Every finding on record at Santa Fe Post-Acute

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices in the facility's kitchen were maintained according to acceptable standards of practice when:Food storage areas: A a staff water bottle was stored in the walk-in refrigerator, a dented can was stored among non-dented cans, there were moldy onions infested with fruit flies circling over them were stored in the dry storage area, and water pitchers were stored wet. In addition, a stored water pitcher had visible debris in it.A towel dispenser was not used in a sanitary manner when staff performed hand hygiene.The cook (CK) failed to check the temperatures of all food prior to plating.There was no thermometer in the dry storage room, and temperature logs were not maintained.Dishwashers (DW 1 and DW 2) did not know how to test the chemical concentration used in the dishwasher.Two resident freezers temperatures were not monitored. These failures had the potential to cause widespread food contamination and placed residents at risk for food borne illnesses. FINDINGS:1.On 6/1/26 at 8:06 A.M., a joint observation of the kitchen and interview was conducted with dietary manager (DM). The walk-in refrigerator was observed. There was an unopened (brand name) water bottle in a bin with the carrots. The DM stated they did not use (brand name) as their water bottle supplier. The DM stated it was a personal water bottle, and personal items should not have been kept in the kitchen refrigerator.The dry storage room was then observed. A large can of fruit cocktail was observed on a rack with other canned goods. The fruit cocktail can was dented in the middle. The dent was approximately two inches wide. The DM stated the dented can should not have been there.There were two boxes of yellow and red onions. Five were mushy and had fuzzy gray spots on them. Three onions had long green leaves growing from them. Fruit flies were flying in and around the onion boxes. There was a spoiled odor coming from the boxes of onions. The DM stated the onions were covered with mold and were no good. The clean dishware area was observed. There were several trays with water pitchers stored on them. The water pitchers were dripping wet with water. The DM stated they were stored ready for use and should not have been stored wet. One wet water pitcher was observed with black debris inside of it. The DM stated it looked like coffee grounds, and the pitcher should have been cleaned better. The DM stated wet dishware could grow bacteria.Fruit flies were flying in and around the onion boxes. There was a spoiled odor coming from the boxes of onions. The DM stated the onions were covered with mold and were no good. The clean dishware area was observed. There were several trays with water pitchers stored on them. The water pitchers were dripping wet. The DM stated they were stored ready for use and should not have been stored wet. One wet water pitcher was observed with black debris inside of it. The DM stated it looked like coffee grounds, and the pitcher should have been cleaned better. The DM stated wet dishware could grow bacteria. A review of the facility's policy titled Dishes and Utensils revised 6/19/25, indicated, .4. Dishes, trays and utensils shall be routinely checked for stains or spots .6. Dishes, trays, and utensils shall be air dried before storage .9. Any dish, tray or utensil with debris should not be used. Send back to the dish room to be properly washed and sanitized.11. Resident's reusable water pitcher must be washed and sanitized.and air dried.A review of the facility's policy titled Dented or Damaged Cans revised 11/4/2024, indicated, .Return any dented or damaged cans. to the distributor for credit. A review of the facility's policy titled Food Storage revised 7/11/24, indicated, 1. Fresh vegetables should be checked and sorted for ripeness.6. Most vegetables should be used within 3 to 5 days.7. Potentially hazardous foods.should be inspected for decay or damage.10. Check for pest infestation regularly.2. On 6/3/26 at 11:24 A.M., a joint observation of the kitchen and interview was conducted with the DM. A dietary aide (DA) was observed washing her hands at the washing station in the dietary kitchen. The DA, using the paper towel dispenser handle, dispensed a long amount of paper towel that touched the top of the trash can. The DA then used the paper towel that touched the trash can to dry her clean hands. The CK was observed washing his hands at the washing station. The CK then touched the paper towel dispenser handle with his clean hand to dispense the paper towel. The CK then dried his hands with the paper towel. Another DA was observed washing their hands and using their clean hand to dispense paper towels using the paper towel dispenser handle. This DA dispensed a long amount of paper towels that entered the open trash can. The opened trash can had trash inside it. The DA used that same paper towel that had been in the interior of the trash can to dry her clean hands. A review of the facility's policy titled Handwashing and Glove Use dated 2020 did not provide guidance related to proper hand hygiene and paper towel use.3. On 6/3/26 at 12:04 P.M., a joint observation in the kitchen and interview was conducted with the DM. The CK took temperatures of some of the food on the steam table and recorded them in the food temperature log. Then the CK put away the temperature log and began plating resident food. The CK did not take the temperatures of the soft pork, bite- size pork, and soups. The DM stated the temperature of all food should have been checked to ensure it reached a safe serving temperature and recorded on the temperature log before being served to residents.A review of the facility's policy titled Food Temperatures dated 2020, indicated, Foods should be served at proper temperature to ensure food safety and palatability.4. On 6/3/26 at 12:35 P.M., a joint observation of the dry storage room and an interview and record review, was conducted with the DM. The dry storage room was observed and did not have a thermometer to monitor the temperature of the room. The DM stated there should always be a thermometer in the dry storage room. A review of the food temperature log indicated there were blank entries for the dry storage room. The DM stated the food temperature log had blank entries for the dry storage room since January 2026.A review of the facility's policy titled Food Storage revised 7/11/24, did not provide guidance related to monitoring the temperature in the dry storage room.5. On 6/3/26 at 1:09 P.M., an observation of the kitchen and interview was conducted with DW 1, DW 2, and the DM. DW 1 was observed running the dishwasher. DW 1 then tested the dishwasher disinfectant level (low temp machine) using chlorine test paper. The chlorine test paper had different shades of purple that would indicate different disinfectant levels present in the dishwashing water. DW 1 was hesitant to test the dishwasher. DW 1 placed the chlorine test paper into the dishwasher water. DW 1 then stated he could not see the test strip because he was tired. At 1:19 P.M., DW 2 was observed running the dishwasher. DW 2 then tested the disinfectant level using the chlorine test paper. DW 2 stated he could not read the test strip because he was color blind. The DM stated this was a concern.On 6/4/26 a record review was conducted. The facility's document titled Dish Machine Temperature Log for April and May 2026 indicated DW 1 tested the dishwashing disinfectant level using the chlorine test paper on 5/28/26. The document further indicated DW 2 tested the dishwashing disinfectant level using the chorine test paper on 4/4/26, 4/5/26, 4/25/26, 4/26/26, 5/2/26, 5/3/26, 5/10/26, 5/16/26, 5/17/26, 5/23/26, 5/28/26, and 5/31/26.6. On 6/4/26 at 8:36 A.M., an observation of the resident refrigerator in station 1 and station 2 was conducted. The temperature logs for refrigerator were taped on the side of refrigerator. The temperature logs had no freezer temperatures recorded.On 6/4/26 at 8:58 A.M., a joint interview and record review was conducted with the DM. The DM stated stated resident freezer temperatures should also be monitored and recorded daily. The DM reviewed the resident refrigerator temperature logs and stated there was no record of freezer temperatures being monitored. The DM stated both resident refrigerator and freezer temperatures should be monitored and recorded.The DM further stated both DW 1 and DW 2 should have been competent to test the sanitation chemical in the dishwasher. The DM stated new hires were not asked about color blindness, but they should include it in their new hire process. The DM stated she did not think DW 1 knew how to use the test strips as someone else usually tested it for him. The DM stated it was her expectation that all dishwashers knew how to test the dishwasher disinfectant levels. The DM stated DW 2 should not have been testing dishwashing disinfectant levels since he was color blind. The DM reviewed the Competency Form for Dietary Aides and Dishwