN 16 was not aware of what the Medicine Ball IV infusion was. RN 16 stated she had no official in-service and had no return demonstration for Medicine Ball IV infusion. On 5/22/26 at 3:15 P.M., an interview was conducted with CN 2 who stated she was the charge nurse for the Subacute Unit. CN 2 stated IV training on Subacute Unit was .conducted at the bedside with an orienting nurse. CN 2 stated the process was to observe the procedure once, followed by a return demonstration. CN 2 stated she trained all RNs who come to Subacute unit, while DON was responsible for the other RNs on the other units. RN 5 stated the medicine ball training was conducted bedside with return demonstration by Subacute nurses, with no formal classroom training provided. A review of the facility's policy titled Intravenous Administration of Fluids and Electrolytes dated 2001 indicated that .10. When infusion is complete: a. For intermittent therapy: (1) clamp tubing and disconnect from catheter;(2) if tubing will be reused, replace sterile cap; and (3) flush catheter per protocol. Review of policy indicated it does not address how to dispose of IV bag or tubing after disconnected. On 5/22/26 at 4:51 P.M., a meeting was held with the Administrator (ADM), Assistant Director of Nursing (ADON 1 and 2), and the Minimum Data Set Nurse (MDSN). The meeting included the California Department of Public Health (CDPH) survey team and the Pharmacy Consultant, as well as a phone call with the leadership team. During this meeting, the participants were informed of an Immediate Jeopardy (IJ - the most serious deficiency type occurring when a facility's noncompliance places the health and safety of residents at risk for actual or potential serious injury, serious harm, serious impairment or death, which requires immediate correction to prevent further or future serious harm). The IJ was related to the facility's failure to ensure RNs were competent in IV medication administration. In addition, a CNA was not competent in his role when he connected IV tubing to a GT port. On 5/23/26 at 6:15 P.M., the facility provided a removal plan. The removal plan was reviewed and was accepted. The IJ Removal Plan indicated: 1) Immediate protective actions: The CNA involved was immediately removed from resident care duties pending investigation and re-education regarding scope of practice and resident safety.2) Corrective measures for the affected residents. 1. The Nurse Consultant provided in-service education to the Director of Nursing and RN Manager regarding safe medication administration, enteral feeding safety, tubing verification, and scope of practice requirements. The RN Manager subsequently conducted in-service education and return demonstration competency validation with nursing leadership staff. All licensed nurses and certified nursing assistants currently in the facility were immediately provided with verbal in-service education and return demonstration competency regarding the following:a. Scope of practice requirementsb. IV tubing and enteral tubing safetyc. G-tube and enteral feeding safetyd. Resident identification procedurese. Safe medication administration practicesf. Requirement that only licensed nurses may administer medications, handle IV administration systems, or connect enteral feeding and medication tubing2. Licensed nurses were instructed that enteral feeding ports, medication ports, and IV tubing connections must be verified prior to administration of any medication, feeding, and/or flush.3. Any nurse or CNA returning from leave, agency assignment, or orientation who has not completed required education and competency validation will not receive a resident assignment until completion of the required training and return demonstration competency.4. The Director of Nursing and/or designee will provide ongoing observation, monitoring, feedback, recommendations, and coaching to nursing staff to ensure continued successful implementation of safe medication administration practices, enteral feeding safety, tubing verification procedures, and compliance with facility policies and procedures.3) Facility-wide changes: 1. The facility's policies were reviewed and/or updated to ensure the facility process will be followed:a. Administering Medications through an Enteral Tubeb. Intravenous Administration of Fluids and Electrolytesc. IV Administrationd. Scope of Practice Guidelinese. Tube Feeding and Enteral Safety2. Monthly monitoring of medication administration competencies, enteral feeding competencies, and orientation completion will be reviewed by the Director of Nursing or designee. Audit findings will be reviewed through the QAPI process monthly and quarterly to ensure ongoing compliance and sustained corrective action.On 5/26/26 at 3:33 P.M., in the presence of the ADM and two ADONs (ADON 1 and ADON 2) the IJ was removed, and the ADM was notified after verifying the IJ removal plan while on-site.On 6/4/26 at 10 A.M., a concurrent interview with (ADON) 1 and a record review of RN competencies were conducted. ADON 1 stated the DON was terminated and currently she was the DON designee. Review of the facility document titled Medication Administration Skills Competencies Checklist for RN 1, RN 11, and RN 16 indicated, IV administration skills and techniques were not on the checklist. There was no confirmation as to whether the RNs were competent in IV administration. ADON 1 stated IV administration checklists were started after 5/22/26, the day after the investigation began. ADON 1 stated no IV competencies were completed for the above nurses prior to them working on the floor and administering IVs. ADON 1 stated the expectation for IV administration was that RNs should have had training and their competency checked before working on the floor and administering IVs, because administering IVs without demonstrated competency could cause medication errors that could lead to resident harm. ADON 1 further stated CNAs need to work within their scope of practice, which included ADLs (activities of daily living), showering, and feeding. ADON 1 stated CNAs should not touch any lines or tubes that are not within their scope of practice, as they could cause harm to residents if done incorrectly.Review of facility policy titled Staffing, Sufficient and Competent Nursing dated 2001 indicated .3. Licensed staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following areas .I. Nursing skills consistent with scope of practice.

Based on observations, interviews, and document review, the facility failed to ensure infection prevention practices were followed by three of five staff members when:Staff did not perform hand hygiene before putting on their personal protective equipment (PPE - wearable gear to protect users from infectious hazards).A licensed nurse (LN) used a breathing treatment unit dose container (singe dose of measured dose of liquid medication) on a resident, after the container landed on the floor.These failures had the potential to spread infection to the residents, staff, and visitors. On 5/23/26 at 8:50 A.M., a medication administration observation was conducted on licensed nurse (LN) 25. LN 25 went in a resident room with a signage indicating Enhanced Barrier Precaution (EBP - an infection control practice to prevent the spread of multi-drug-resistant organisms and requires healthcare staff to wear gloves and gowns during high-contact activities) to check a resident's vital signs. LN 25 put on his gloves and gown without performing hand hygiene. LN 25 exited the resident's room and proceeded to prepare the resident's medication. One of the medication LN 25 prepared was a breathing treatment unit dose container. As LN 25 removed the unit dose container from the box, LN 25 dropped the unit dose container on the floor, picked it up and placed the container on top of the medication cart. LN 25 used the hand sanitizer to clean his hands and then grabbed the unit dose container and used it on the resident. On 5/23/26 at 9:05 A.M., during an interview with LN 25, LN 25 stated he should not have used the unit dose container when it dropped on the floor. LN 25 stated the unit dose that dropped on the floor was dirty and should not have been used to prevent spread of infection. LN 25 also added that he should have performed hand hygiene before putting on his gown and gloves to ensure that his hands were clean. On 5/23/26 at 9:25 A.M., two certified nursing assistants were observed assisting a resident back to bed. The resident was on EBP. Both CNAs did not performed hand hygiene before putting on their gloves and gowns. On 5/23/26 at 9:30 A.M., LN 26 stated that staff should perform hand hygiene prior to putting on their personal protective equipment (PPE) to ensure their hands are clean and help avoid the spread of infection. A review of the facility's policy and procedure titled Infection Prevention and Control Program, revised on April 2025, indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. A review of the facility's policy and procedure titled Handwashing/Hand Hygiene, revised on December 2025, indicated, Hand hygiene is the primary means for preventing healthcare associated infections (HAIs) and the transmission of multidrug-resistant organisms (MDROs). 1. Perform hand hygiene before applying non-sterile gloves.

Based on observation, interview, and record review, the facility failed to ensure a medication was administered according to the professional standards of practice for one of four sampled residents, (Resident 25), when the manufacturer's instructions and directions on the pharmacy label for Budesonide inhalation suspension (a medication to control symptoms of lung disease) were not followed during administration. This deficient practice had the potential for Resident 25 to not receive the full efficacy of the medication and to develop side-effects such as an oral thrush (a yeast infection on the mouth and throat with primary symptoms of white patches on tongue, cheeks, gums or tonsils with bleeding and pain).Findings:A review of Resident 25's admission Record, indicated the resident was admitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease (an inflammatory lung disease that restricts airflow) with exacerbation, unspecified emphysema (lung disease that restricts air flow) and chronic respiratory failure with hypoxia (lack of oxygen). A review of Resident 25's PACS-Medication Administration Record for the month of May 2026 indicated, Budesonide Inhalation Suspension 0.5 milligram (mg)/2 milliliter (ml). 2 ml, Inhale orally in the morning for sob [shortness of breath]/wheezing [high pitched sound when breathing] with start date of 3/15/26 at 9:00 A.M. A review of Resident 25's Budesonide inhalation's pharmacy label included the following instructions, Shake gently.Rinse mouth after each use. On 5/23/26 at 8:50 A.M, a concurrent observation and interview was conducted with licensed staff (LN) 20 while inside Resident 25's room. Resident 25 was observed sitting up in bed, alert and talking to LN 20. LN 20 was observed to be grabbing and squirting Budesonide inhalation suspension into the nebulizer (device that turns liquid medication into a fine mist). LN 20 then started administering the medication without shaking the medication inside the nebulizer. LN 20 stated it would take about eight to ten minutes for the nebulization (inhaling the fine medication mist). LN 20 stated all he had to do after administering the medication was check Resident 20's lung sounds. On 5/23/26 at 9:36 A.M, another interview was conducted with LN 20. LN 20 stated Resident 25 completed the Budesonide inhalation administration. LN 20 stated Resident 25 did not rinse his mouth after the Budesonide administration. LN 20 stated he had no knowledge of the need for the resident to rinse mouth and spit out the water. LN 20 stated he did not check the administration instructions label affixed to the Budesonide packaging. LN 20 stated not following the instructions for rinsing and spitting could increase the possibility of Resident 25 developing oral thrush. On 5/23/26 at 4:10 P.M., an interview was conducted with LN 27. LN 27 stated she was currently taking care of Resident 25 and had previously administered Resident 25's Budesonide inhalation. LN 27 stated she did not know Resident 25 needed to rinse his mouth and spit after Budesonide administration. LN 27 pulled out Resident 25's Budesonide medication from the medication cart and viewed the packaging label and instructions. LN 27 stated she had not read the instructions prior to administering the medication to the resident. LN 27 stated the instructions on the medication label included shaking the medication gently prior to administering and rinsing the mouth with water and spitting after the administration of Budesonide. LN 27 stated she did not know the purpose of swishing and spitting was to lessen the risk of side effects like oral thrush. On 5/23/26 at 3:54 P.M., an interview was conducted with the director of staff development (DSD). The DSD stated licensed nurses should read all administration instructions prior to administering each medication. The DSD stated inhalation medications, especially ones containing steroids (medication for inflammation) like Budesonide should be followed by rinsing the mouth with water and spitting it out. The DSD stated all LNs administering the medication should be aware of this. The DSD stated Resident 25 could develop an oral thrush, which would be uncomfortable for the resident. A review of the Budesonide Patient Information Leaflet provided by the facility, last revised February 2026, indicated, BUDESONIDE 0.25 MG/2ML [NAME].BUDESONIDE SUSPENSION FOR NEBULIZER-INHALATION.COMMON BRAND NAME(S): Pulmicort.USES: Budesonide is used to control and prevent symptoms (wheezing and shortness of breath).HOW TO USE: .Shake the container gently before use.To prevent dry mouth, hoarseness, and oral yeast infections, gargle, rinse your mouth with water and spit out after each use.SIDE EFFECTS:.Tell your doctor right away if you have any serious sideeffects [sic], including: white patches in your mouth or on yourtongue [sic].A review of the facility's policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer dated 2001, indicated, .Purpose.The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway.General Guidelines.1. Follow the medication administration guidelines. The policy did not provide guidance specific to medications like Budesonide.

Based on interviews and document review, the facility failed to ensure that their Facility Assessment included and addressed the nurse competencies related to administration of medication via intravenous (IV - into a vein) route, including the use of an IV bulb infusion system (a disposable, portable, and non-electric device used to deliver intravenous medication safely over a preset amount of time) . As a result, nurses who were not trained and whose competencies were not assessed on the IV bulb infusion system, were assigned to administer IV medication using the bulb infusion system. This may result in significant medication error and may cause harm to the resident. (cross reference F 726) A review of the facility's Facility Assessment, dated 4/1/26, indicated the facility provides IV medications and the number/average range of residents receiving IV medications was 3-4 residents. The document also indicated competencies to consider included Medication administration - injectable, oral, subcutaneous, topical. Intravenous route of medication administration was not included in the Facility Assessment. On 5/23/26 at 10:10 A.M., during an interview with the Administrator (ADM), the ADM acknowledged that the Facility Assessment should have included IV medication administration, as well as the IV bulb infusion system. A review of the facility's policy and procedure titled Facility Assessment, revised on December 2024, indicated, A facility assessment is conducted annually to determine and update the capacity to meet the needs of and competently care for residents during day-to-day operations (including nights and weekends) and emergencies.

Based on observation, interview, and record review, the facility failed to ensure six out of seven residents (187, 126, 2, 181, 73, 43) were free of any potential or actual significant medication errors when: Licensed Nurse (LN) 1 prepared eight morning medications for Resident 76 including clozapine (used for schizophrenia, a distorted perception of reality), topiramate (used to treat seizures, abnormal and disruptive electrical activity in the brain), and levetiracetam (used to treat seizures) and gave the medications to LN 2 to administer. LN 2 then administered Resident 76's medications to Resident 187. LN 51 administered medications to Resident 126 without verifying Resident 126's identity.LN 52 administered a medication to Resident 2 without verifying his identity.LNs 3 and 4 administered medications to Resident 181 without verifying his identity.LN 5 administered medications to Residents 73 and 43 without verifying their identities. These failures led Resident 187 to experience a change of condition (any new or worsening change from a person's normal health condition), which required the resident to be transferred to the hospital for evaluation and subsequently admitted . In addition, these failures to properly identify residents prior to administering medications had the potential for Resident 126, Resident 2, Resident 181, Resident 73, Resident 43 and other facility residents to experience serious injury, harm, impairment and death due to receiving another resident's medications in error. Findings:1. On 5/11/26, a review of Resident 187's facesheet indicated she was admitted tothe facility on 2/20/26. On 4/29/26 at 10:10 A.M., Resident 187 received her prescribed medications, which included: Escitalopram (a medication used to treat depression, a condition characterized by excessive sadness), Lamotrigine (a medication used to treat bipolar disorder, a condition characterized by drastic shifts in mood and energy), Metoprolol (a medication used to treat high blood pressure), and Lactobacillus (a probiotic, used to promote gut health). During an interview with the Charge Nurse (CN) on 5/12/26 at 8:11 A.M., the CN stated a medication error occurred on 4/29/26 in which Resident 187 was given Resident 76's medications.A review of Resident 187's medical record indicated the CN documented, .Resident [187] mistakenly received medications intended for another resident. in a progress note dated 4/29/26 at 1:09 P.M.A review of Resident 76's medical record indicated she was admitted on [DATE]. Resident 76's oral morning medications included the following:clozapine 100 mg (milligrams, unit of measure) tablet A drug review of clozapine on Daily Med (a free drug resource site provided by the National Library of Medicine), updated 10/8/25, indicated side effects, including sedation and tachycardia (fast heart rate). Black box warnings (BBW, the highest level warning that the Food and Drug Administration [FDA, a government agency that regulates medications] requires from drug manufacturers) were also listed for clozapine, such as severe neutropenia (lower than normal neutrophils, a type of white blood cell that fights infections), seizures, orthostatic hypotension (a drop in blood pressure upon a change in positioning), cardiomyopathy (diseased heart muscles that affect the heart's ability to pump blood to the whole body), increased mortality (death) in elderly patients with dementia (group of disorders characterized by memory loss and difficulty thinking)-related psychosis (a condition characterized by a distorted perception of reality).A drug review of clozapine on Micromedex (a drug resource site), undated, indicated adverse effects, including sedation, somnolence and tachycardia, ventricular arrhythmia (abnormal heart rhythm starting in the lower chambers of the heart).topiramate 25 mgPer Daily Med, updated 5/22/25, side effects of topiramate included somnolence, fatigue, oligohidrosis (diminished sweating), cognitive-related (mental processes like thinking and remembering) dysfunction.Per Micromedex, undated, a serious adverse effect of topiramate as drug-induced (caused by a medication) encephalopathy (brain dysfunction).Levetiracetam 500 mg tabletPer Daily Med, updated 4/29/24, side effects of levetiracetam included somnolence, fatigue, dizziness, headache, and serious skin reactions requiring discontinuation of the drug.Per Micromedex, undated, side effects of levetiracetam included decreased bone mineral density (bone strength), abnormal behavior and irritability.famotidine 20 mg tabletPer Micromedex, undated, side effects of famotidine included headache, dizziness and rhabdomyolysis (a serious condition in which damaged muscles break down).senna two-8.6 mg tablets (17.2 mg total dose)Per Micromedex, undated, the side effects of senna include out of range (outside normal values) electrolytes (essential minerals in the body that can be lost due to diarrhea).cholecalciferol two 1000-unit tabletsfish oil capsule (a medication or supplement enclosed in a shell)lactobacillus capsuleA review of Micromedex indicated drug interactions between clozapine and other drugs, such as escitalopram, famotidine and topiramate increased the risk of QT prolongation (a delay for the heart to recharge between beats, which increase the risk for life-threatening heart rhythms and sudden death). Additionally, a drug interaction between escitalopram and famotidine increased the risk of QT prolongation. During an interview with the Certified Nursing Assistant (CNA) on 5/13/26 at 9:26 A.M., the CNA stated Resident 187 normally has a lot of energy. During an interview with the Certified Occupational Therapy Assistant (COTA) on 5/13/26 at 9:51 A.M., the COTA stated Resident 187 arrived for her therapy (rehabilitation, [rehab]) session on 4/29/26 at approximately between 1-2 P.M., in her wheelchair wanting to ride a bike. The COTA stated he noticed Resident 187 became lethargic (a state of severe fatigue, sluggishness, or lack of energy and enthusiasm) and sleepy all of a sudden.less than 5 minutes. A review of +Resident 187's progress note, dated 4/29/26, indicated Resident 187 returned from rehab at 1:55 P.M. (less than 1 hour after receiving the wrong medications) due to a sudden change of condition. During a telephone interview with LN 1 on 5/13/26 at 3:32 P.M., LN 1 stated she was orienting LN 2 on 4/29/26. LN 1 stated she prepared Resident 76's morning medications scheduled for 9 A.M. at around 1 P.M. LN 1 stated she put the medications in a cup and wrote the room number on the cup. LN 1 stated she then told LN 2 the resident's name and gave the cup full of Resident 76's morning medications to LN 2. Shortly after, LN 1 stated she turned around and saw LN 2 exiting Resident 187's room. The CN was notified of the medication error about 5 minutes later. LN 1 stated it was not standard practice to prepare medications for another nurse to administer. During a telephone interview with LN 2 on 5/13/26 at 4:10 P.M., LN 2 stated she was working with LN 1 on 4/29/26. LN 2 stated LN 1 prepared medications and handed them to her to administer. LN 2 stated Residents 187 and 76 had similar names. LN 2 stated she asked Resident 187 for her name and date of birth but did not verify the Medication Administration Record (MAR, document that has a complete and accurate record of all medications administered to a resident to ensure patient safety). LN 2 stated Resident 187 didn't have the wristband [an ID bracelet]. LN 2 stated after the incident, LN 1 was told by the Director of Nursing (DON) she had to be with LN 2 when LN 2 administered medications. A review of the Unusual Occurrence Report, dated 4/30/26, indicated, .Resident [187] assessed and monitored continuously following identification of medication error[;] Physician, Nurse Practitioner, responsible party, and facility leadership notified. A review of Resident 187's medical record indicated a progress note, dated 4/29/26 in which the CN documented, Resident returned from REHAB to [her] room at [1:55 P.M.] due to a sudden decline in function while exercising.resident was noted with altered mental status [a change in mental function], eyes closed, pin point [sic] pupils [shrinkage of the black center of the eyes, which lets light into the eye], not responding to verbal [sounds, including speech] stimuli [things that trigger a reaction], responsive to tactile [touch] stimuli (sternal rub [an assessment of consciousness, or awareness, by rubbing the chest with knuckles]) with moaning and groaning, mouth open, eyes not tracking.BP [blood pressure] 136/72, HR [heart rate] 83, RR [respiratory rate] 20, O2 [oxygen] 88% on RA [room air], Temp [temperature] 99.2. 1 dose of Narcan [brand name of naloxone, an emergency medication that reverses the effects of opioid [strong painkillers] overdose, such as unresponsiveness, pinpoint pupils and shallow breathing] administered, ineffective .Administered 2nd dose of Narcan, ineffective. Call placed to 911.at [2:07 P.M.] .in-route to [hospital] ER [emergency room] at [2:20 P.M.].During an interview with the DON on 5/14/26 at 11:52 A.M., the DON stated Resident 187 experienced a change of condition as a result of receiving the wrong medications. The DON stated Resident 187 received naloxone twice. The DON stated Resident 187 was sent to the hospital for somnolence (drowsiness, sleepiness, or a strong biological drive to fall asleep) and atrial fibrillation (it is an irregular, often rapid heart rate). The DON stated nursing staff were expected to check residents' identification for every medication administration. The DON stated the medication error occurred because LNs 1 and 2 did not follow the medication rights. The DON stated Residents 187 and 76 had similar names and Resident 187 didn't have an armband [wristband] on. The DON further stated, For safety and per policy, you have to follow eight medication rights [safety measures for medication administration] to ensure you're giving the right meds [medications] to the right resident. A review of the facility's Medication Rights, card, undated, indicated: 1. RIGHT PATIENT 2. RIGHT MEDICATION 3. RIGHT DOSE 4. RIGHT ROUTE 5. RIGHT TIME 6. RIGHT DOCUMENTATION 7. RIGHT REASON 8. RIGHT RESPONSE During an interview with the CN on 5/19/26 at 3:38 P.M., the CN stated LNs 1 and 2 informed him of a medication error on 4/29/26 at 1:09 P.M. in which Resident 187 received all of Resident 76's oral medications scheduled for 9 A.M., including clozapine, topiramate, levetiracetam, famotidine, senna, cholecalciferol, fish oil, and lactobacillus. The CN stated Resident 187 declined (worsening condition) in the rehab gym (room where therapy or rehabilitative activities take place) and returned from rehab at 1:55 P.M. on 4/29/26. The CN stated he and other nurses observed Resident 187's symptoms on 4/29/26 (documented in Resident 187's progress notes). The CN stated he administered two doses of Narcan to Resident 187. The CN stated the standard practice for identifying residents was to ask residents for their full names, dates of birth, and to check their wristbands, if residents were alert and could answer. The CN stated if residents could not answer, nurses were to have another nurse look at the residents' photos in their charts (medical records) to collectively identify the residents. The CN stated it was absolutely not standard practice for one nurse to prepare medications for another nurse to administer. The CN stated each nurse was to administer whatever medications he or she prepared and should never administer medications prepared by another nurse. The CN stated LNs 1 and 2 failed to properly identify the residents and failed to give medications on time and to the right resident. The CN stated the medication error resulted in Resident 187 experiencing adverse reactions requiring the facility to send her to the hospital. The CN stated the medication error did have an outcome on [Resident 187] adversely. The CN stated Resident 187 was admitted to the hospital for somnolence and AFib. The CN stated Resident 187 was treated for AFib at the hospital, but the facility did not have AFib listed as a pre-existing health condition.A review of Resident 187's hospital record indicated an Emergency Department (ED) note from the physician for the encounter date of 4/29/26. The ED physician documented Resident 187's .symptoms are consistent with being given clozapine and Topamax [brand name for topiramate] with the patient being naive to [never had] these medications. She was observed carefully, still no improvement somnolence [sic] therefore will be admitted [hospitalized ] for overnight observation. A review of Resident 187's hospital record indicated a physician documented under a section titled ASSESSMENT/PLAN, dated 4/30/26, Resident 187 [d]eveloped paroxysmal [sudden and temporary] A-fib with RVR [rapid ventricular rate, fast or faster than normal heart rate] overnight.[physician] started her on Cardizem [brand name of diltiazem, a medication used to treat heart conditions] drip [administered through the veins].Received also a dose of digoxin [a heart medication].Consulted cardiology [physician specializing in the heart and cardiovascular system]. A review of Resident 187's medical record indicated a Progress Note, dated 5/1/26 at 12:30 P.M. in which the DON documented, Resident returned from.Hospital at 12pm. Resident 187 was unavailable for interview from 5/13/26 onwards. A review of Resident 187's medical record indicated a Progress Note dated 5/12/26 at 10:30 P.M. The Progress Note indicated, Resident observed with acute change in behavior/mental status which began at [4 P.M.].PRN [as needed] Ativan [brand name of lorazepam, a medication for anxiety, a condition characterized by excess worrying] was offered per order, but resident refused stating, 'You guys are trying to kill me here,' and stated 'you guys have poisoned me here before.Resident was picked up by [the] ambulance at [10:30 P.M.].During an interview regarding the medication administration process with Resident 76 on 5/13/26 at 9:35 A.M., Resident 76 was asked if nursing staff asked for her name and date of birth before giving her medications. Resident 76 stated, no. Resident 76 was asked if nursing staff checked her wristband before medication administration. Resident 76 stated, no. Resident 76 stated medications were given later than usual, only one time.2. During a concurrent medication administration observation and interview with LN 51 on 5/11/26 at 12:41 P.M., LN 51 was observed preparing and administering one medication to Resident 126, gabapentin (a medication used for various neurological conditions). During the observation, LN 51 did not ask for Resident 126's name and date of birth or ask to see Resident 126's wristband. Resident 126 was observed walking to receive the medications and taking them standing upright. When asked how she verified Resident 126's identity prior to medication administration, LN 51 stated she looked at Resident 126's wristband. A drug review of gabapentin on Micromedex, undated, indicated side effects include peripheral edema (swelling in the extremities due to fluid accumulation), vomiting, viral disease (illness caused by a virus), ataxia (lack of muscle control resulting in unsteady movements), nystagmus (rapid, involuntary and repetitive movement of the eyes), dizziness, somnolence, hypoglycemia (low blood sugar) and respiratory depression (slowed or shallow breathing). 3. During a medication administration observation on 5/11/26 at 3:34 P.M., LN 52 administered an unlabeled medication in a syringe to Resident 2. LN 52 stated the medication in the syringe was Novolog (brand name type of insulin [aspart], used to lower blood sugar). When asked how she identified Resident 2, LN 52 stated she looked at Resident 2's wristband. LN 52 was asked to show the surveyors Resident 2's wristband. Resident 2's wristband was observed to be illegible. LN 52 was asked how she read the wristband. LN 52 stated the wristband was all faded, but it is him. LN 52 was asked how she knew it was Resident 2. LN 52 stated she had him before and could not talk. LN 52 stated nursing staff were to check a resident's name, wristband and date of birth . LN 52 stated nursing staff were not to use the resident's room number to verify identification. A drug review of insulin aspart on Micromedex, undated, indicated side effects such as hypoglycemia and headache. 4. During a concurrent medication administration observation and interview with LNs 3 and 4 on 5/12/26 at 8:19 A.M., LN 3 was observed training LN 4 on preparing and administering medications for Resident 181. Medications included hyoscyamine (a medication used to treat excessive salivation), quetiapine (a medication used to treat various psychiatric conditions), lorazepam (a medication used to treat anxiety), and morphine (a powerful medication used to control pain). LNs 3 and 4 were asked to obtain Resident 181's permission to observe his medication administration. LN 3 stated Resident 181 was confused but would not mind the observation. LN 3 did not ask for Resident 181's name or date of birth . Resident 181 was observed with his arms covered under a blanket. During the observation, neither LN 3 nor LN 4 were observed or heard verifying Resident 181's identity prior to administering his medications. When asked how they knew who it was, LN 3 stated, I already know him. LN 3 then stated they asked for Resident 181's name and date of birth when they obtained his permission. A drug review of hyoscyamine on Micromedex, modified 5/13/26, indicated side effects such as diminished sweating, xerostomia (dry mouth), dizziness, somnolence, blurred vision, tachycardia, palpitations, delay when starting to pass urine, and psychotic disorder (psychosis). A drug review of quetiapine on Micromedex, undated, indicated side effects such as orthostatic hypotension, tachycardia, weight gain, abdominal pain, xerostomia, backache, dizziness, headache, fatigue, pain, somnolence, asthenia (weakness), tremor (involuntary movement), extrapyramidal disease (drug-induced uncontrollable movement disorders), syncope (fainting) and sudden cardiac death. A drug review of lorazepam on Micromedex, modified 5/21/26, indicated side effects such as dizziness, asthenia, unsteadiness and depression. A drug review of morphine on Micromedex indicated side effects such as pruritus (itchiness), constipation, nausea, vomiting, dizziness, orthostatic hypotension, respiratory depression, and cardiac arrest (a medical emergency in which the heart suddenly stops working). 5. During a medication administration observation on 5/12/26 at 9:14 A.M., LN 5 was observed preparing and administering six medications for Resident 73, including gabapentin, lamotrigine (a medication used for various neurological and psychiatric conditions), levetiracetam, multivitamins with minerals (a supplement), docusate (a stool softener), and Vitamin D (a supplement). LN 5 was approached for a medication administration observation moment prior at 9:11 A.M., while finishing a medication administration for another resident. LN 5 was followed until she reached Resident 73's room. LN 5 was observed obtaining Resident 73's permission for observation. During the observation, LN 5 did not verify Resident 73's identity prior to administering Resident 73's six medications. A drug review of lamotrigine on Micromedex indicated side effects such as rash, abdominal pain, nausea, vomiting, diarrhea, ataxia, dizziness, somnolence, tremor, blurred vision, diplopia (double vision), dysmenorrhea (painful menstruation), rhinitis (runny nose), liver failure, and cardiac dysrhythmia (irregular, abnormal heartbeat that is either too fast or too slow). During an interview with Resident 73 on 5/12/26 at 2:55 P.M., Resident 73 was asked if nursing staff typically asked for her name and date of birth . Resident 73 replied in the affirmative. Resident 73 was asked if nursing staff typically looked at her wristband. Resident 73 stated, no, because they know me. We've known each other for 5 years. 6. During a concurrent medication administration observation and interview on 5/12/26 at 9:26 A.M., LN 5 was observed preparing and administering six medications for Resident 43, who was sitting outside his door. The medications included donepezil (used for dementia), escitalopram (used to treat depression or anxiety), aspirin, Vitamin D, multivitamins, and docusate. During the observation, LN 5 did not verify Resident 43's identity prior to administering his medications. When asked about verifying the identities of Residents 73 and 43, LN 5 stated, I didn't do that, my bad. LN 5 stated nursing staff were supposed to check residents' wristbands and ask residents their names. LN 5 then stated she asked for Resident 73's name and name tag. LN 5 was informed that this verification process was not observed. A drug review of donepezil on Micromedex, modified 5/14/26, indicated side effects such as hypertension, syncope, nausea, vomiting, diarrhea, dizziness, insomnia (inability to fall or stay asleep), fatigue, urinary incontinence (uncontrollable urine leakage), gastrointestinal hemorrhage (severe bleeding), and prolonged QT interval (a delay for the heart to recharge between beats, which increase the risk for life-threatening heart rhythms and sudden death). A drug review of escitalopram on Micromedex, modified 5/22/26, indicated side effects such as diaphoresis (excessive sweating), nausea, fatigue, prolonged QT interval and hemorrhage. A drug review of aspirin on Micromedex indicated side effects such as gastrointestinal ulcer (open sore), hemorrhage, tinnitus (ringing in the ear), and angioedema (swelling under the skin in the lips, tongue, or eyelids).A review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 4/19, indicated, .9. The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident may include: checking identification band;checking photograph attached to medical record; andif necessary, verifying resident identification with other facility personnel.10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.26. Medications ordered for a particular resident may not be administered to another resident. On 5/14/26 at 4:41 P.M., a meeting was held with the Administrator (ADM), DON, Assistant Director of Nursing (ADON) 1, ADON 2, Minimum Data Set (MDS, a mandated assessment tool used in nursing homes) Nurse (MDSN), Nurse Consultant (NC), Regional [NAME] President (RVP) and the survey team including the nurse surveyor supervisor. The facility was notified of Immediate Jeopardy (IJ, the most serious deficiency type occurring when a facility's noncompliance places the health and safety of residents at risk for actual or potential serious injury, serious harm, serious impairment or death, which requires immediate correction to prevent further or future serious harm).The IJ was related to the facility's failure to properly verify resident identification prior to medication administration on 4/29/26, and during medication pass observations on 5/11/26-5/12/26 and for the facility's failure to ensure the same nurse who prepared medications administered them on 4/29/26. The IJ Template was provided to the ADM via email. The facility initiated a plan to remove the IJ. After the IJ announcement, on 5/14/26 at 4:49 P.M., the RVP stated, It's preventable. I'm sorry about that for the residents. We'll get it fixed.On 5/14/26 at 6:20 P.M., the facility provided a removal plan. The removal plan was reviewed and was not acceptable.On 5/18/26 at 8:12 A.M., the facility resubmitted a removal plan. The removal plan was reviewed and was not acceptable.On 5/18/26 at 12:22 P.M., the facility resubmitted a removal plan. The removal plan was reviewed and was not acceptable.On 5/18/26 at 4:10 P.M., the facility resubmitted a removal plan. The removal plan was reviewed and was accepted at 4:56 P.M. The IJ Removal Plan indicated:Immediate protective actions.A visual inspection of resident identification armbands started on 5/14/26 at 8 P.M. by the ADM and Social Services to ensure all residents willing to wear an identification armband had one in place.[r]esidents who declined to wear an identification armband were reviewed to ensure an appropriate care plan was implemented and/or updated to address resident identification during medication administration.Corrective measures for the affected residents.Resident 187 was transferred to an acute care facility on 5/12/26 and was not in the facility.Facility-wide system changes. Licensed Nurses must utilize at least two (2) resident identifiers prior to medication administration, such as resident name and date of birth .Nurses received a mandatory in-service and competency evaluation via a return demonstration prior to administering medications. On 5/19/26 at 1:27 P.M., after onsite verification of the implementation of the facility's IJ removal plan, the IJ was removed. After the IJ was removed, the surveyor verified that the facility's non-compliance remained at a scope of isolated (when one or a very limited number of residents are affected and/or a very limited number of staff are involved) and lower severity of Level 3 (Actual Harm that is Not Immediate Jeopardy). On 5/19/26 at 1:27 P.M., the ADM was notified of the removal of the IJ.

Based on observation, interview, and record review, the facility failed to ensure two of four licensed nurses (LN 1 and LN 2) reviewed for medication administration training and competency were trained and deemed competent to administer medications through a facility approved and documented validation evaluation. Licensed Nurse (LN) 1 prepared eight morning medications for Resident 6 including clozapine (used for schizophrenia, a distorted perception of reality), topiramate (used to treat seizures, abnormal and disruptive electrical activity in the brain), and levetiracetam (used to treat seizures) and gave the medications to LN 2 to administer. LN 2 then administered Resident 76's medications to Resident 187. In addition, four other LNs (LN 51, LN 52, LN 3, and LN) did not verify resident identification prior to administering their medications. This failure resulted in LNs failing to follow medication administration rights, including verification of resident identity before administering medication. As a result, Resident 187 received medications ordered for Resident 76 during medication administration training, experienced a significant change in condition, and required hospital admission. Nurses failure to identify the residents identity prior to administering medication may result in residents getting the wrong medication and can result in significant harm to the residents. (cross referenced at F-760) Medication administration observations were conducted for Residents 126, 2, 181, 73, and 43. Licensed Nurses (LNs) did not verify resident identification prior to medication administration as follows: - On 5/11/26 at 12:41 P.M., LN 51 administered a medication to Resident 126 without verifying Resident 126's identity. - On 5/11/26 at 3:34 P.M., LN 52 administered an unlabeled medication in a syringe to Resident 2 without verifying his identity. Resident 2's wristband was observed to be illegible. - On 5/12/26 at 8:19 A.M., LN 3 was observed training LN 4 on preparing and administering medications for Resident 181. Both LNs 3 and 4 administered medications to Resident 181 without verifying his identity. - On 5/12/26 at 9:14 A.M., LN 5 prepared and administered six medications for Resident 73. LN 5 did not verify Resident 73's identity prior to administering Resident 73's medications. - On 5/12/26 at 9:26 A.M., LN 5 prepared and administered six medications for Resident 43. LN 5 did not verify Resident 43's identity prior to giving his medications. 2. Resident 187 was admitted to the facility on [DATE] with diagnoses of depression and bipolar disorder (mental health condition that causes dramatic shifts in a person's mood), per the facility admission record. Resident 76 was admitted to the facility on [DATE] with diagnoses of epilepsy (a brain condition that causes repeated seizures), schizoaffective disorder bipolar type (a mental illness with mood swings and psychosis), and extrapyramidal and movement disorder (medication related movement issues, tremors and stiffness) per the facility admission record. A review of the change of condition note, dated 4/29/26, 1:09 P.M., indicated Resident 187, .mistakenly received medications intended for another resident. A review of the nursing progress note dated 4/29/26, 1:55 P.M., indicated Resident 187 suffered a sudden decline in function with noted altered mental status and was transferred to the hospital emergency room. A review of the facility's medication error report (MER), dated 5/1/26, indicated Resident 187 received Resident 76's scheduled 9 A.M. medications and supplements in error on 4/29/26. The MER indicated medications administered to Resident 187 that could result in altered stated of cognition included benztropine mesylate 76mg (an anticholinergic med that can affect confusion, sedation and heart rate changes), Topamax 765mg and Keppra 500mg (anticonvulsant medications associated with dizziness and confusion), and clozapine 100mg (atypical antipsychotic that can cause sedation, low blood pressure and cardiac complications. The MER indicated Resident 187's mental status became altered after the medications administered in error. The MER further indicated the medications administered in error had the potential to cause serious neurological side effects when combined with Resident 187's routine medications (see F760 for Resident 187's prescribed medications). The MER further indicated the error occurred because the LNs (1, 2) failed to confirm Resident 187's identity before medication administration according to the facility's medication administration procedure and resident identification process. During an interview on 5/13/26 at 3:33 P.M., licensed nurse (LN) 1 stated she was assigned to orient and train newly hired LN 2 during medication administration on the morning of 4/29/26. LN 1 prepared Resident 76's medications and instructed LN 2 to administer the medications to Resident 76. LN 1 stated, she observed LN 2 exiting Resident 187's room shortly afterward. LN 1 stated LN 2 reported she administered Resident 76's medications to Resident 187 because the residents had similar sounding names. LN 1 stated she and LN 2 did not follow nursing medication administration rights, including administering the medication to the right resident at the right time. LN 1 stated Resident 187 experienced a change in mental status and was sent to the hospital. LN 1 stated she had been working at the facility for a little over two months, had never trained another nurse before, and had not received training from the facility on how to precept a newly hired nurse during medication administration. LN 1 stated she had not completed a skills competency checklist upon hire or before being allowed to administer medications to residents at the facility. During an interview on 5/13/26 at 4:11 P.M., LN 2 stated she was being trained by LN 1 during medication administration on 4/29/26. LN 2 stated LN 1 had prepared the medication from the medication cart, placed it in a medication cup, and asked her to administer the medications to Resident 187. LN 2 stated she did not remove the medications from the cart herself and did not compare the medications to the physician's orders in the medication administration record (MAR) before administering the medications to Resident 187. LN 2 stated she did not verify the medications in the cup matched the physician's orders for Resident 187 before administration. LN 2 stated Resident 76 and Resident 187 had similar sounding names, and she must have heard the wrong name when LN 1 asked her to administer the medications. LN 2 stated she did not verify the medications in the cup matched the physician's orders for Resident 187 before administration. LN 2 stated Resident 76 and Resident 187 had similar sounding names, and she must have heard the wrong name when LN 1 asked her to administer the medications. LN 2 stated there were other times that day she had administered medications prepared by LN 1 without checking them against the MAR. LN 2 stated nurses were expected to verify that the MAR order matched the resident's name on their armband before administering medication. LN 2 stated she had not completed that step in the medication administration process, which resulted in a medication error. LN 2 stated LN 1 informed her she was new to the facility and had not been instructed on how to train another nurse. LN 2 also stated the facility did not provide LN 1 with guidelines for training. LN 2 stated she felt the facility's medication training procedures and new hire orientation were inadequate for new nurses. During an interview and concurrent record review on 5/14/26 at 9:36 A.M., LN 1 and LN 2's employee files were reviewed with the director of nursing (DON). The DON stated the assistant director of nursing (ADON 1) or the DON was responsible for overseeing newly hired LN competencies were completed and documented. The DON stated the facility kept documentation of licensed nurse skilled competencies, including medication administration training, in the employee personal files. Review of LN 1's employee file indicated LN 1 was hired on 3/4/26 and the file contained no record of completed medication administration competencies upon hire, or before the medication administration error on 4/29/26. Review of LN 2's employee file indicated LN 2 was hired on 4/22/26 and did not contain documentation of completed medication administration competencies before the medication administration error on 4/29/26. The DON stated the facility recognized there was a problem with their current medication administration training process. A review of the facility policy titled, Administering Medications, revised April 2019, indicated, Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation. 29. New personnel authorized to administer medications are not permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. 30. The charge nurse must accompany new nursing personnel on their medication rounds for a minimum of three (3) days to ensure established procedures are followed and proper resident identification methods are learned. During an interview on 05/19/26 at 4:05 PM, The DON acknowledged LN 1 was a new nurse who was placed in a role to train other new nurses on medication cart without having completed her own medication administration competencies. The DON stated the facility acknowledged they had problems with training new hires and ensuring staff competency, both of which needed to be addressed for resident safety. The DON stated they did not have a written policy or procedure to ensure nurses designated as new hire preceptors were deemed competent to train new nurses regarding medication administration. The DON stated the facility had many issues to fix regarding orientation of new employees. The DON stated it was important to ensure nurses were competent and could pass medications correctly before training another nurse on medication administration. The DON acknowledged Resident 187 experienced a change of condition that led to a hospital admission following a medication error made by LN 1 and LN 2. The DON stated not ensuring nurses were competent in medication administration places all residents at risk of serious harm if something goes wrong. The DON acknowledged the policy indicated a charge nurse must accompany new nursing personnel on their medication rounds for three days to ensure established resident identification procedures were followed. The DON stated the facility had not followed the written procedure for training new LNs outlined in the medication administration policy. A review of the facility policy title Staffing, Sufficient and Competent Nursing, revised March 2026, indicated, Policy Statement: The facility provides sufficient nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation. Competent Staff: 1. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. 2. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. 3. Licensed staff must demonstrate the skills and techniques necessary to care for resident needs including {but not limited to) the following areas. I. medication management. 5. Competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure: a. programming for staff training results in nursing competency; b. gaps in education are identified and addressed; c. education topics and skills needed are determined based on the resident population; d. tracking or other mechanisms are in place to evaluate effectiveness of training; and e. training includes critical thinking skills and managing care in a complex environment with multiple interruptions. The facility had no written policy regarding the training of preceptors to orient and train new nurses. On 5/14/26 at 4:41 P.M., a meeting was held with the Administrator (ADM), DON, Assistant Director of Nursing (ADON) 1, ADON 2, Minimum Data Set (MDS, a mandated assessment tool used in nursing homes) Nurse (MDSN), Nurse Consultant (NC), Regional [NAME] President (RVP) and the survey team including the nurse surveyor supervisor. The facility was notified of Immediate Jeopardy (IJ, the most serious deficiency type occurring when a facility's noncompliance places the health and safety of residents at risk for actual or potential serious injury, serious harm, serious impairment or death, which requires immediate correction to prevent further or future serious harm). The IJ was related to the facility's failure to ensure LNs were trained under a structured medication administration competency process before administering medications to residents. In addition, the facility failed to ensure LNs assigned to precept newly hired LNs during medication administration had documented medication administration competency and preceptor training. The facility also failed to ensure all LNs had completed a competency checklist and return demonstration validation of medication administration prior to administering medications to residents. The facility's failure to ensure LNs were competent in medication administration and resident identification procedures resulted in a significant medication error on 4/29/26. The failure continued during medication administration observations from 5/11/26 through 5/12/26, when LNs failed to verify resident identity before administering medications. On 5/14/26 at 6:20 P.M., the facility provided a removal plan. The removal plan was reviewed and was not acceptable. On 5/18/26 at 8:12 A.M., the facility resubmitted a removal plan. The removal plan was reviewed and was not acceptable. On 5/18/26 at 12:22 P.M., the facility resubmitted a removal plan. The removal plan was reviewed and was not acceptable. On 5/18/26 at 4:10 P.M., the facility resubmitted a removal plan. The removal plan was reviewed and was accepted at 4:56 P.M. The IJ Removal Plan indicated: 1. Immediate protective actions: Beginning on 5/14/26 at 7:45 P.M., Nursing leadership and LNs received immediate verbal in-service education and return demonstration competency evaluation regarding safe medication administration practices. The NC educated the DON, the DON then educated the nurse managers (NM), and the NMs educated the LNs on the floor and oncoming LNs. The removal plan indicated, .Nurses were not permitted to administer medications until they received the required in-service education and successfully completed the competency evaluation. The education and competency evaluation included the eight rights of medication administration, resident identification protocols, and the requirement the LN who dispensed the medication must administer the medication. The facility placed medication rights posters on all medication carts. 2. Corrective measures for affected LNs: The facility required LNs to complete medication administration competency validation through return demonstration and documented completion on the medication administration competency checklist. The facility required nursing staff who were on leave, registry nurses, agency nurses, and LNs who had not completed the required in-service education and return demonstration competency evaluation to complete both before receiving a nursing assignment. A daily review of LN staff assigned to residents was conducted by nursing leadership to ensure in-service education was completed and medication administration competency checklist 3. Facility-wide system changes: The removal plan indicated the facility developed criteria to evaluate and approve licensed nurses to train or orient other nursing staff on medication administration. LNs approved to train other nurses were required to meet criteria that included six months (minimum) off satisfactory medication administration performance, a completed medication administration competency evaluation, and reevaluation of medication administration competency at six months, and DON or designee approval before training or orienting other staff. The facility required the DON or designee to provide ongoing observation, feedback and coaching to trainers and trainees during the medication administration training process. The removal plan indicated continued monitoring of LN medication administration competency for those LNs approved to provide training and orientation would be conducted by the DON. The facility required new hired LNs to complete facility orientation, required in-service education, medication administration competency evaluation, return demonstration, and DON approval before being permitted to independently administer medications. . The following policies were reviewed and/or updated to ensure the facility process will be followed: a. Administering Medications; b. Resident Identification System; c. Performance Evaluations; d. Staffing, Sufficient and Competent Nursing; e. Train the Trainer Competency, medication administration. On 5/19/26 at 1:27 P.M., after onsite verification of the implementation of the facility's IJ removal plan, the IJ was removed. After the IJ was removed, the surveyor verified that the facility's non-compliance remained at a scope of isolated (when one or a very limited number of residents are affected and/or a very limited number of staff are involved) and lower severity of Level 3 (Actual Harm that is Not Immediate Jeopardy). On 5/19/26 at 1:27 P.M., the ADM was notified of the removal of the IJ.

Based on interview and record review, the facility failed to employ a full-time, qualified Social Services Director (SSD) who met the qualifications specified in the regulation (Code of Federal Regulation, S483.70) for facility's with greater than 120 beds. The facility was licensed with a 240 bed capacity. This deficient practice placed all 221 residents at risk of not receiving medically-related social services necessary to attain their highest practicable well-being. Cross Reference: F 791, F 628Findings: On 5/20/26 at 9:37 A.M., a triggered task for extended survey was conducted. An interview and record review with the Administrator (ADM) and Assistant Director of Nursing (ADON) 2 were conducted. The ADM stated the Social Service Director (SSD) resigned in April 2026 and the facility had a part time SSD from another facility. The ADM stated the facility employed four social service assistants, but none of them had a bachelor's degree in social work. A review of the facility's policy titled, Social Services, revised September 2021, indicated, .Our facilities provides medically-related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. Per a facility job description, dated 12/2025 and titled Position: Social Services Director, .Education and/ or Experience: Bachelor's Degree in Social Work or in Human Services and 2 years of supervised social work experience in a healthcare setting.Master in Social Work preferred.

Based on interviews and record reviews, the facility failed to develop a care plan (detailed plan with information about a resident's treatment, goal, and interventions) for: 1. The care of resident (Resident 249) with Chronic Obstructive Pulmonary Disease (COPD - a long-term lung disease that cause inflammation and damage to the airways, making it difficult to breathe),2. The care of resident's medication (Resident 197), 3. The care of a resident's amputation and limited hand ROM (Resident 238),4. A resident (Resident 109) who was assessed as at risk for elopement (when resident departs unsupervised and undetected).5. In addition, a resident's (Resident 29) care plan was not implemented related to nutritional health shakes. Resident 29 did not receive the nutritional health shakes on 5/11/26 and 5/12/26 per the physician's orders. As a result, the lack of a resident centered care plan with specific interventions had the potential to result in delayed care, miscommunication among caregivers, and a decreased physical well-being of the residents. Cross Reference: F 580, F 688, and F 689. Findings: 1. A review of Resident 249's admission Record was conducted, readmitted on [DATE] with a diagnosis that included COPD. On 5/14/26 at 11:36 A.M., an interview and record review was conducted with Licensed Nurse (LN 56). LN 56 reviewed Resident 249's care plan and stated there were no parameters set in the care plan for oxygen therapy. LN 56 stated that a resident with COPD should have a patient centered care plan. LN 56 stated there should have been specific oxygen orders in the care plan and parameters of what oxygen level was acceptable for Resident 249. A review of Resident 249's care plan dated 12/19/25 indicated .oxygen use per physician order . No parameters for oxygen use on what is acceptable for Resident 249. On 5/14/26 at 5:35 P.M., a telephone interview was conducted with Resident 249's attending physician (AP). The AP stated for a COPD patient there should have been supplemental oxygen. The AP stated that she was under the impression that the facility had policies in place regarding saturation oxygen (SpO2) (level of oxygen in the blood) thresholds of 92-95% for resident with COPD. The AP stated that she was not asked to place an order for oxygen thresholds or an oxygen order. On 5/19/26 at 10:05 A.M., an interview and joint record review was conducted with the Director of Nursing (DON). The DON stated for residents with a diagnosis of COPD, the care plan should have included details on oxygen if needed, parameters for notifying the MD, and respiratory signs and symptoms to observe for. The DON stated the physician should establish normal parameters for the resident with COPD. The DON stated there were no set parameters for Resident 249 and there should have been in the care plan. 2. Resident 197 was re-admitted to the facility on [DATE] with diagnoses including subsegmental thrombotic pulmonary embolism (a type of blood clot in the lung) according to the facility's admission Record. During an observation and interview on 5/11/26 at 8:54 A.M. Resident 197 was in bed lying on her right side. Resident 197 stated she was not sure what medications she was taking. A review of physician's orders (POS) in the electronic medical record (EMR) for Resident 197 was conducted. The POS indicated, Eliquis [blood thinner medication] Oral Tablet 5 MG [Apixaban] Give 5 mg by mouth two times a day for Clot prevention. An interview and joint record review was conducted with Licensed Nurse (LN) 31 on 5/13/26 at 3:21 P.M. LN 31 reviewed Resident 197's care plans in the EMR. LN 31 stated there was no care plan to address Resident 197's use of an anticoagulant. LN 31 stated there should be a care plan. LN 31 further stated the purpose of the care plan was to monitor the side effects of the medication and how to care for the resident. During an interview on 5/19/26 at 11:05 A.M. with the Director of Nursing, the DON stated there should have been a care plan because the resident was on the medication and needed monitoring for side effects of the medication. The DON stated the care plan directed how to take care of the resident. 3. Resident 238 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury (TBI-a sudden and violent blow to the head causing damage to the brain) according to the facility's admission Record. During an observation and interview on 5/12/26 at 2:55 P.M., Resident 238 was observed propelling his wheelchair using his left hand and right foot, heading out of the dining room to his room. Resident 238 had a sock over left below the knee amputation (BKA) and his right hand fully closed. Resident 238 attempted to open his right hand and was only able to lift the fifth finger (pinky). Resident 238 stated his right hand has been broken for a while. An interview with Certified Nurse Assistant (CNA) 31 was conducted on 5/13/26 at 8:46 A.M. CNA 31 stated Resident 238 had an amputation of the left leg and kept his right hand closed. An interview and joint record review was conducted with the Minimum Data Set Nurse (MDSN- a nurse who assessed and evaluated the quality of care being given to residents) on 5/19/26 at 8:48 A.M. The MDSN stated the most recent quarterly Minimum Data Set (MDS-a clinical assessment tool) assessment for Resident 238 was completed on 3/17/26. The MDSN stated section GG0115A indicated Resident 238 had impairment on one side of upper extremity and impairment on lower extremity. The MDSN stated Resident 238's admission MDS dated [DATE] also indicated impairment of upper and lower extremities. The MDSN checked the care plans for Resident 238 and stated Resident 238's left BKA and impairment of the right hand was not care planned. The MDSN stated it was important to have a care plan to ensure the Interdisciplinary Team (IDT- team members with various areas of expertise who work together toward the goals of their residents) and all staff knew the resident's needs and how to accommodate them. During an interview with the DON on 5/19/26 at 11:05 A.M., the DON stated it was important to care plan resident's BKA to know how to care for the resident, monitor for changes and address any changes. The DON stated it was important to care plan resident's right hand limitation for staff to know that the resident had limited range of motion (ROM) and have interventions to prevent from worsening. The DON further stated if there were no interventions, the resident's hand can decrease in function. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated March 2022 was conducted. The P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 4. Resident 109 was admitted to the facility on [DATE], with diagnoses which included traumatic subarachnoid hemorrhage (bleeding from a damaged artery in the brain), schizophrenia (mental health disorders), seizures (uncontrollable muscle tone movements, stiffness, twitching or limpness), syncope (fainting or passing out) and collapse, per the facility's admission Record. A review of Resident 109's History and Physical (H&P), dated 4/16/26, was conducted. The H&P indicated Resident 109 could make her needs known but did not have the capacity to make her own decisions. A review of Resident 109's elopement and wandering risk assessment (the potential danger when a patient, often deemed too ill or impaired to make sound decisions, leaves a healthcare facility unauthorized, posing immediate threats to their health or safety) dated 4/14/26 was conducted. The elopement form and wandering risk assessment indicated Resident 109 had a score of 14. Per the facility's elopement form, a score of 10 or greater, the resident was considered at risk for elopement and wandering. A review of Resident 109's care plan on elopement and wandering was conducted. There was no care plan developed for Resident 109's risk for elopement and wandering. On 5/18/26 at 3:53 P.M., an interview was conducted with CNA 22. CNA 22 stated she was familiar with Resident 109. CNA 22 stated Resident 109 was sometimes agitated and wandered around. CNA 22 stated Resident 109 would ask the CNA to call a taxi for her because she wanted to go home, and that she wanted to leave. CNA 22 stated on 5/10/26, she was assigned to provide care to Resident 109. CNA 22 stated she started her shift at 3 P.M. and she did not recall seeing Resident 109. CNA 22 stated that day (5/10/26) she was so busy and she did not realize Resident 109 was not in her room until the time she was passing the dinner meal tray around 5:15 P.M. to 5:30 P.M. CNA 22 stated no one had set eyes on Resident 109. On 5/19/26 at 10:45 A.M., a telephone interview was conducted with Licensed Nurse 21. LN 21 stated she was familiar with Resident 109 and had worked with her for a month. LN 21 stated Resident 109 was alert and oriented but had delusions (false beliefs) that she was at the facility because she was pregnant and needed an abortion. LN 21 stated during the PM shift (3-11 PM), Resident 109 would sit in front of her room waiting for smoking time. LN 21 stated Resident 109 would also pace in the hallway and in front of her room and would refuse her medications because we are poisoning her and that she was pregnant. LN 21 stated some days she wants abortion; some days she wants to keep her baby. LN 21 stated on the day of the incident (5/10/26, Sunday), Resident 109 left the facility without their knowledge. LN 21 stated she vividly remembered because she was busy helping the morning (AM) shift nurse since the AM nurse was behind. LN 21 stated there were a few things going on at the same time on 5/10/26. LN 21 stated she did not recall seeing Resident 109 when she arrived on 5/10/26 at 3 P.M. LN 21 stated she and CNA 22 realized Resident 109 was not in her room on 5/10/26 past 5 P.M., when LN 21 was about to give medications to Resident 109 and CNA 22 delivered Resident 109's dinner tray. LN 21 stated they went to check for Resident 109 around the facility but could not find her. LN 21 stated at the time she was about to call code green (a facility code to call attention that a resident is missing), she received a call from the fire department at around 6:10 P.M. stating that Resident 109 was found a few blocks away from the facility. LN 21 stated with a wandering and risk assessment score of 10, the resident would be considered at risk for elopement. A record review of the facility's investigation timeline dated 5/10/26 indicated no staff directly witnessed resident exiting the facility premises. Per the same investigation timeline, Resident 109 was determined to exit the facility through the side door at station 1 at around 1:20 P.M. on 5/10/26. Per the same timeline, the fire department called the facility at around 6:10 P.M. to inform the LN that Resident 109 was found one block away from the facility. On 5/19/26 at 12:08 P.M., a joint review of Resident 109's clinical record and an interview was conducted with Assistant Director of Nursing (ADON) 2. ADON 2 stated Resident 109 had an elopement and wandering risk assessment score of 14 on 4/14/26. ADON 2 stated for a risk assessment of 10 or greater, the resident was considered at risk for elopement. ADON 2 stated she did not see a care plan in Resident 109's clinical record. ADON 2 stated a care plan should have been developed for Resident 109's risk of elopement and interventions should have been put in place to prevent elopement and untoward events. On 5/19/26 at 4:17 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was that the resident should have been identified as elopement risk, and interventions should have been put in place to ensure the resident did not leave the facility for safety reasons. The DON stated a care plan should have been developed for Resident 109 so the staff would understand as to what would be the interventions to prevent the resident from elopement and wandering out of the facility. A review of the facility's policy titled, Wandering and Elopements, revised March 2019, indicated, The facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for resident.1. If identified as at risk for wandering, elopement.the resident's care plan will include strategies and interventions to maintain the resident's safety. A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. 5. Resident 29 was readmitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing), per the facility's admission Record. A review of Resident 29's physician order dated 2/26/26 indicated, Mighty shake (health shake) three times a day for supplement. Resident 29's diet order included puree texture diet with teaspoon (TSP) sips of mildly thick liquids only. A review of Resident 29's nutritional care plan dated 4/6/26, indicated, Mighty shake TID (three times a day) 118 milliliters (mls, unit of measurement) related to weight loss. On 5/11/26 at 1:21 P.M., an observation was conducted of Resident 29 in her room. Resident 29 did not respond to her name. A note over the resident's head was observed hung at the cork board. The note indicated Speech Language Pathologist (SLP, therapist that treats speech and swallowing capabilities) precautions instructing the staff to assist feeding Resident 29 and used teaspoon to sip liquids after three bites. On 5/11/26 at 1:22 P.M., an observation was conducted of Restorative Nursing Assistant (RNA) 21 feeding Resident 29 during lunch time. Resident 29's meal tray consisted of pureed regular fortified diet, mashed potatoes, mildly thick fruit juice and syrup. The meal ticket for Resident 29 indicated mighty shake. The meal tray did not contain the mighty shake as ordered by the physician. On 5/13/26 at 10:25 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 23. CNA 23 stated she was familiar with Resident 29, and that Resident 29 was totally dependent on staff. CNA 23 stated Resident 29 had a sip of thickened liquid using a teaspoon. CNA 23 stated normally, the mighty shake came with the meal tray. CNA 23 stated she fed Resident 29 during breakfast and there was no mighty shake in her meal tray. On 5/18/26 at 3:19 P.M., an interview was conducted with RNA 21. RNA 21 stated she remembered feeding Resident 29 on Monday (5/11/26). RNA 21 stated there was no mighty shake in Resident 29's lunch meal tray. RNA 21 stated she knew what a mighty shakes looked like. On 5/18/26 at 3:21 P.M., an observation of the mighty shakes and an interview with RNA 21, Dietary Aide (DA) 21 and Dietary Director (DD) were conducted in the kitchen. RNA 21 stated to DA 21 and the DD that she fed Resident 29 on 5/11/26 (Monday) during lunch time, and that she did not see a mighty shake on Resident 29's meal tray. The DD stated if mighty shakes were not on the resident's meal tray on Monday and Tuesday, it would have been placed on the meal trays by Tuesday lunch time. On 5/19/26 at 12:18 P.M., a joint record review of Resident 29's clinical record and an interview was conducted with the Assistant Director of Nursing (ADON) 2. ADON 2 stated the care plan should have been implemented for Resident 29's nutritional health shakes to prevent weight loss. On 5/19/26 at 4:17 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the staff should have implemented Resident 29's care plan and if there was no mighty shake in the meal tray, the CNAs should have communicated it to the Licensed Nurse (LNs) so they can inform the kitchen. The DON stated the purpose of the care plan was for the team to evaluate if the interventions that was put in place was working. A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to ensure the safe labeling and storage of medications in accordance with accepted professional standards when:Refrigerated medications were stored outside proper temperature controls in one of two inspected medication rooms. This failure had the potential for residents to be administered medications that were ineffective, which could result in adverse resident outcomes.Expired medications were not removed from stock in three of six inspected active medication carts. In addition, a medication for a discharged resident (Resident 122) was not separated from active medications in the medication cart. This failure had the potential for residents to receive deteriorated (reduced quality) and ineffective medications.Multiple in-use medications were not labeled with the date opened and/or the beyond use date (BUD, the last date opened medications can safely be used) in three of six inspected medication carts. In addition, for one of nine sampled residents (Resident 198) observed for medications administration, a medication was observed to be administered without a date opened or BUD recorded. This failure had the potential for residents to receive deteriorated (reduced quality) and ineffective medications.Multiple medications had prescription labels only on the outer carton and did not have prescription labels affixed to the devices (inhalers mouthpiece or insulin [used to lower blood sugar] vials). This failure had the potential for residents to receive the wrong inhaler or insulin, which could result in adverse resident outcomes, infections from accidental cross-contamination (germs), and medication errors.Findings:1. During a concurrent observation and interview on 5/12/26 at 3:10 P.M., an inspection of the Station 3 medication room was conducted with Licensed Nurse (LN) 54. A medication refrigerator was inspected. A thermometer inside read 34 F (degrees Fahrenheit, a measurement of temperature). LN 54 verified the temperature reading. Three boxes each containing a Mantoux (diagnostic test to detect tuberculosis infection) vial were observed in the refrigerator. The manufacturer labeling indicated, Store at.35 to 46 F. LN 54 stated the storage temperature was off.During a concurrent observation of the Station 3 medication room and interview with the Assistant Director of Nursing (ADON) 2 on 5/12/26 at 3:26 P.M., ADON 2 stated the Mantoux vials were not stored at an appropriate temperature.The refrigerator was observed to contain other medications, including the following:an emergency medication kit, which contained vials of injectable lorazepam (a medication used to treat anxiety, a condition characterized by excessive worrying) and different types of insulin (a medication used to lower blood sugar),acetaminophen (used for pain or fever) suppositories (medications designed to be inserted into a body cavity, such as the rectum) for Resident 91,Epogen (a medication for anemia) for Resident 102,Epogen for Resident 17,Epogen for Resident 129,insulin glargine yfgn (a type of insulin) for a resident,Lantus (a type of insulin, brand name for insulin glargine) for Resident 151,Lantus for Resident 235,Lantus for Resident 72,Basaglar (a type of insulin, brand name for insulin glargine) kwikpen (a prefilled injection device, a pen) for Resident 160,Humalog (a type of insulin, brand name of insulin lispro) for a resident,Fiasp (a type of insulin, brand name of insulin aspart) for a resident,Novolog (a type of insulin, brand name of insulin aspart) for Resident 17,Humulin R (a type of insulin, brand name for regular insulin) for Resident 63,Insulin lispro (a type of insulin) for Resident 176Arexvy (a vaccine that protects against Respiratory Syncytial Virus, RSV, an illness of the lungs) vial kit for Resident 63,Latanoprost (an eye drop used for glaucoma, elevated pressure in the eye) for Residents 235, andLatanoprost for Resident 153.During an interview with the Director of Nursing (DON) on 5/20/26 at 7:57 A.M., the DON stated the medication refrigerators should have a temperature range of 36-46 F. The DON confirmed the Station 3 medication room refrigerator was out of range during the inspection on 5/12/26.A review of the Epogen PI, provided by the facility, indicated, .Store at 36 F to 46 F.A drug review of insulin glargine, provided by the facility, indicated .Store unopened insulin glargine vials and pens at 36 to 46 F.A drug review of insulin aspart, provided by the facility, indicated .Store unopened insulin aspart vials.and pens under refrigeration (36 to 46 F.).A drug review of insulin lispro, provided by the facility, indicated .Store lispro in refrigerator (36 to 46 F.).A drug review of regular insulin, provided by the facility, indicated .Store unopened vials and pens in refrigerator at 36 to 46 F.A drug review of the Arexvy PI, provided by the facility, indicated .Store refrigerated between.(36 F and 46 F).A drug review of latanoprost PI, provided by the facility, indicated .Store unopened bottle(s) under refrigeration.(36 to 46 F).2. During a concurrent observation and interview on 5/11/26 at 3:34 P.M., an inspection of the Station 2 Medication Cart 2A was conducted with LN 52. Two expired bottles of medications were observed stored in the medication cart available for use:Vitamin B6 (a vitamin) 100 mg expired 3/2026,Aspirin (blood thinner used to prevent heart attacks and strokes or for pain) 325 mg enteric coated (EC, designed to release in the small intestine) expired 12/2025.LN 52 acknowledged both medication bottles were expired. LN 52 stated expired medication were to be discarded because they would be ineffective.During a concurrent observation and interview on 5/13/26 at 12:02 P.M. with ADON 2, the Station 3 Medication Cart 3B was inspected. A bottle of bisacodyl (a laxative, used to stimulate bowel movements) 5 mg tablets with a manufacturer expiration date of 3/2026 was observed stored in the medication cart available for use. ADON 2 stated the expired bisacodyl bottle should not be in the active medication cart.During a concurrent observation and interview with LN 53 on 5/13/26 at 12:23 P.M., an inspection of the Sation 3 Medication Cart 3A was conducted. A bottle of Vitamin B6 100 mg with a manufacturer expiration date of 3/2026 was observed stored in the medication cart, available for use. LN 53 acknowledged the bottle of Vitamin B6 was expired.In addition, Trelegy Ellipta (a medication used to treat respiratory conditions) 100/62.5/25 mcg (micrograms, a unit of measure) for Resident 122 was observed stored in the medication cart, without a label on the inhaler mouthpiece. LN 53 stated Resident 122's inhaler should have a label on the device.A review of Resident 122's medical record indicated he was discharged from the facility on 5/7/26.During an interview with the DON on 5/20/26 at 7:57 A.M., the DON stated nursing staff were expected to remove and immediately replace medications nearing their expiration date or if they were already expired. The DON stated nursing staff should have removed Resident 122's medication from the medication cart.A review of the facility's P&P titled, Medication Labeling and Storage, revised 2/23, indicated, .3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.A review of the facility's P&P titled, Discontinued Medications, revised 11/22, indicated, .3. Discontinued medications are destroyed or returned to the issuing pharmacy.3a. During a concurrent observation and interview with LN 52 on 5/11/26 at 3:34 P.M., an inspection of the Station 2 Medication Cart 2A was conducted. An opened fluticasone-salmeterol (medication for respiratory conditions) inhaler for Resident 253 was observed stored in the medication cart, available for use, without a date open or BUD recorded on the date opened and BUD sticker affixed to the outer carton. LN 52 confirmed the medication was in use and acknowledged it should have a date recorded on it. The manufacturer product labeling indicated on the outer carton, indicated, .Discard the inhaler 1 month after opening the foil pouch.3b. During a concurrent observation and interview with ADON 2 on 5/13/26 at 11:40 A.M., an inspection of the Station 4 Medication Cart 4A was conducted. Two opened foil pouches were found in a carton of budesonide (a medication used for various conditions, including respiratory ones) for Resident 175. The opened foil pouches did not have a date open. ADON 2 confirmed the carton of budesonide did not have the date opened on it and acknowledged it should have one. The manufacturer labeling indicated, .Once the foil.is opened, use.within 2 weeks.3c. During a concurrent observation and interview with ADON 2 on 5/13/26 at 12:02 P.M., an inspection of the Station 3 Medication Cart 3B was conducted. A pharmacy bottle of levetiracetam (a medication used to treat seizures, abnormal and disruptive electrical activity in the brain) oral suspension (liquid medication) for Resident 15 was observed with a prescription label affixed to the bottle from pharmacy, but the BUD sticker from pharmacy was left blank. ADON 2 acknowledged that the BUD sticker from the pharmacy was blank.3d. During a concurrent medication administration observation and interview, LN 3 was observed training LN 4 in preparing and administering 11 medications for Resident 198. One of the medications was Spiriva (a medication used for respiratory conditions). Both the BUD date and date opened stickers were observed to be blank. The manufacturer labeling on the inhaler indicated, Discard 3 months after insertion of cartridge into inhaler. The inhaler also had a blank space to record the Discard by. date. After reading the manufacturer labeling on the product, LN 3 stated the medication should have a date open or BUD recorded.During an interview with the DON on 5/20/26 at 7:57 A.M., the DON stated the BUD stickers should be utilized by nursing staff. The DON stated nursing staff were expected to record the BUD on the stickers to ensure medications they are administering were still good. The DON stated all medications, including the levetiracetam suspension, needed to have a BUD.A review of the facility's P&P titled, Administering Medications, revised 4/19, indicated, .12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.4a. During a concurrent observation and interview with ADON 2 on 5/13/26 at 12:02 P.M., an inspection of the Station 3 Medication Cart 3B was conducted. Resident 82's Trelegy Ellipta (medication for respiratory conditions) inhaler was observed stored in the medication cart. The inhaler was inside an outer carton that had the prescription label from the pharmacy, but the inhaler mouthpiece inside the medication carton did not have a prescription label attached to it. ADON 2 acknowledged the inhaler did not have a prescription label affixed to it.4b. During a concurrent observation and interview with LN 53 on 5/13/26 at 12:23 P.M., an inspection of the Station 3 Medication Cart 3A was conducted. A vial of insulin observed stored in the medication cart for Resident 72, in an outer bag that had a pharmacy prescription label. The insulin vial, itself, did not have a prescription label attached to it.During an interview with the DON on 5/20/26 at 7:57 A.M., the DON stated medications should have a prescription label both on the outer carton and on the medication inside.A review of the facility's P&P titled, Medication Labeling and Storage, revised 2/23, indicated, .Medication Labeling 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. The medication label includes, at a minimum.d. expiration date.8. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.

Based on observation, interviews, and record reviews, the facility failed to ensure the physician was notified when a prescribed medication was unavailable and not administered for one of three residents (Resident 249) reviewed for physician notification. This failure to notify the physician of the unavailable medication and missed doses had the potential to negatively affect Resident 249's treatment and clinical condition.Findings: A review of Resident 249's admission Record, readmitted on [DATE] with a diagnosis that included Chronic Obstructive Pulmonary Disease (COPD - a long-term lung disease that cause inflammation and damage to the airways, making it difficult to breathe) was conducted. A review of Resident 249's physician order for levetiracetam (medication to prevent seizures) 1500 milligrams (mg) twice a day for seizures and an order for Incruse Ellipta (treatment for COPD) Inhalation Aerosol Powder Breath Activated 1 puff inhale orally in the morning for shortness of breath (SOB/wheezing) dated 12/18/25 was conducted. Resident 249's Medication Administration Record (MAR) for 2/2026 indicated levetiracetam was not administered on 2/17/26 at 9 A.M and 5 P.M. and on 2/18/26 at 9 A.M. and was documented as on order. Resident 249's MAR for 2/2026 indicated Incruse Ellipta inhaler was not administered on 2/17/26 and 2/18/26 and was documented as on order. On 5/13/26 at 4:23 P.M., an interview and joint record review was conducted with Licensed Nurse (LN 6). LN 6 reviewed Resident 249's [DATE]/2026 for levetiracetam and Incruse Ellipta inhaler. LN 6 stated it was not given on 2/17/26 and 2/18/26. LN 6 stated on order meant that medication was pending delivery from the pharmacy. LN 6 stated if a medication was not received within two hours, the pharmacy should be called. LN 6 stated if the dose was not received in four hours, the physician should be notified. LN 6 stated there was no documentation that the pharmacy or the physician being contacted and there should have been. On 5/14/26 at 5:35 P.M., a telephone interview was conducted with Resident 249's attending physician (AP). The AP stated Resident 249 was high risk for a seizure. The AP stated she should have been notified about missing doses as she would have wanted to know the reason why it was not available. The AP also stated she would have considered administering a loading dose after Resident 249 missed three consecutive doses of levetiracetam. On 5/19/26 at 10:05 A.M., an interview and joint record review was conducted with the Director of Nursing (DON). The DON reviewed Resident 249's MAR for 2/2026 for levetiracetam and inhaler missed doses on 2/17/26 and 2/18/26. The DON stated nursing staff should have called the pharmacy and notified the physician even after one missed dose. A review of facility policy and procedures titled Change in a Resident's Condition or Status, dated 2001, indicated .1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): .f. refusal of treatment or medication two or more consecutive times.

Based on observation, interview, and record review, the facility failed to ensure a resident was free from restraint for one of eight sampled residents (Resident 151) reviewed for restraint. This failure had the potential to restrict Resident 151's freedom of movement. Findings: Resident 151 was readmitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (a change in how your brain works due to an underlying condition, it can cause confusion, memory loss), per the facility's admission Record. On 5/11/26 at 3:51 P.M., an observation of Resident 151 and an interview with the Hospitality Aide (HA) 21 were conducted in Resident 151's room. There was a falling-star icon noted by the resident's name. HA 21 was watching the resident while Resident 151 was asleep. HA 21 stated Resident 151 was placed on one-on-one due to a fall risk. On 5/12/26 at 8:29 A.M., an observation of Resident 151 and an interview with Restorative Nursing Assistant (RNA) 21 was conducted in Resident 151's room. Resident 151 was in bed. The foot of the bed was elevated, and an opened geri chair (reclining chair) was on the left side of the bed with the half rails of the bed raised. Resident 151 held to the rails and tried to get up but unable to. Resident 151 attempted to get up several times but was unsuccessful. RNA 21 stated Resident 151 was trying to get up but was a known fall risk. On 5/13/26 at 8:52 A.M., an interview was conducted with CNA 24. CNA 24 stated Resident 151 was placed on one on one because she was a fall risk. CNA 24 stated when Resident 151 was aggressive and she would get up unassisted. CNA 24 stated the geri chair should not have been there because it restricted Resident 151's movement. On 5/13/26 at 9:50 A.M., a follow up interview was conducted with RNA 21. RNA 21 stated she provided one-on-one supervision for Resident 151 on 5/12/26. RNA 21 stated Resident 151 was jumping from bed to the geri- chair. RNA 21 stated Resident 151 crawled from the bed, but was unable to because the foot of the bed was elevated. RNA 21 stated the reason she placed the geri chair closed to Resident 151's bed was to allow the resident more space and ensure her safety. RNA 21 stated she had planned to walk Resident 151 out of her room, but I was told not to because you guys (surveyors) are here. On 5/13/26 at 4:03 P.M., an interview was conducted with Licensed Nurse (LN) 22. LN 22 stated Resident 151 was confused and demented (impaired memory and thinking skills). LN 22 stated Resident 151 was placed on one-to-one supervision due to a previous falls. LN 22 stated there should be no restraints to restrict the resident's movement in the bed or in the chair. LN 22 stated we are not to restrain her. On 5/19/26 at 12:31 P.M., an interview was conducted with the Assistant Director of Nursing (ADON) 2. ADON 2 stated the expectation was to ensure resident's safety but not to restrain Resident 151. ADON 2 stated the staff should have used an intervention to calm Resident 151 down. ADON 2 stated Resident 151 should not have been restricted from moving in her bed. On 5/19/26 at 4:17 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 151's movement should not have been restricted. The DON stated if the resident was agitated, the staff should have implemented interventions such as changing the resident's environment, getting her out of bed, or offering a geri chair. The DON stated the staff should not hinder or restrict Resident 151's movements in any way. Per the facility's policy, titled Use of Restraints, revised April 2017, .Restraints shall only be used for the safety and well-being of the resident(s).Restraints shall only be use to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls.

Based on interview and record review the facility failed to notify the State Long-Term Care Ombudsman (patient advocate) regarding a facility-initiated transfer for one of three residents (Resident 248) for discharge process. This failure to notify the Ombudsman had the potential to limit resident advocacy (patient rights) services and protections related to transfer and discharge rights.Findings:A review of Resident 248's admission Record indicated Resident 248 was readmitted to the facility on [DATE] and discharge on [DATE] to an acute care hospital for a change in condition. On 5/19/26 at 10:05 A.M., an interview and joint record review was conducted with the Director of Nursing (DON). The DON reviewed Resident 248's discharge note, which indicated the resident was discharged to an acute care hospital on 2/20/26. The DON stated nursing staff should have completed the Ombudsman notification and that Social Services should have sent the notification form to the Ombudsman. The DON stated it was important to send notification to the Ombudsman as part of resident's rights and to ensure that the resident advocate was adequately informed. A review of the facility's policy titled Transfer or Discharge Notices, dated 2001, indicated .4. A copy of the notice is sent to the Office of the State Long-Term Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

Based on observation, interview and record review, the facility failed to update or revise care plans for two of eight residents reviewed for care planning (Resident 244 and 50). This failure had the potential to result in delayed care, miscommunication among caregivers, and decreased physical well-being of the residents.Findings: 1. Resident 244 was re-admitted to the facility on [DATE] with diagnosis including Alzheimer's Disease (a brain disorder that slowly destroys memory, thinking skills and eventually the ability to carry out simple tasks) according to the facility's admission Record. During the facility's re-certification survey on [DATE], a facility reported incident was investigated involving Resident 244 and Licensed Nurse (LN) 32. A review of Resident's 244's progress note (PN) in the Electronic Medical Record (EMR) was conducted. PN dated [DATE] at 10:11 A.M. indicated, LATE ENTRY.Staff member reported an incident involving the resident to the administrator on behalf of a housekeeper for an alleged abuse.the housekeeper witnessed LN yelling and assisting resident in a concerning manner. A review of the facility's Alleged Abuse Investigation dated [DATE] was conducted. The investigation indicated, Following completion of investigation, the allegation was determined to be unsubstantiated.The assigned [Licensed Vocational Nurse] LVN was cleared to return to work The LVN will not be assigned to resident's unit and will undergo additional in-service training and re-education regarding interactions.Resident presents at baseline with no observable signs of ongoing distress or adverse psychosocial effects related to the reported incident. A review of care plans in EMR for Resident 244 was conducted. A care plan initiated on [DATE] indicated, A staff member alleged that a LVN was aggressive when attempting to assist and redirect resident.Interventions. Alleged abuse reported.Observe for signs and symptoms of distress such as crying, social isolation and withdrawal from normal demeanor, deviation from past spiritual beliefs, inability to control behavior or anger, and stereotyped responses to any stressor. The care plan did not indicate not assigning the LN 32 to care for Resident 244 as indicated in the facility's abuse allegation investigation. An interview was conducted with the Administrator (ADM) on [DATE] at 10:58 A.M. The ADM stated he completed investigations for abuse allegations. For weekend incidents, a manager would initiate the investigation then he would follow up on Monday. The ADM stated the Director of Nursing (DON) would be responsible for reassigning staff if needed. An interview was conducted with the DON on [DATE] at 11:05 A.M. The DON stated the five-day summary of investigation was based on Interdisciplinary (IDT-team members with various areas of expertise who work together toward the goals of their residents) collaboration to make a decision on what was best for the resident and should be carried over to care plan. The DON stated care plans were for staff to know the plan of care and how to care for the resident. 2. Resident 50 was admitted to the facility on [DATE] with diagnoses including dementia (an impairment of brain function, such as memory loss and judgment) according to the facility's admission Record. During an observation and interview on [DATE] at 8:11 A.M., Resident 50 was in bed repeatedly stated, We are rich, we are rich, we are rich, we are rich, then stated he was okay. During a review of physician's orders (POS) in the electronic medical record (EMR) for Resident 50, the POS indicated, Resident is admitted to Hospice Care.Admitting DX [diagnosis]: Primary: Unspecified Severe Protein-Calorie Malnutrition [inadequate intake of nutrients to meet the body's needs] Secondary: Senile Degeneration of the Brain [a progressive, age-related decline in cognitive function].certifies that the resident is terminally ill with a prognosis of of [sic] six months or less if disease runs its normal course. An interview and joint record review was conducted on [DATE] at 2:50 P.M. with Licensed Nurse (LN) 31. LN 31 reviewed care plans in the EMR for Resident 50. LN 31 stated Resident 50 had a care plan which indicated full code (life saving measures used if a person's breathing or heartbeat stops). LN 31 reviewed Resident 50's Physician's Order for Life-Sustaining Treatment (POLST- written order which outlines a resident's treatment preferences). LN 31 stated the POLST indicated Do Not Resuscitate (DNR-a medical order for providers not to perform CPR), comfort care. LN 31 stated the care plan was inaccurate and there should be a care plan according to Resident 50's POLST. An interview was conducted with the Social Service Designee (SS) on [DATE] at 8 A.M. The SS stated she was responsible for residents' care plans pertaining to smoking, discharges, psychosocial well-being, POLST and hospice. The SS reviewed Resident 50's care plan and POLST in the EMR. The SS stated Resident 50's care plan did not match the POLST. The SS stated Resident 50's care plan should match Resident 50's POLST for staff to know what to do in an emergency. During an interview with the Director of Nursing (DON) on [DATE] at 11 A.M., the DON stated Resident 50's care plan for full code did not match resident's POLST for no code. The DON stated the inaccurate care plan was a problem because it was against resident and or family's wishes. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated [DATE] was conducted. The P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to address a resident's limited range of motion (ROM- the full movement potential of a joint, measuring both distance and direction it can bend, straighten, or rotate) on the right hand for one of eight residents (Resident 238), reviewed for positioning and limited ROM. As a result, Resident 238 had the potential for contractures (shortening of muscles and tendons, often leading to permanent deformity and stiffening of joints) and a decline in movement. Findings: Resident 238 was admitted to the facility on [DATE] with diagnosis including traumatic brain injury (TBI- a sudden and violent blow to the head causing damage to the brain) according to the facility's admission Record. During an observation and interview on 5/12/26 at 2:55 P.M., Resident 238 was observed propelling his wheelchair using his left hand and right foot, heading out of the dining room. Resident 238 entered his room. Resident 238 had a sock over the left below the knee amputation (BKA) and his right hand was fully closed. Resident 238 attempted to open his right hand and was only able to lift the fifth finger (pinky). Resident 238 stated his right hand has been broken for a while. An interview with Certified Nurse Assistant (CNA) 31 was conducted on 5/13/26 at 8:46 A.M. CNA 31 stated Resident 238 required assistance with dressing due to right hand being closed. On 5/13/26 at 10:54 A.M. Resident 238 was in the dining room with a hospital gown asking staff for cigarettes. Resident 238's right hand was closed and Resident 238 stated he could not open his right hand. Resident 238 stated staff did not do anything for his right hand. An interview was conducted on 5/14/26 at 8:28 A.M. with the Director of Rehab (DOR). The DOR stated he had not seen Resident 238's right hand. The DOR reviewed the electronic medical record (EMR) for Resident 238. The DOR stated Resident 238 had occupational therapy (OT) from 9/15/25 through 10/23/25 and the OT discharge note did not address Resident 238's right hand. A follow up interview on 5/19/26 at 8:03 A.M. with the DOR was conducted. The DOR stated Resident 238 was assessed on 5/14/26 and Resident 238 was able to fully open his right hand/fingers without limitation. The DOR then stated, Resident 238 did have limitation of right fingers, including the right thumb. The DOR stated Resident 238 should have been referred to Restorative Nursing Assistant (RNA- a CNA who work alongside rehab staff to provide exercises for residents with limited mobility). During an interview on 5/19/26 at 8:12 A.M. with the RNA, the RNA stated Resident 238 kept his right hand closed. The RNA stated Resident 238 could not fully open the right hand, especially the right thumb. The RNA stated Resident 238 only had sit to stand exercises in the past but no exercises for the right hand. During an interview and joint record review on 5/19/26 at 8:32 A.M. with the Unit Manager (UM), the UM stated the most recent nursing weekly summary dated 5/6/26 did not address Resident 238's right hand limitation. During an interview on 5/19/26 at 8:37 A.M. with Licensed Nurse (LN) 31, LN 31 stated Resident 238 had always had his right hand closed and did not have orders for a splint. LN 31 stated Resident 238 needed assistance with dressing and toileting due to contracture of right hand. An interview and joint record review was conducted with the Minimum Data Set Nurse (MDSN- a nurse who assessed and evaluated the quality of care being given to residents) on 5/19/26 at 8:48 A.M. The MDSN stated the most recent quarterly Minimum Data Set (MDS-a clinical assessment tool) assessment for Resident 238 was completed on 3/17/26. The MDSN stated section GG0115A indicated Resident 238 had impairment on one side of upper extremity and impairment on lower extremity. The MDSN stated Resident 238's admission MDS dated [DATE] also indicated impairment of upper and lower extremities. An interview was conducted on 5/19/26 at 11:05 A.M. with the Director of Nursing (DON). The DON stated it was important to care plan Resident 238's right hand limitation for staff to know that resident had limited ROM and have interventions to prevent from worsening. The DON stated if there were no interventions, Resident 238's hand can decrease in function. The DON stated rehab treatments were to maintain or improve resident's current level of function. During a review of the facility's undated policy and procedure (P&P) titled, Specialized Rehabilitative Services, the P&P indicated, Our facility will provide Rehabilitative Services to residents as indicated.Once a resident has met his/her care goals, a licensed professional can either discontinue treatment or initiate a maintenance program which either Nursing or Restorative Aides will implement to assure that the resident maintains his/her functional and physical status.

Based on observation, interviews and record reviews, the facility failed to ensure adequate supervision was provided to a resident who was at risk for elopement (when resident departs unsupervised and undetected) for one sampled resident (Resident 109) reviewed for elopement. As a result, Resident 109 successfully eloped and unsafely wandered out of the Skilled Nursing Facility (SNF) on 5/10/26. Resident 109 was found by the fire department on 5/10/26 and was brought back to SNF on 5/10/26 past 6:10 P.M. Cross Reference: F 656Findings: Resident 109 was admitted to the facility on [DATE], with diagnoses which included traumatic subarachnoid hemorrhage (bleeding from a damaged artery in the brain), schizophrenia (mental health disorders), seizures (uncontrollable muscle tone movements, stiffness, twitching or limpness), syncope (fainting or passing out) and collapse, per the facility's admission Record. A review of Resident 109's History and Physical (H&P), dated 4/16/26, was conducted. The H&P indicated Resident 109 could make her needs known but did not have the capacity to make her own decisions. A review of Resident 109's minimum data set (MDS - a federally mandated resident assessment tool) dated 4/24/26, indicated Resident 109's Brief Interview for mental status (ability to think and recall) had a score of 9 which indicated Resident 109 had moderate cognitive impairment. A review of Resident 109's elopement and wandering risk assessment (the potential danger when a patient, often deemed too ill or impaired to make sound decisions, leaves a healthcare facility unauthorized, posing immediate threats to their health or safety) dated 4/14/26 was conducted. The elopement form and wandering risk assessment indicated Resident 109 had a score of 14. Per the facility's elopement form, a score of 10 or greater, the resident was considered at risk for elopement and wandering. On 5/11/26 at 11:41 A.M., an observation and an interview of Resident 109 was conducted. Resident 109 was sitting in a chair in front of her room with a facility staff watching her. When asked how she was, Resident 109 got up her chair and stated to leave her alone. On 5/11/26 at 9:42 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 21. CNA 21 stated Resident 109 was confused but she knew when she wanted something. CNA 21 stated Resident 109 prior to eloping from the facility, Resident 109 would pace in the hallway and in the nurses' station. On 5/18/26 at 3:53 P.M., an interview was conducted with CNA 22. CNA 22 stated she was familiar with Resident 109. CNA 22 stated Resident 109 was sometimes agitated and wandered around. CNA 22 stated Resident 109 would ask the CNA to call a taxi for her because she wanted to go home, and that she wanted to leave. CNA 22 stated on 5/10/26, she was assigned to provide care to Resident 109. CNA 22 stated she started her shift at 3 P.M. and she did not recall seeing Resident 109. CNA 22 stated that day (5/10/26) she was so busy and she did not realize Resident 109 was not in her room until the time she was passing the dinner meal tray around 5:15 P.M. to 5:30 P.M. CNA 22 stated no one had set eyes on Resident 109. On 5/19/26 at 10:45 A.M., a telephone interview was conducted with Licensed Nurse 21. LN 21 stated she was familiar with Resident 109 and had worked with her for a month. LN 21 stated Resident 109 was alert and oriented but had delusions (false beliefs) that she was at the facility because she was pregnant and needed an abortion. LN 21 stated in the PM shift (3-11 PM), Resident 109 would sit in front of her room waiting for the smoking time. LN 21 stated Resident 109 would also pace in the hallway and in front of her room and refused her medications because we are poisoning her and that she was pregnant. LN 21 stated some days she wants abortion; some days she wants to keep her baby. LN 21 stated on the day of the incident (5/10/26, Sunday), Resident 109 left the facility without their knowledge. LN 21 stated she vividly remember because she was busy helping the morning (AM) shift nurse since the AM nurse was behind. LN 21 stated there were few things going on at the same time on 5/10/26. LN 21 stated she did not recall seeing Resident 109 when she arrived on 5/10/26 at 3 P.M. LN 21 stated she and CNA 22 realized Resident 109 was not in her room on 5/10/26 past 5 P.M., when LN 21 was about to give the medications to Resident 109 and CNA 22 delivered Resident 109's dinner tray. LN 21 stated they went to check Resident 109 around the facility but could not find her. LN 21 stated at the time she was about to call code green (a facility code to call attention that a resident is missing), she received a call from the fire department at around 6:10 P.M. that Resident 109 was found few blocks away from the facility. A record review of the facility's investigation timeline dated 5/10/26 indicated no staff directly witnessed resident exiting the facility premises. Per the same investigation timeline, Resident 109 was determined to exit the facility through the side door at station 1 at around 1:20 P.M. on 5/10/26. Per the same timeline, the fire department called the facility at around 6:10 P.M. to inform the LN that Resident 109 was found one block away from the facility. On 5/19/26 at 12:08 P.M., a joint review of Resident 109's clinical record and an interview was conducted with Assistant Director of Nursing (ADON) 2. ADON 2 stated Resident 109 had elopement and wandering risk assessment score of 14 on 4/14/26, ADON 2 stated for a risk assessment of 10 or greater, the resident was considered at risk for elopement. On 5/19/26 at 4:17 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was that the resident should have been identified as an elopement risk, and interventions should have been put in place to ensure the resident did not leave the facility for safety reasons. A review of the facility's policy titled, Wandering and Elopements, revised March 2019, indicated, The facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for resident. A review of the facility's policy titled, Safety and Supervision of Residents, revised July 2017, indicated, .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services according to facility policies and procedures when:Random controlled medication (medications with a high abuse potential) use audit for three of five sampled residents (Residents 108, 90, and 66) indicated medications were signed out of the controlled drug record (CDR, count sheet used to track controlled medications), but were not documented on the Medication Administration Record (MAR - section of the medical record where all medications given to the resident are recorded to ensure patient safety) to indicate they were administered to the residents. This failure had the potential for diversion (unlawful distribution or use), mismanagement of controlled medications and inadequate narcotic accountability, healthcare professional clinical decision-making based on an incomplete medical record which could result in adverse resident outcomes, and the potential to not meet the needs of the residents in the facility.An unlabeled syringe containing medication was observed stored in the medication cart and administered to a resident (Resident 2). This failure had the potential for Resident 2 to receive deteriorated (reduced quality) or the wrong medication.LN 56 administered Resident 94 a medication that did not have a dose on the order. This failure had the potential for Resident 94 to receive the wrong dose and experience adverse health outcomes.A medication for Resident 228 was not available for administration. This failure had the potential for Resident 228 to not receive the therapeutic benefit of his medication.Findings:During an inspection of the Station 2 Medication Cart 2A conducted with Licensed Nurse (LN) 52 on 5/11/26 at 3:34 P.M., the CDRs for Residents 108 and 90 receiving PRN (as needed) controlled medications were requested for review. Additionally, a CDR for Resident 66 from the Station 4 Medication Cart 4A was requested for review on 5/13/26 at 11:40 A.M. from the Assistant Director of Nursing (ADON) 2.a. A review of Resident 108's medical record indicated an order for hydrocodone-acetaminophen (a controlled medication used to manage pain) 5/325 milligram (mg, unit of measurement) tablet - give one tablet by mouth every 4 hours as needed for moderate pain, dated 4/23/26. During a concurrent interview and record review with the Director of Nursing (DON) on 5/20/26 at 7:57 A.M., Resident 108's CDR and May 2026 MAR were reviewed. Resident 108's CDR for hydrocodone-acetaminophen 5/325 mg indicated that on 5/3/26, nursing staff signed out of the CDR to acknowledge one tablet of hydrocodone-acetaminophen 5/325 mg was taken out of the package for Resident 108's 8 A.M. medication administration; there was no documentation of administration for the hydrocodone-acetaminophen 5/325 mg tablet on Resident 108's MAR. The DON confirmed there was no documentation of administration for hydrocodone-acetaminophen 5/325mg on Resident 108's MAR on 5/3/26 at 8 A.M. b. A review of Resident 90's medical record indicated an order for hydrocodone-acetaminophen 5/325 mg tablet - give one tablet by mouth every 6 hours as needed for severe pain, dated 9/25/25.During a concurrent interview and record review with the DON on 5/20/26 at 7:57 A.M., Resident 90's CDR and May 2026 MAR were reviewed. Resident 90's CDR for hydrocodone-acetaminophen 5/325 mg indicated that on 5/3/26, nursing staff signed out of the CDR to acknowledge one tablet of hydrocodone-acetaminophen 5/325 mg was taken out of the package for Resident 90's 8 A.M., 2 P.M., and 8 P.M. medication administration; there was no documentation of administration for the hydrocodone-acetaminophen 5/325 mg tablet on Resident 90's MAR for 5/3/26. The DON confirmed there was no documentation of administration for hydrocodone-acetaminophen 5/325 mg on Resident 90's MAR on 5/3/26 at 8 A.M., 2 P.M., and 8 P.M. c. A review of Resident 66's medical record indicated an order for hydrocodone-acetaminophen 10/325 mg tablet - give one tablet by mouth every 6 hours as needed for severe pain, dated 4/21/26.During a concurrent interview and record review with the DON on 5/20/26 at 7:57 A.M., Resident 66's CDR and May 2026 MAR were reviewed. Resident 66's CDR for hydrocodone-acetaminophen 10/325 mg indicated that on 5/11/26, nursing staff signed out of the CDR to acknowledge one tablet of hydrocodone-acetaminophen 10/325 mg was taken out of the package for Resident 66's 10:11 A.M. medication administration; there was no documentation of administration for the hydrocodone-acetaminophen 10/325 mg tablet on Resident 66's MAR on 5/11/26 at 10:11 A.M.The DON confirmed there was no documentation of administration for hydrocodone-acetaminophen 10/325 mg on Resident 66's May 2026 MAR on 5/11/26 at 10:11 A.M. The DON stated nursing staff were expected to document on both the CDR and the MAR. The DON stated the CDR and MAR should match.A review of the facility's policy and procedure (P&P) titled, Controlled Substances, revised 11/22, indicated, .Handling Controlled Substances.4.an individual.controlled substance record is made for each resident who will be receiving a controlled substance.This record contains.h. date and time received; i. time of administration.l. signature of nurse administering medication. 2. During an inspection of the Station 2 Medication Cart 2A with LN 52 on 5/11/26 at 3:34 P.M., an unlabeled syringe containing medication was observed stored in a drawer available for use. LN 52 stated she had just drawn up the medication from an insulin (a medication used to lower blood sugar) vial into the syringe for Resident 2. LN 52 stated the medication was due and administered it to Resident 2. A review of Resident 2's medical record indicated an order for Novolog (brand name of insulin aspart, a type of rapid-acting insulin) inject per sliding scale (a predetermined dose of insulin at specific times depending on blood sugar levels) subcutaneously (into the fat under the skin) before meals (at 6:30 A.M., 12 P.M. and 4:30 P.M.) for diabetes, dated 4/16/26. During a concurrent interview and record review with ADON 1 and LN 57 on 5/13/26 at 10:25 A.M., ADON 1 stated LN 52 documented the insulin was administered as given on 5/11/26 at 3:40 P.M. When asked when Resident 2 had dinner, ADON 1 stated the medical record does not have a record of the mealtime, only has the intake which is recorded afterwards. ADON 1 stated dinner time was from 4:30 P.M. to 5:30 P.M. When asked about the appropriateness of administering a rapid-acting insulin 1 hour before dinner, ADON 1 stated that would depend on if Resident 2 had a snack. ADON 1 stated the medical record did not have a record of the time of snack consumption. During an interview with the DON on 5/20/26 at 7:57 A.M., the DON stated nursing staff were to administer medications they drew up right away. The DON stated that while nursing staff had a 1-hour window before and a 1-hour window after to administer a medication scheduled for a specific time, insulin was a different medication. The DON stated insulin correlated with food intake and nursing staff were to follow the order and administer it accordingly. A drug review of Novolog on Micromedex (a drug resource site) indicated Novolog was to be [a]dminister[ed] within 5 to 10 minutes of a meal A review of the facility's P&P titled, Insulin Administration, revised 3/25, indicated, .2. The three key characteristics of insulin are: a. Onset of action - how quickly the insulin reaches the bloodstream and begins to lower blood glucose; b. Peak effects - the time when the insulin is at its maximum effectiveness; and c. Duration of effects - the length of time during which the insulin is effective. The document indicated rapid-acting insulin as having an onset of within 15 min[utes], a peak of 0.5-1.5 hrs [hours], and a duration of 4-6 hrs. 3. During a concurrent medication administration observation and interview on 5/19/26 at 8:09 A.M., LN 56 was observed preparing and administering 14 medications for Resident 94. One of the medications LN 56 prepared and administered to Resident 94 was the following:calcium carbonate 500 mg chewable tablet - 2 tabletsA review of Resident 94's medical record indicated an active order for the following:calcium carbonate oral tablet - give 2 tablet [sic] by mouth four times a day for heartburn, started 1/28/26.During an interview with LN 56 on 5/19/26 at 12:39 P.M., LN 56 confirmed the bottle of calcium carbonate used to administer Resident 94's dose contained 500 mg chewable tablets. LN 56 stated the order was not complete because it did not indicate a dose for calcium carbonate.During an interview with the DON on 5/20/26 at 7:57 P.M., the DON stated she did not see a dose for the calcium carbonate order. The DON stated the order for calcium carbonate could have been for a different dosage. A review of the facility's MEDICATION RIGHTS card, undated, indicated, .3. RIGHT DOSE. A review of the facility's P&P titled, Administering medications, revised 4/19, indicated, .8. If a dosage is believed to be inappropriate or excessive for a resident.the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. 4. During a medication administration observation on 5/19/26 at 8:45 A.M., LN 4 was observed preparing and administering three medications for Resident 228. LN 4 stated she did not have Resident 228's zinc (a mineral) order on hand.A review of Resident 228's medical record indicated an active order for the following:zinc sulfate oral tablet 220 mg - give 1 tablet by mouth two times a day to promote wound healing for 14 days, started 5/18/26. During an interview with LN 4 on 5/19/26 at 2:54 P.M., when asked if the zinc medication was available to administer to Resident 228, LN 4 stated she did not have a moment to check (if the medication had been delivered by pharmacy). During an interview with the DON on 5/20/26 at 7:57 A.M., the DON stated nursing staff were expected to notify the physician, reach out to pharmacy regarding delivery and central supply regarding drug availability. A review of the facility's P&P titled, Pharmacy Services - Role of the Provider Pharmacy, revised 4/19, indicated, .a. Supply the facility with approved medications. A review of the facility's P&P titled, Administering Medications revised 4/19, indicated, .4. Medications are administered in accordance with prescriber orders.

Based on observation, interview, and record review, the facility failed to ensure four of four residents (Resident 3, 4, 5, and 6) were free from physical abuse when:1. Resident 5's behavioral triggers (stimuli that may cause a specific action or response) were not identified, assessed, and care planned.2. Resident 6's wandering behavior into other residents' rooms was not identified, assessed, and care planned.As a result:1. Resident 5, when triggered, pushed Resident 4 down on 11/14/25, punched Resident 3 in the mouth on 12/25/25, and yelled at and grabbed Resident 6's arm on 12/30/25. Resident 3 sustained a laceration to the inner upper lip, experienced pain, and was distressed.2. Resident 6 entered Resident 5's room on 12/30/25 and put on his clothes. Resident 5 yelled and grabbed Resident 6 who then struck Resident 5 in the face causing him to fall to the floor.These failures to manage Resident 5 and Resident 6's behaviors put other residents on the secured unit (unit where residents need added supervision due to mental disorders and/or cognitive impairment) at risk for abuse. Cross reference F610, F742, and F744.On 1/8/26 at 8:30 A.M., an onsite visit was conducted to investigate two facility reported incidents of alleged abuse.A review of the facility's Report of Suspected Dependent Adult/Elder Abuse form (SOC 341, a form submitted to the State agency to report allegations of abuse) dated 12/25/25, indicated Resident 3 was seated in her wheelchair in the dining room when Resident 5 approached her and attempted to pull her wheelchair backwards. Resident 3 turned towards Resident 5 and instructed him to stop. Resident 5 then struck Resident 3 in the face for no apparent provocation. Resident 3 was noted with laceration to the upper inner lip. First aid and pain medication was administered to Resident 3. A review of the facility's Report of Suspected Dependent Adult/Elder Abuse form dated 12/30/25, indicated, .[Resident 5] was ambulating down the hallway when he approached [Resident 6] and began yelling at him, and grabbed his arm. Before staff could intervene, [Resident 6] swung at [Resident 5] striking him in the face and causing [Resident 5] to fall to the ground.A review of the facility's Daily Census dated 1/8/26, indicated there were currently 60 residents on the secured unit.1. The First Reported Incident (occurring on 12/25/25):A review of Resident 3's admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses to include anxiety.A review of Resident 3's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 10/22/25, indicated the resident scored 15 out of 15 on the brief interview of mental status (which meant the resident was cognitively intact). A review of Resident 4's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include Alzheimer's dementia (a progressive brain disorder that affects memory, thinking, and behavior).A review of Resident 5's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include traumatic brain injury, post-traumatic stress disorder (PTSD, a mental health condition that develops after exposure to a traumatic event), bipolar disorder (a mood disorder that alternates between depression and mania), and Alzheimer's dementia.A review of Resident 5's Summary of Physician Discharge Instructions (hospital documentation) dated 8/4/25, indicated, .Safety Plan.How will you know when you are in crisis and that the safety plan should be used? What are your personal red flags . 2. I get angry or aggravated when people are [stealing] from me.A review of Resident 5's nursing note dated 11/14/25, indicated, .[Resident 4] was standing near the food cart when [Resident 5] .pushed him aside. This caused the other resident [Resident 4] to loss [sic] his balance and fall to the ground.A review of Resident 3's IDT (interdisciplinary team) note dated 12/26/25, indicated, . [Resident 3] was seated in her wheelchair in the dining room when another resident [Resident 5] approached her and attempted to pull her wheelchair backwards. [Resident 3] turned towards the other resident [Resident 5] and instructed him to stop. The other resident [Resident 5] then struck this resident [Resident 3] in the face. This resident [Resident 3] was noted with laceration to the upper inner lip. First aid administered. Resident medicated for pain.A review of Resident 3's Alert Charting notes dated 12/26/25 and 12/27/25, indicated, Resident is on alert charting for being subject of aggression, neuro-check [an assessment] on progress, pain being treated with Tylenol as order [sic].On 1/8/26 at 9:41 A.M., an observation and interview was conducted with Resident 3 while inside her room. Resident 3 stated the incident with Resident 5 occurred on Christmas during lunchtime. Resident 3 stated Resident 5 got a hold of her wheelchair and would not let go. Resident 3 stated she told Resident 5 to let go of her wheelchair and he punched me in the mouth. Resident 3 pointed to one of her front teeth and stated being punched in the mouth had loosened one of her teeth. Resident 3 was asked if she experienced any pain from the incident and the resident stated, Oh, God yes. Resident 3 stated she got hurt and the pain lasted a long time. Resident 3 stated staff were not close enough to intervene until she got punched. Resident 3 stated staff told her Resident 5 was no longer in the facility and was gone. Resident 3 stated she would feel afraid if Resident 5 was on the unit and would not feel safe because of his violent nature. Resident 3 stated she was aware Resident 5 had hit other residents before.On 1/8/26 at 9:57 A.M., an observation was conducted in the hallway. Resident 5 approached and asked, Are you theft investigators? Here to investigate the thefts? Resident 5 was observed with staff providing 1:1 supervision (one staff assigned to provide continuous supervision).On 1/8/26 at 10:12 A.M., an interview was conducted with Resident 5 in front of the nurses' station. Resident 5 was asked about the altercations he was involved in with other residents. Resident 5 stated, Which one do you want to know about first? Resident 5 alleged Resident 3 had put her feet on the table to irritate him. Resident 5 stated he threw Resident 3's feet on the floor. Resident 5 was observed walking around the unit wearing white medical tape on his jacket with his name handwritten with black ink. L.V.N. [licensed vocational nurse], was also written underneath his name.On 1/8/26 at 10:30 A.M., an interview was conducted with Resident 1 while in the dining hall. Resident 1 was Resident 5's roommate. Resident 1 stated he was afraid of his roommate (Resident 5). Resident 1 stated, [Resident 5] said he'd kill me.On 1/8/26 at 12:43 P.M., an interview was conducted with certified nursing assistant (CNA) 1. CNA 1 stated she was working on 12/25/25 and had witnessed the incident between Resident 3 and Resident 5. CNA 1 stated Resident 3 was in front of the meal cart and Resident 5 was holding onto Resident 3's wheelchair handle. CNA 1 stated Resident 3 told Resident 5 to let go and he did not like to be told that. CNA 1 stated Resident 5 punched Resident 3 in the mouth with a closed fist. CNA 1 stated, It was a hard hit. CNA 1 stated she saw blood in Resident 3's mouth and the resident was screaming and saying, It hurts, it hurts. CNA 1 stated she was right next to the residents when the altercation happened, but things happened so fast and without warning. CNA 1 stated based on her abuse prevention training, this incident was physical abuse.CNA 1 further stated she was also present during an incident on 11/14/25 with Resident 5 and Resident 4. CNA 1 stated Resident 4 was touching the meal carts and that Resident 5 did not like that. CNA 1 stated Resident 5 pushed Resident 4 away [from the meal carts] so hard when he fell, I was afraid he'd die because he may have hit his head. CNA 1 stated Resident 5's behavior was impulsive and seemed to come out of nowhere. CNA 1 stated she was not aware of what triggered Resident 5's aggressive behavior.CNA 1 stated Resident 1 was Resident 5's roommate. CNA 1 stated it was believable when Resident 1 said Resident 5 threatened to kill him. CNA 1 stated she would take what Resident 1 said seriously. CNA 1 stated if she was Resident 5's roommate, I would absolutely not be comfortable because I've seen what [Resident 5's] capable of doing.On 1/8/26 at 3:30 P.M., an interview was conducted with the assistant director of nursing (ADON). The ADON stated Resident 5 gets triggered by other residents. The ADON stated Resident 5 was specifically triggered when residents went in his room, opened his closet, and went into or were around the food carts during meals. The ADON stated Resident 5 thought he was a licensed nurse and wanted to control who touched the food carts.On 1/9/26 at 10:06 A.M., an interview was conducted with CNA 2. CNA 2 stated she provided 1:1 supervision to Resident 5 yesterday. CNA 2 stated Resident 5 got agitated by other residents. CNA 2 stated she was not aware of any behavioral triggers or of a PTSD diagnosis for Resident 5. CNA 2 stated all staff on the unit should be aware of any of Resident 5's behavioral triggers in order to prevent the resident from being triggered. CNA 2 stated Resident 5 thought about theft and seemed focused on people frequently stealing. CNA 2 stated based on her facility provided abuse prevention training, whether provoked or unprovoked, being punched in the mouth was physical abuse.On 1/9/26 at 10:20 A.M., an interview was conducted with CNA 3. CNA 3 stated she was familiar with Resident 5 and his behavior. CNA 3 stated Resident 5 would get upset and yell when other residents were yelling. CNA 3 stated Resident 5 was focused on his belongings and potential theft. CNA 3 stated Resident 5 was concerned about who entered his room because he thought the person was coming into his room to steal. CNA 3 stated Resident 5 did not like it when other residents were around the food carts because he thought they were going to steal the food. CNA 3 stated Resident 5 thought he was a nurse who worked at the facility. CNA 3 stated Resident 5 would help other residents by pushing their wheelchairs. CNA 3 stated she did not think it was a good idea for Resident 5 to wear medical tape identifying himself as a licensed vocational nurse. CNA 3 stated other confused residents on the unit could approach him thinking he was the nurse and Resident 5 may react aggressively toward them. CNA 3 stated Resident 5 believed he was a staff nurse which may empower him. CNA 3 stated she was aware Resident 5 had altercations with other residents, but she did not know who those residents were. CNA 3 stated it was important for all staff to know who the residents that were involved in the altercations with Resident 5 were. CNA 3 stated knowing who they were would help prevent further altercations from occurring. CNA 3 stated all staff on the unit should be aware of Resident 5's behavioral triggers to prevent his aggression. CNA 3 stated based on her facility provided abuse prevention training, when Resident 5 pushed and punched other residents, this was physical abuse.On 1/9/26 at 11:19 A.M., a joint interview and record review was conducted with licensed nurse (LN) 1. LN 1 stated she provided care to Resident 5 yesterday. LN 1 stated she did not know Resident 5 had behavioral triggers. LN 1 stated it was important for all staff on the unit to know what Resident 5's triggers were to avoid his aggressive behavior. LN 1 stated she was unaware of Resident 5's PTSD diagnosis and triggers. LN 1 stated residents with PTSD could become aggressive and hurt others when triggered. LN 1 reviewed Resident 5's care plans and stated Resident 5's behavioral triggers were not identified and care planned. LN 1 stated this should have been done. LN 1 stated she saw Resident 5 wearing medical tape on his jacket identifying himself as an L.V.N. LN 1 stated it was not safe for him to present himself as a staff nurse. LN 1 stated if other residents approached Resident 5 thinking he was the nurse, it may trigger his aggression and lead to an altercation. LN 1 stated it may also empower Resident 5 to have a perceived authority over other residents. LN 1 stated based on her facility provided training, pushing and punching other residents was physical abuse.On 1/9/26 at 2 P.M., a joint interview and record review was conducted with LN 2. LN 2 stated Resident 5 was triggered by other residents yelling and things had to be a certain way for him because he believed he built the building and was in charge. LN 2 stated, We play along with him to avoid his aggression or anger. LN 2 stated Resident 5 believed other people stole his things. LN 2 stated Resident 5 [was] usually the aggressor with other residents on the unit. LN 2 reviewed Resident 5's clinical record and stated his care plans did not identify resident-specific triggers or interventions to prevent the resident from being triggered. LN 2 stated she was not aware Resident 5 identified himself as a staff nurse in writing on medical tape that was worn on his jacket. LN 2 stated this was unacceptable. LN 2 stated it may give him a feeling of authority over others and was not safe.On 1/9/26 at 3 P.M., a joint interview and record review was conducted with the director of staff development (DSD). The DSD stated she provided the abuse prevention training in the facility. The DSD stated residents with unmanaged behaviors could lead to altercations and abuse. The DSD stated behavioral and PTSD triggers had to be assessed with clear understanding of the reasons so further triggering could be avoided. The DSD stated all staff on the unit should be aware of Resident 5's behavioral triggers and these should have been put on the resident's care plan. The DSD stated the care plan should then have relevant interventions to prevent, address, and handle the behavior should it occur. The DSD stated not knowing Resident 5's triggers could lead to incidents of abuse. The DSD reviewed Resident 5's clinical record and written care plans and stated the resident's behavioral and PTSD care plans did not identify resident-specific triggers. The DSD stated all staff should be aware Resident 5 was preoccupied with thoughts of theft and that people were stealing from him. The DSD stated interventions should have included means to prevent situations from occurring when other residents went into his room or were around the meal carts. The DSD stated it was not appropriate for Resident 5 to have the designation as an L.V.N. on his jacket. The DSD stated it may empower Resident 5 to take action with other residents during perceived wrongs. The DSD further stated when Resident 5 punched Resident 3 in the mouth, this was physical abuse and caused harm to Resident 3. The DSD stated Resident 3 should not have been told Resident 5 was gone from the facility. The DSD stated Resident 3 should have been informed of a plan to keep her safe from Resident 5 to prevent the resident from experiencing fear or being traumatized. The DSD stated Resident 5's roommate (Resident 1) should have been interviewed to make sure he was safe around Resident 5. On 1/12/26 at 9:30 A.M., a joint interview and record review was conducted with the ADON. The ADON stated when Resident 5 hit Resident 3 in the mouth that was considered physical abuse. The ADON reviewed Resident 3's clinical record and stated there was no documentation the resident had been seen by the physician or dentist after being punched in the mouth on 12/25/25. The ADON stated this should have been done soon after the incident to make sure Resident 3 sustained no injuries. The ADON stated residents who experienced abuse should be told of the plan to keep them safe from the perpetrator. The ADON stated there was no documentation in Resident 3's clinical record that she was informed of how she would be protected from Resident 5. The ADON stated Resident 3 was informed over the weekend that Resident 5 was on the unit, and she was offered a room change off the unit. The ADON stated Resident 3 accepted the room change and felt safer away from Resident 5.The ADON stated everyone on the unit should have been aware of Resident 5's behavioral triggers that caused him agitation and aggression which led to incidents of abuse. The ADON stated Resident 5 became aggressive when other residents were around the meal carts, and going into his room or closet. The ADON reviewed Resident 5's clinical record and written care plans and stated those specific behavioral triggers were not identified, assessed, and care planned. The ADON stated a lock was placed on Resident 5's closet after the incident occurred with Resident 6. The ADON acknowledged the need for a lock on Resident 5's closet should have been identified sooner. The ADON stated these behavioral triggers should have been care planned. The ADON stated Resident 5's behavior was not identified and care planned after Resident 5 pushed Resident 4 down for opening the meal cart on 11/14/25. The ADON stated corrective action after that incident should have identified Resident 5's triggers to prevent further incidents of abuse. The ADON stated Resident 5 should not have been identifying himself as an L.V.N. on the unit as he could think he was in charge. The ADON stated this was unsafe. The ADON further stated all staff on the unit should be aware of which residents Resident 5 had altercations with to prevent further incidents of abuse from occurring.2. The Second Reported Incident (occurring on 12/30/25): A review of Resident 6's admission Record indicated the resident was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses to include unspecified dementia (loss of cognitive functioning) and schizophrenia (a mental disorder characterized by paranoia and delusions). A review of Resident 6's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 12/12/25, indicated the resident scored 5 out of 15 on the brief interview of mental status (which meant the resident was cognitively impaired).A review of Resident 6's History and Physical Examination dated 12/12/25, indicated the resident, Does NOT have capacity to understand and make decisions. The document also indicated that Resident 6 was conserved (had a court-appointed decision maker).A review of Resident 6's SBAR Summary for Providers dated 12/1/25, indicated the resident was, .now going in another resident room slamming doors.Resident hard to redirect despite being approached calmly, explanation and encouragement [sic].A review of Resident 6's Nurse's Note dated 12/30/25, indicated, .[Resident 5] was ambulating down the hallway when he approached [Resident 6] and began yelling at him, and grabbed his arm. Before staff could intervene, [Resident 6] swung at [Resident 5] striking him in the face and causing [Resident 5] to fall to the ground.A review of Resident 5's Progress Notes dated 12/30/25, indicated the resident was sent out to the hospital for evaluation after the altercation with Resident 6. Resident 5 had a CT scan (computed tomography, a view of body's internal structures) of his head with negative results (no injuries).On 1/8/25 at 10:07 A.M., an observation and interview was conducted with Resident 6 while inside the resident's room. Resident 6 was observed seated in a chair and bent over hitting a supplemental protein shake container on the floor. An interview was attempted, but Resident 6 mumbled incoherently to himself. Resident 6's room was next door to Resident 5's room.On 1/8/26 at 10:12 A.M., an interview was conducted with Resident 5 in front of the nurses' station. Resident 5 stated he had an altercation because he saw Resident 6 wearing his shoes and he wanted them back. Resident 5 stated he went to Resident 6 and started to take them off him. Resident 5 stated Resident 6 then punched him and threw him across the hall where he hit his head on the door jamb. Resident 5 stated Resident 6 proceeded to kick him in the stomach. Resident 5's account of the incident with Resident 6 did not entirely make sense. On 1/8/26 at 12:12 P.M., an interview was conducted with the physical therapy assistant (PTA). The PTA stated on 12/30/25, she was walking a resident on the unit and heard yelling down the hall by Resident 5 and Resident 6's room. The PTA stated she saw Resident 6 take a swing at Resident 5 and she ran over to intervene. The PTA stated Resident 5 was on the floor and had been hit once. The PTA stated Resident 5 was conscious with no apparent injuries.On 1/8/26 at 12:43 P.M., an interview was conducted with CNA 1. CNA 1 stated Resident 6 was mentally gone. CNA 1 stated Resident 6 wandered into other residents' rooms. CNA 1 stated Resident 6 was easily startled and would react physically when grabbed by another person.On 1/8/26 at 3:30 P.M., an interview was conducted with the ADON. The ADON stated on 12/30/25, Resident 6 did go into Resident 5's room and into his closet. The ADON stated Resident 6 did put on Resident 5's clothing. The ADON stated Resident 5 would have been triggered by this incident.On 1/9/26 at 10:20 A.M., an interview was conducted with CNA 3. CNA 3 stated Resident 6 was, very confused and frequently wandered into other residents' rooms. CNA 3 stated she thought Resident 6 did this due to his confusion and he thought he was in his own room. CNA 3 stated on 12/30/25, Resident 6 had been inside of Resident 5's room, most of the day. CNA 3 stated she redirected Resident 6 away from Resident 5's room more than once but he refused to be redirected. CNA 3 stated she informed LN 3 that Resident 6 was not responding to redirection. CNA 3 stated she was not sure what had been done about it. CNA 3 stated Resident 5 was not aware Resident 6 had been in his room most of the day. CNA 3 stated she was not present during the altercation but was aware Resident 5 had caught Resident 6 wearing his clothing. CNA 3 stated this would have triggered Resident 5's aggression. CNA 3 stated Resident 5 and Resident 6's rooms were right next door to each other and were too close together.On 1/9/26 at 11:19 A.M., an interview was conducted with LN 1. LN 1 stated Resident 6 was confused and wandered. LN 1 stated when Resident 6 was not redirectable on 12/30/25, the LN should have moved him to the nurses' station and called for help. LN 1 stated she thought Resident 5 and Resident 6's rooms should not have been right next to each other as Resident 6 was easily confused.On 1/9/26 at 3 P.M., a joint interview and record review was conducted with the DSD. The DSD reviewed Resident 6's clinical record and written care plans. The DSD stated Resident 6 had a wandering behavior and was known to enter other residents' rooms. The DSD stated wandering into other residents' rooms and rummaging or taking things could lead to altercations and incidents of abuse. The DSD stated Resident 6's wandering into other residents' rooms should have been addressed in the resident's care plan with resident-specific interventions to prevent it from happening. The DSD stated after the incident with Resident 6 and Resident 5 on 12/30/25, Resident 6's wandering into other residents' rooms still had not been identified and care planned. The DSD stated it should have been identified, assessed, and care planned.On 1/12/26 at 9:03 A.M., an interview was conducted with LN 3. LN 3 stated she was the LN assigned to Resident 5 and Resident 6 on 12/30/25. LN 3 stated she was not aware of Resident 6 having been inside Resident 5's room most of that day. LN 3 stated she was not aware of CNA 3 reporting that Resident 6 was not redirectable. LN 3 stated Resident 6 should have been brought to an activity or placed in another area to prevent re-entering Resident 5's room. LN 3 stated Resident 5 would be set off knowing or seeing Resident 6 in his room. LN 3 stated Resident 6's care plan should have personalized interventions to mitigate Resident 6's wandering into other residents' rooms.On 1/12/26 at 9:30 A.M., a joint interview and record review was conducted with the ADON. The ADON stated Resident 6 wandered into other residents' rooms which could lead to altercations, especially with Resident 5 as this would cause him to become aggressive. The ADON stated when staff noticed Resident 6 was not redirectable out of Resident 5's room on 12/30/25, the resident should have been: Asked what he wanted, provided a room change away from Resident 5's room, and had visual reminders placed on his door to indicate which room was his. The ADON reviewed Resident 6's clinical record and written care plans and stated his wandering into other residents' rooms was not addressed. The ADON stated interventions should have been put in place to address and prevent Resident 6's unsafe wandering into other residents' rooms.On 1/12/26 at 2:25 P.M., an interview was conducted with the administrator (ADM). The ADON was also present. The ADM stated all staff on Resident 5's unit should have been aware of his behavioral triggers that led to altercations and abuse with other residents. The ADM acknowledged there was a pattern of Resident 5 being triggered by residents near the meal carts and going in his room which led to physical altercations. The ADM stated aggressive behaviors that caused abuse should have been care planned to prevent reoccurrence. The ADM stated it was physical abuse when Resident 5 punched Resident 3 in the mouth. The ADM further stated Resident 6's wandering into other residents' rooms should have been addressed and care planned as the behavior could lead to altercations.A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation Prevention Program revised April 2021, indicated, Residents have the right to be free from . physical abuse . The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: other residents A review of the facility's policy titled Resident-to-Resident Altercations dated September 2022 indicated, . Behaviors that may provoke a reaction by residents or others include.physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving. rummaging through other's property and wandering into other's rooms/space. If two residents are involved in an altercation, staff.identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation. make any necessary changes in the care plan.document in the resident's clinical record all interventions and their effectiveness.A review of the facility's policy titled Behavioral Assessment, Intervention, and Monitoring revised February 2025, indicated, 1. Residents will have minimal complications associated with the management of altered or impaired behavior. 'Behavioral interventions' refers to individualized, nonpharmacological approaches to care that are provided as part of a supportive physical and psychosocial environment, directed toward understanding, preventing, relieving.a resident's distress.As part of the comprehensive assessment, staff evaluate .c. the resident's typical or past responses to stress.and other triggers.The IDT thoroughly evaluates new or changing behavioral symptoms to identify underlying causes and address any modifiable factors. Interventions and Management.The IDT evaluates the behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develops a plan of care accordingly.Safety strategies are implemented immediately, if necessary, to protect the resident and others from harm. Interventions are individualized and part of the overall care environment.

Based on interviews and record reviews, the facility failed to implement their policies related to accidents and supervision, elopements (leave without notice) and signing residents out, when staff did not: 1. Identified one of one resident (Resident 1) who left the facility and implement a search procedure (code green) when Resident 1 was not found in the facility. The facility did not announce a code green until the following day, approximately 12 hours since Resident 1 was last seen in the facility. 2. Consistently obtain a physician's order for an out on pass (OOP - out on pass, leave of absence), assess, and document in his clinical record the time he went out on pass and consistently sign the OOP form. The lack of communication among staff that they did not set eyes on Resident 1 resulted in Resident 1 leaving the facility unnoticed by staff, was hit by a pickup truck, and died on the night of [DATE]. Findings: On [DATE], the Department received a facility reported incident (FRI) related to quality of care and resident safety. On [DATE], a follow up unannounced onsite to the facility was conducted. 1. On [DATE], [DATE], and [DATE], a review of Resident 1's clinical record was conducted. A record review was conducted of Resident 1. Resident 1 was readmitted to the facility on [DATE], with diagnoses which included schizoaffective disorder (a condition where symptoms of both psychotic (a mental disorder characterized by a disconnection in reality and mood disorders are present together during one episode), per the facility's Admission Record. A record review was conducted of Resident 1.Resident 1's History and Physical (H & P), dated [DATE], indicated the attending physician (AP) documented Resident 1 was admitted to the facility for rehabilitation and Resident 1 had the capacity to understand and make decisions. A record review was conducted of Resident 1. Resident 1's minimum data set (MDS - an assessment tool), completed [DATE], indicated Resident 1's brief interview for mental status (BIMS, ability to recall) score was ,d+[DATE] (a score of 13 to 15 suggests the patient is cognitively [process of acquiring knowledge and understanding] intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). A record review of Resident 1's physician orders were conducted. Per Resident 1's physician order dated [DATE] at 11:27 A.M., Telephone order .may go oop (out on pass) for 4 hours, one time only for oop for 1 Day. A record review was conducted of Resident 1's licensed progress notes. Per a licensed nurse (LN) progress note dated [DATE] at 6:45 P.M., LN 3 documented, Resident observed in facility at approximately 1830 (6:30 pm) at nurse's station talking with staff, in stable condition. A record review was conducted of Resident 1's progress notes. Per a LN progress note dated [DATE] at 12:52 A.M., LN 4 documented, When doing rounds noted resident is not in his room. per pm shift nurse. resident signed out himself. A record review was conducted of Resident 1.Per a change in condition (CIC) progress notes dated [DATE] at 8:57 A.M., LN 1 documented, Nursing observations. evaluation, and recommendations are: Unable to locate resident .code green initiated, res. was not present in facility . A record review was conducted of Resident 1's licensed nurse (LN) progress notes . Per a LN progress note dated [DATE] at 9:30 A.M., LN 1 documented, Certified Nursing Assistant (CNA) notified this nurse at approximately ,d+[DATE] this morning that res (Resident 1) is not in his room. Rounds made, res is not in his room or anywhere in the facility . A record review was conducted of Resident 1's physician order summary. Per Resident 1's order summary active as of [DATE], indicated there was no physician order for OOP. On [DATE] at 3:22 P.M., an interview with CNA 1 was conducted. CNA 1 stated he worked on [DATE] from 12 midnight (MN) to 6:30 A.M., and Resident 1 was assigned to him. CNA 1 stated Resident 1 was alert, oriented, and was ambulatory without assistive devices. CNA 1 stated he did not find Resident 1 in his bed. Per CNA 1, he looked for Resident 1 in the facility, did not find him and did not report to the licensed nurse (LN) 4 that Resident 1 was nowhere to be found. Per CNA 1, since LN 4 did not ask him to look for Resident 1, he kept his assumption that LN 4 knew Resident 1's whereabouts. CNA 1 stated the facility's policy was when the staff did not find a resident in his/her bed, staff need to inform the LNs, code green is called, and the staff will look for the resident in and out of the building. CNA 1 stated he completed his shift without knowledge of code green initiated. On [DATE] at 4:39 P.M., an interview with CNA 2 was conducted. CNA 2 stated on [DATE], Resident 1 was assigned to him. CNA 2 stated he last saw Resident 1 around 8 P.M. at the nurses' station talking with LN 2. CNA 2 stated he left around 10:30 P.M. and did not check if Resident 1 was in his bed because Resident 1's door was closed. CNA 2 stated Resident 1 would regularly go out of the facility around 6 P.M. and came back around 9 -9:30 P.M. to sleep. CNA 2 stated, Sometimes he stays out longer, we don't see him the next day. If I leave at 10:30 P.M., the time I will get to see him is when I come back the next day. I work 8 hours. CNA 2 stated from 8 -10:30 P.M., no code green was called. On [DATE] at 2:07 P.M., a joint review of Resident 1's clinical record and an interview with LN 1 was conducted. LN 1 stated she was familiar with Resident 1 going OOP. LN 1 stated the facility's process was when a resident went out on pass, LNs would have to assess the resident, obtain a physician's order, signed the resident in and out, document in the binder titled Leave of Absence (LOA - going out on pass to leave the facility) and document in the resident's progress notes. LN 1 stated on [DATE], she obtained an order from Resident 1's AP for OOP and knew Resident 1 left during her shift. LN 1 stated on [DATE] in the morning shift (7 A.M to 3 P.M.), Resident 1 was nowhere to be found and a code green was initiated. On [DATE] at 9:48 A.M., a telephone interview with the AP was conducted. The AP stated she was not aware Resident 1 went OOP few times a day. The AP stated the LNs should have been getting a physician's order every time residents under her care went OOP. The AP stated each OOP was applicable with each event. The AP stated, They have to call me. The AP stated she knew Resident 1 went OOP on [DATE] and that he was back for dinner. The AP stated she did not know what happened until the following morning that Resident 1 was nowhere to be found. On [DATE] at 11:19 A.M., a telephone interview with the Social Services Director (SSD) was conducted. The SSD stated she was informed Resident 1 was not in the facility on [DATE] around ,d+[DATE]:30 A.M. The SSD stated a code green was called at this time and a search was conducted, but the staff did not find Resident 1 in and out of the building. The SSD stated she called the police department and a police officer called back to inform SSD that on [DATE] at around 10:47 P.M., Resident 1 was crossing the street, got hit by a pickup truck, and died . On [DATE] at 11:58 P.M., a telephone interview with LN 2 was conducted. LN 2 stated she was familiar with Resident 1. LN 2 stated Resident 1 was not assigned to her, but she talked to him on [DATE] around ,d+[DATE] P.M. LN 2 stated Resident 1 was alert and oriented and walked independently. LN 2 stated the policy was for the residents to inform the LNs about going OOP, LNs obtained a physician's order, residents sign in and out the LOA binder, and a LN will have to sign them off. LN 2 stated with Resident 1's AP, the LNs were to get a physician's order when her residents requested to go OOP. LN 2 also stated during endorsement or change of shifts, the outgoing and the incoming LNs were to make rounds, give reports and check the residents' whereabouts. LN 2 stated on [DATE], she left the facility around 11:20 P.M., and on her way out, she noticed there was an accident and several police cars and officers in the street (a block away from the facility). On [DATE] at 12:20 P.M., a telephone interview with LN 3 was conducted. LN 3 stated she worked as a floater (move from one section of the facility to another, working in different areas). LN 3 stated she knew Resident 1 in passing and would go OOP accompanied by other LNs. LN 3 stated on [DATE], she worked at 3 P.M - 11 P.M. shift. LN 3 stated Resident 1 was assigned to her, and this was the second time she had him. LN 3 stated she did not consider Resident 1 an elopement risk. LN 3 stated she had seen Resident 1 walked out and come back to the facility. Per LN 3, on [DATE], she received a report from the morning LN that Resident 1 went OOP in the morning and that, He will come back. Per LN 3, around 6:30 P.M., she saw Resident 1 while she was passing medications (meds). Per LN 3, during the shift change (11 PM - 7 AM), the oncoming LN (LN 4) reported to her that Resident 1 was not in his bed. LN 3 stated, I wasn't worried, he knew that he was supposed to sign in. I was busy, I looked over and saw him there, he was back on my shift. Per LN 3, she and LN 4 did not make rounds together. LN 3 stated, I assumed most likely he was around .he does walk around and was not an elopement risk. LN 3 stated she and LN 4 did not verify the leave of absence (LOA) binder if Resident 1 had signed out. LN 3 stated Resident 1 had meds and she did not give it since she thought Resident 1 was not in his bed. LN 3 stated there was no door alarm that went off during her shift. LN 3 further stated, I assume he was asleep. To me, he was fine, he closed his room and I assume he was in his room, I should have not assumed, I learned that now. Should have I known that we should have looked around to find him. On [DATE] at 1:15 P.M., a telephone interview with security guard (SG) was conducted. SG stated on [DATE], he worked from 9 P.M. to 5 A.M. SG stated he last saw Resident 1 headed back to the building at around 9 P.M. Per SG, there was no code green that was called during his shift. On [DATE] at 3:21 P.M., a telephone interview with LN 4 was conducted. LN 4 stated he was familiar with Resident 1. Per LN 4, Resident 1 went in and out of the building any time of the day and sometimes snuck out. Per LN 4, during the change of shift on [DATE], he noticed Resident 1 was not in his bed and asked LN 3. Per LN 4, LN 3 told him Resident 1 signed out. LN 4 stated he did not find the LOA binder to verify if Resident 1 went OOP. LN 4 stated he lost track. LN 4 stated should LN 3 had not mentioned Resident 1 was on OOP, We could have looked for him. LN 4 stated Resident 1 usually visited the area where he had the accident. LN 4 stated, I passed by that area. I saw him there before. 2. On [DATE] at 2:07 P.M., a joint review of Resident 1's clinical record and an interview with LN 1 was conducted. LN 1 stated Resident 1 regularly went OOP. Per LN 1, Resident 1's OOP form had incomplete documentation. LN 1 stated there were columns for residents and the LNs had to fill up which included the date, time out, scheduled return time, name of Responsible Party (RP), signature of RP, nurse initial, RP contact number, time returned, Signature of RP when returned and another column for the nurse initial. LN 1 stated and verified that Resident 1 went OOP on the following dates: - [DATE], Resident 1 left at 12:37 P.M., came back at 4:45 P.M. LN 1 stated the OOP form was incomplete missing the signature of RP when returned. - [DATE], LN 1 stated Resident 1 left again at 7 P.M. LN 1 stated there was no physician's order, and the OOP form was incomplete missing LN signature for the 7 P.M. OOP, RP signature when returned, time returned, and LN signature when Resident 1 came back after the 7 P.M. OOP. - [DATE], LN 1 stated Resident 1 left at 2:25 P.M., came back at 3:30 P.M. LN 1 stated there was no physician's order, and the OOP form was missing the RP signature when returned and LN signature when Resident 1 came back. - [DATE], LN 1 stated Resident 1 left at 11:26 A.M. LN 1 stated the OOP form was missing the scheduled return time, the nurse initial, the RP contact number, the signature of RP when returned and LN signature when Resident 1 came back. - [DATE], LN 1 stated Resident 1 left 4:58 P.M. LN 1 stated there was no physician's order for the 4:58 P.M. OOP and the OOP form was missing the scheduled return time, the RP contact number, the time returned, the signature of RP when returned and LN signature when Resident 1 came back. - [DATE], LN 1 stated there was no physician's order and the OOP form was missing the time out, the scheduled return time, RP signature when returned, time returned and the LNs signature when Resident 1 went out and came back to the facility. - [DATE], LN 1 stated Resident 1's OOP form had two entries. LN 1 stated the OOP form was missing the time out, the scheduled return time, the nurse initial, and the RP signature when returned. LN 1 stated she was the one who signed the resident back at 4 P.M. - [DATE], LN 1 stated Resident 1 left again at 5:26 P.M. LN 1 stated the OOP form was incomplete and missing the scheduled return time, the nurse initial, and the RP signature when returned. LN 1 stated she mistakenly signed the column for nurse initial. LN 1 stated there were no physician's order on both events. - [DATE], LN 1 stated the OOP form was incomplete and missing the time out, the scheduled return time, the nurse initial, and the RP signature when returned. LN 1 stated she was the one who signed the resident back but did not indicate the time. - [DATE], LN 1 stated the OOP form was incomplete and missing the time out, the scheduled return time, the nurse initial, and the RP signature when returned. LN 1 stated she was not sure whose signature was in the form if it was the RP or the LN. - [DATE], LN 1 stated Resident 1 left at 11:46 A.M., and was expected to return 3:45 P.M. LN 1 stated the OOP form was incomplete and missing the signature of RP, the RP contact number, the time returned and the RP signature when returned. LN 1 stated the policy was to fill up the OOP form completely so that the staff knew where the residents were. LN 1 stated aside from obtaining a physician's order and filling out the OOP form, the LNs must document in the residents' clinical record when they leave the facility and when they come back. LN 1 stated the staff should be aware when residents leave OOP and their condition before and after their OOP. The following dates had missing LN progress documentation: [DATE], [DATE], [DATE], [DATE] at 5:26 P.M. event, [DATE], and on [DATE], no documentation when Resident 1 came back to the building. On [DATE] at 12:58 P.M., a telephone interview with LN 5 was conducted. LN 5 stated Resident 1 was admitted on [DATE] and there was no OOP order for the resident. Per LN 5, the LNs should be obtaining an order from the attending physician every time Resident 1 goes OOP. On [DATE] at 3:30 P.M., a telephone interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated the expectation was when the staff did not see the resident in their room or in their bed, the staff should initiate a code green, start searching for the resident, and notify the attending physician, the RP and the management. The ADON stated if unable to locate the resident, the staff should call the police. The ADON stated the staff should have made rounds to ensure Resident 1 was in his bed for resident safety. The ADON also stated the expectation was to complete the OOP form and document that the residents were acknowledging that they were going out of the building and staff knew they were out. This was to inform the residents that the facility was not liable when they went out of the building and that knew the risks. A record review of the facility's policy was conducted. Per the facility's policy titled Safety and Supervision of Residents, revised [DATE], .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Individualized, Resident-Centered Approach to Safety. 1. Our individualized, resident-centered approach to safety addresses safety .for individual residents, 2. The interdisciplinary care team shall analyze information obtained from .observations to identify any specific accident hazards or risks for individual residents .3. The care team shall target interventions to reduce individual risks related to hazards .including adequate supervision .4. Implementing interventions to reduce accident risks .shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions .d. Ensuring that interventions are implemented; and e. Documenting interventions .Systems Approach to Safety, 1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified .and individual resident risk factors, and then adjusts interventions accordingly, 2. Resident supervision is a core component of the systems approach to safety .Resident Risks and Environmental Hazards, 1. Due to their complexity and scope, certain resident risk factors .are addressed in dedicated policies and procedures. These risk factors .include .5. Unsafe Wandering . A record review of the facility's policy was conducted. Per the facility's policy titled Elopements, revised [DATE], Staff shall investigate and report all cases of missing residents . Policy Interpretation and Implementation, 1. Staff shall promptly report any resident who .is suspected of being missing to the Charge Nurse or Director of Nursing .4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave of pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative .the Attending Physician, law enforcement officials .d. Provide search teams .e. Initiate an extensive search of the surrounding area . A record review of the facility's policy was conducted. Per the facility's policy titled Signing Residents Out, revised [DATE], All residents leaving the premises must be signed out .1. Each resident leaving the premises (excluding transfers/ discharges) must be signed out. 2. A sign-out register is located at each nurses' station. Registers must indicate the resident's expected time of return .

Based on interview and record review, the facility failed to provide a safe environment for two of five residents (Resident 1 and Resident 2) reviewed for accidents when: 1. Resident 1 ' s fall risk was inaccurately assessed, and no fall preventative measures were initiated after the facility determined that Resident 1 was at risk for fall. 2. Resident 2 was not consistently provided with 1:1 monitoring as planned. As a result, Resident 1 fell and sustained a sacral fracture (a break on the large, triangle-shape bone in the lower spine that forms part of hip) that caused the resident to experience severe pain. For Resident 2, this failure had the potential to result in more falls and/ or fall with injury. Findings: 1. A review of Resident 1 ' s undated Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included history of falling. A review of Resident 1 ' s History and Physical, dated 1/20/23, indicated that Resident 1 had generalized weakness and had a fall incident. A review of Resident 1 ' s progress notes, dated 2/2/23, indicated that on 2/1/23 at approximately midnight to 1 am, Resident 1 walked to the bathroom without calling for assistance and fell . According to the same record, Resident 1 was sent to the hospital on 2/1/23. An interview and joint record review of Resident 1 ' s Fall Risk Assessment was conducted with licensed nurse (LN) 1 on 2/10/23 at 1:53 P.M. LN 1 remembered Resident 1 and confirmed that she conducted and completed Resident 1 ' s Fall Risk Assessment on 1/20/23. LN 1 stated, prior to Resident 1 ' s admission to the facility, Resident 1 was treated at the hospital due to a fall that Resident 1 experienced at home. LN 1 stated she had access to Resident 1 ' s hospital medical record and that she (LN 1) knew about Resident 1 ' s history of fall. LN 1 reviewed Resident 1 ' s Fall Risk Assessment completed on 1/20/23. LN 1 stated that Resident 1 scored 8, which according to the Fall Risk Assessment document, dated 1/20/23, a score of 0-8 meant low risk. Further review of the document indicated that Resident 1 did not take any medications, such as antihypertensives (medications use to treat high blood pressure), anticonvulsants (medications for uncontrolled body movement), and psychotropics (medications that affect mental function and behavior) that could be considered contributors to falls. However, a review of Resident 1 ' s hospital visit summary, dated 1/20/23, indicated that Resident 1 took antihypertensive, anticonvulsant, and psychotropic medications while at the hospital, prior to being admitted to the facility. LN 1 stated the Fall Risk Assessment, completed on 1/20/23, was inaccurate. LN 1 acknowledged that if she marked the three medications that Resident 1 took at the hospital, Resident 1 would have been assessed as moderate risk for fall. An interview and joint record review of Resident 1 ' s care plan was conducted with LN 1 on 2/10/23 at 2:05 P.M. LN 1 reviewed Resident 1 ' s care plan but could not locate a care plan related to Resident 1 ' s risk for fall. LN 1 could not locate documentation of fall preventative measures initiated prior to Resident 1 ' s fall incident on 2/1/23. LN 1 stated fall preventative interventions should have been initiated for Resident 1 on admission to help prevent fall incidents. A review of Resident 1 ' s Emergency Department Note, dated 2/1/23, indicated that Resident 1 was taken to the emergency department with a complaint of severe buttock pain after an unwitnessed fall. A review of Resident 1 ' s CT (a medical imaging technique used to obtain detailed internal images of the body) of the Pelvis, completed at the hospital on 2/1/23, indicated, acute transverse fractures involving the S4 and S5 vertebra (two bones on the tailbone broke horizontally to its length). An interview with Assistant Director of Nursing (ADON) 1 was conducted on 3/13/23 at 8:55 A.M. ADON 1 stated that Resident 1 ' s Fall Risk Assessment, completed by LN 1 on 1/20/23, was inaccurate. The ADON stated Resident 1 should have been placed at a high risk for fall on admission due to the resident ' s fall incident at home, prior to going to the hospital. ADON 1 stated fall preventative measures should have been started for Resident 1 immediately on admission to help prevent fall incidents. ADON 1 stated it was important for residents to have accurate fall assessments so staff could initiate appropriate fall preventative measures. ADON 1 also stated that initiating fall preventative measures timely was important to help prevent fall incidents. 2. Resident 2 was admitted to the facility on [DATE] with diagnoses that included abnormalities with gait (manner of walking) and mobility (movement) according to the undated Admission Record. A review of Resident 2 ' s Minimum Data Set (MDS -assessment tool), dated 2/13/23, indicated that Resident 2 required extensive assistance with walking in room and in the hallway. A review of Resident 2 ' s Fall Risk Assessment, dated 2/9/23, indicated a score of 4. According to the Fall Risk Assessment document, a score of 0-8 meant low risk for fall. A review of Resident 2 ' s the following Progress Notes indicated Resident 2 ' s fall incidents: - On 2/11/23 at 12:42 A.M., Resident 2 was found on the floor with the left side of his face resting on the floor. Resident 2 was not able to recall and verbalize what happened. Per the same record, Resident 2 ' s physician ordered to send the resident to the hospital. On 2/11/23 at 12:39 P.M., Resident 2 returned to the facility with diagnosis of left ulna fracture (break on one of the forearm bones). On 2/11/23 at 9:36 P.M., Resident 2 was placed on a 1:1 (can only observe one patient at any given time) sitter. - On 2/24/23 at 5:27 P.M., Resident 2 stood up, in the presence of the 1:1 sitter, and lowered himself to the floor and started crawling. According to the note, 1:1 sitter will be continued. - On 2/28/23 at 7:51 A.M., Resident 2 was found sitting on the floor. Resident 2 stated he needed to go to the bathroom. There was no documentation that Resident 2 had a 1:1 sitter at the time of the fall incident. - On 3/2/23 at 1:35 A.M., Resident 2 was found on the floor in the bathroom. The certified nursing assistant (CNA) assigned to Resident 2 was waiting outside of the bathroom door for the resident to call. The CNA heard something fell and found Resident 2 on the bathroom floor. A review of Resident 2 ' s Fall Risk Assessment, dated 2/13/23, indicated a score of 24. Per the document, a score of 16-42 meant high risk for fall. An interview with CNA 1 was conducted on 3/13/23 at 11:01 A.M. CNA 1 stated she took care of Resident 2 in the past. CNA 1 stated that after Resident 2 returned from the hospital on 2/1/23 after a fall, Resident 2 had been placed on 1:1 sitter. A telephone interview with CNA 2 was conducted on 3/13/23 at 2:32 P.M. CNA 2 stated Resident 2 was confused and was able to walk around the facility independently. CNA 2 stated after Resident 2 ' s first fall on 2/11/23, Resident 2 was placed on 1:1 sitter for safety. CNA 2 stated she was the CNA who assisted Resident 2 to the bathroom, on 3/2/23, where the resident was found on the bathroom floor. CNA 2 stated she took Resident 2 the bathroom and left the resident to get a brief. CNA 2 stated when she returned, she found the resident on the floor. CNA 2 acknowledged that she should not have left Resident 2 alone inside the bathroom since the resident was supposed to be on a 1:1 monitoring. CNA 2 stated she should have called for assistance using the call light instead of leaving the resident unsupervised. An interview and joint record review was conducted with LN 2 on 3/14/23 at 6:44 A.M. LN 2 stated Resident 2 was placed on 1:1 monitoring after the resident fell the first time on 2/11/23. LN 2 stated 1:1 monitoring would mean that staff was present with the resident 24 hrs. per day and 7 days a week. LN 2 reviewed Resident 2 ' s progress notes related to the falls on 2/28/23 and 3/2/23. LN 2 stated that if Resident 2 was provided 1:1 monitoring as planned, Resident 2 ' s fall incidents could have been prevented. An interview with LN 3 was conducted on 3/14/23 at 3:14 P.M. LN 3 stated Resident 2 was placed on 1:1 monitoring. LN 3 stated 1:1 monitoring meant that somebody would always be beside the resident. An interview with the Director of Nursing (DON), Assistant Director of Nursing (ADON) 1, and ADON 2 was conducted on 3/14/23 at 3:28 A.M. All three acknowledged that Resident 2 should have been provided 1:1 monitoring to help prevent falls and injuries due to falls. A review of the facility ' s policy and procedure titled Fall Risk Assessment, revised March 2018, was conducted. The policy indicated, .1. Upon admission, the nursing staff and the physician will review a resident ' s record for history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling overtime. 2. The nursing staff will ask the resident and/or his/her family about any history of the resident falling. 3. The nursing staff, attending physician, and consultant pharmacist will review for medications or medication combinations that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia (poor muscle control), or hypotension (low blood pressure). A review of the facility ' s policy and procedure titled Managing Falls and Fall Risk, revised March 2018, was conducted. The policy indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The policy also indicated, .1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.

Based on interview and record review, the facility failed to protect 2 of 9 sampled residents, (Resident's 1, 2) when an allegation that Certified Nursing Assistant (CNA) 1 was inappropriate during a brief change (incontinent care) and the facility did not suspend the CNA. Resident 2 also made similar allegations against the same CNA. This failure increased Resident 1 and 2's risk for psychosocial distress (emotional suffering) and had the potential to put residents in the facility at further risk of abuse. Findings: 1. Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's history and physical (H & P) report, dated 3/23/21, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set MDS- an assessment tool, dated 3/9/21, Section C, indicated BIM (Brief Interview for Mental Status) Summary Score was 14 out of 15 (cognition intact). The MDS also indicated the resident required extensive assistance with bed mobility, transfers from bed, wheelchair to a standing position, dressing, toileting and personal hygiene. On 3/29/21 at 10:55 A.M., an interview with Resident 1 was conducted on Station 3. Resident 1 stated, the incident occurred during the night shift of 3/12/21 at 5 A.M. during a brief change. Resident 1 stated, CNA 1 .pressed above her vagina in a circular motion, felt it was in a violating fashion, in a sexual way like abuse, while applying barrier cream. Resident 1 further stated, she was molested as a child and as a teenager by a family member and was abused by a staff member at another facility in the past. Resident 1 stated, she knows the difference between a sexual and nonsexual act. Resident 1 stated, she reported the allegation to staff because she felt she was abused. Resident 1 stated, she notified CNA 12 on the PM shift (2:30 P.M. - 10:30 P.M.) on 3/13/21 of the alleged abuse. On 3/29/21, a review of the facilities' night shift assignment sheet for Station 3, dated 3/13/21, indicated CNA 1 was assigned to station 4 for his shift. On 3/29/21, a review of Resident 1's care plan titled abuse, dated 3/26/21, indicated the staff would make sure Resident 1 felt safe in the facility, would notify the administrator and law enforcement, follow the abuse protocol, and initiate psych consult. This care plan was developed in regards to Resident 1's allegation of abuse reported to staff on 3/20/21. On 4/1/21 at 11:52 A.M., an interview with Licensed Nurse (LN) 6 was conducted. LN 6 stated, she had been notified by CNA 12 about Resident 1's allegation on 3/13/21 at 11 P.M. LN 6 stated, she interviewed Resident 1 about the allegation; and Resident 1 stated CNA 1 on the night shift (10 P.M. - 7 A.M.) of 3/12/21 was .rough on her and felt violated in her private area when her brief was changed. LN 6 stated, she notified the Director of Nursing (DON) of Resident 1's allegation on 3/13/21 at 11:30 P.M., via telephone for the potential allegation of abuse. LN 6 further stated that CNA 1 came in for his scheduled night shift (10:30 P.M. - 7 A.M.) on 3/13/21 and was reassigned to Station four (4) for his shift. On 4/5/21, a review of Resident 1's Psychology Consult, dated 3/31/21, indicated, the reported alleged abuse by Resident 1 on 3/13/21, was perceived as sexual abuse. 2. Resident 2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's history and physical (H & P) report, dated 2/28/21, indicated the resident had the capacity to understand and make decisions. A review of Resident 2's Minimum Data Set MDS - an assessment tool, dated 3/5/21, Section C, indicated Resident 2's BIM (Brief Interview for Mental Status) Summary Score was 15 out of 15 (cognition intact). The MDS also indicated the resident required extensive assistance with bed mobility, dressing, toileting and personal hygiene. On 4/5/21 at 11:09 A.M., an interview with Resident 2 was conducted on Station 3. Resident 2 stated, the alleged abuse occurred on the night shift (10:30 P.M. - 7 A.M.) on 3/19/21 at 2 A.M. during a brief change. Resident 2 stated, CNA 1 .inappropriately rubbed her vagina area in a circular motion, while applying barrier cream. Resident 2 stated, she asked CNA 1 to stop and he did. Resident 2 stated, he should not be touching me there (points to vaginal area) only her husband was supposed to touch her like that. Resident 2 stated, she felt CNA 1 had touched her inappropriately. Resident 2 further stated, she had been raped by two family members between ages 13 - [AGE] years old. Resident 2 stated, she did not want this CNA taking care of her anymore. Resident 2 stated, she notified CNA 16 on the PM shift (2:30 P.M. - 10:30 P.M.) on 3/20/21 of the alleged abuse. On 4/12/21 at 10:21 A.M., an interview with LN 5 was conducted. LN 5 stated, she had been notified on 3/20/21 at 9:30 P.M. by LN 3 regarding Resident 2's allegation. LN 5 stated, she interviewed Resident 2 on 3/20/21 at 9:45 P.M. about the allegation, and Resident 2 stated that CNA 1 on the night shift (10:30 P.M. - 7 A.M.) of 3/19/21 had .inappropriately rubbed her vagina area in a circular motion, when her brief was changed. Resident stated, only her husband should be touching her there and felt that CNA 1 was inappropriate. Resident 2 further stated, she did not want this CNA taking care of her. LN 5 stated, she notified the DON on 3/20/21 at 11:30 P.M. via telephone. CNA 1 came in for his scheduled night shift (10:30 P.M. - 7 A.M.) on 3/20/21 and was sent home after the second allegation. On 4/5/21, a review of the facility's night shift assignment sheet for station 3, dated 3/19/2021, indicated CNA 1 worked on station 3 and was assigned to care for Resident 1 and Resident 2. On 4/5/21, a review of LN 5's post documentation of allegation titled, Safety Events dated 3/20/21, indicated Resident 2 had exhibited expressions and indications of distress shaky hands and verbalized feeling victimized. On 4/5/21, a review of Resident 2's psychology consult, dated 4/7/21 indicated Resident 2 had moderate to severe anxiety from past traumatic events (abuse history) grief reactions and persistent negative emotional state; fear, horror, anger, guilt and shame. Resident 2 stated, she was no longer able to control who knew of her history of abuse, this upsets her and she cried all night and continues to cry a lot still. On 4/13/21 at 2:37 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated, CNA 1 was not suspended. The DON stated she had been notified by LN 6 on 3/13/21 at 11:30 P.M. by telephone of Resident 1's allegation that occurred on 3/12/21. The DON stated, because Resident 1 stated, It was not sexual, she did not feel it was abuse; CNA 1 was not suspended but reassigned to another section. The DON was notified by LN 5 on 3/20/21 at 11:30 P.M. by telephone of Resident 2's allegation that occurred on 3/19/21. The DON stated, CNA 1 was suspended on 3/20/21, eight days after Resident 1's initial allegation. The DON stated, CNA 1 should have been suspended to protect the other residents. The DON stated, the expectation was for staff to treat residents with respect and that residents where to be free from abuse. The DON further stated, she did not follow the facility's abuse policy. On 4/13/21 at 2:51 P.M., an interview with the Administrator was conducted. The Administrator stated, she was the abuse coordinator. The Administrator stated CNA 1 was not suspended because she did not feel it was abuse since Resident 1 stated the allegation was not sexual. The Administrator stated, CNA 1 should have been suspended to protect the residents. The Administrator stated, resident abuse was not allowed and that residents should be free from abuse. The Administrator further stated, they did not follow the facility's abuse policy. On 4/13/21 at 3:11 P.M., a review of the facilities abuse policy was conducted with the Administrator. The facility's policy, titled Abuse Investigation and Reporting, revised July 2017, indicated, .#4. The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation .#5. The administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. The Administrator stated, the facility's policy needed to indicate residents should be free of abuse.

Based on observation, interview and record review, the facility failed to provide services necessary to avoid physical harm when Resident 1 was left alone in the shower room resulting in a fall which caused a facial fracture. Findings: Resident 1(RT) was originally admitted to the facility on [DATE]. Her latest return was on 04/21/2018. RT 1's admitting [DIAGNOSES REDACTED]. On 04/25/18 at 2:30 P.M., an observation was conducted in room [ROOM NUMBER]. Upon entering the room, the bathroom with common shower room were on the left. There were two beds. Bed A was near the window and bed B near the 2 closets. Upon entering the bathroom, the sink and countertop were catty corner on the right hand side, the toilet was on the left hand side. The entrance to the shower was approximately 2 feet forward. The shower area was on the right side. The shower area was approximately 5 ft x 4 ft. The floor and walls were tiled. When facing the shower area, the fixtures were all on the right hand side. The removable shower head and the shower valve were about 3.5 ft from the floor and were mounted to the wall. Grip bars were mounted on 2 walls approximately 3 feet from the floor. One of the walls with the grip bar was the right hand side with the shower fixtures and the back wall. The nearest call bell was on the other side of the shower wall next to the sink. During the same tour at 2:40 P.M., RT 1 was observed lying on her left side in bed. RT 1 had a 4 x 4 gauze on her right cheek held in place by 2 pieces of paper tape. Scattered blackish blue skin discoloration was observed around the right eye and lower chin. RT 1 is Arabic speaking only. RT 1 had a grimace on her face. RT 1 was shaking her head and had her hand over the gauze. On 04/25/18 at 3 P.M., during an interview with RT's son and RP (Responsible party), the RP said, my mom has been at the facility about one and a half years. Before the fall, she was OK. She was more talkative. When I asked my mom what happened, she said she wasn't sitting in the chair right. She told me she was left in the shower room alone. My mom said she stood up. She was trying to fix herself that's why she fell . When my mom fell , her face hit the shower faucet valve. The roommate saw the CNA in the room getting my mom's clothes out of the closet. On 04/25/18 at 3:15 P.M. an interview with CNA 1 was conducted. CNA 1 said she was assigned to give RT 1 a shower on 04/19/18. CNA 1 said she has been working at SDPA approximately 2 years and that was the first time she had given RT 1 a shower. CNA 1 said, at the beginning of the shower, she was adjusting herself. I thought she was uncomfortable. I tried to pull her back but could only do what I could. I made sure the shower chair was locked. She wanted extra time to rinse herself so I handed her the shower head. I turned around to pick up linen that had fallen off the bathroom counter top onto the floor. I had only turned my back for 3 or 4 seconds. That's when I heard a smack. By the time I turned around, she was already on the floor. She doesn't speak English but we have two staff who speak Arabic. When I saw her on the floor, I checked her for consciousness and covered her with a sheet. I opened the door and yelled for help. The RNA who was translating said, the resident said her face hurt. On 04/25/18 at 3:45 P.M., RT 1 was interviewed using the Universal Language Services for Arabic interpretation. Per Interpreter 1, RT 1 said, I was not secure in the chair when we started. The chair wasn't secure that's why I fell . I was alone in the shower room. On 04/25/18 at 4 P.M., during record review, Progress Notes written by the PA dated 04/19/18 at 10:30 A.M. indicated, Per nursing, patient was left unsupervised for a few moments and slipped in the shower hitting her face .patient able to follow commands, equal strength noted to all extremities although significant right sided facial droop noted .nursing reported laceration measuring approximately. 5.5 cm .Plan: Fall; Acute: patient with facial laceration and right sided facial droop sent by EMS to hospital for further evaluation and treatment. On 04/25/18 at 1:30 P.M., during an interview with the Director of Nursing (DON). The DON said, RT 1 was sent out on the morning of 04/19/18. She had a laceration on the right cheek that's why we sent her out. She was admitted to the General Acute Care Hospital. On 04/25/18 at 4:05 P.M., a review of the physician hospital history and physical note, documented by physician (MD)1, dated 4/20/18, was conducted. The physician note indicated, RT 1 was admitted on [DATE]. Chief Complaint: Mechanical fall, right facial laceration .The patient was evaluated by the ER physician. The patient had a CT scan of the facial bones consistent with focal fracture with anterior wall of the right maxillary sinus at the site of the soft tissue. On 05/09/18 at 2:40 P.M., an interview was conducted with RT 1's roommate, Resident 2(RT 2). RT 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RT2's BIMS score was 7. RT 2 was interviewed using the Universal Language Service for Arabic interpretation. According to Interpreter 2, RT 2 was oriented to the day and place. RT 2 said she remembered the day her roommate fell . RT 2 stated, the CNA went to the closet to get clothes. She should have gotten them before she went in the shower. We heard a Boom. That was when she fell . They all rushed in after that. On 05/09/18 at 3 P.M., record review of a document titled, Shower/Tub Bath, revised (MONTH) 2010, indicated under General Guidelines, .2. Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. During a joint interview with DON and QA nurse on 05/10/18 at 5:06 P.M., the DON said, We expect staff to stay with the resident at all times during a shower. We remind them to get everything ready and adequately prepared before taking the resident to the shower room.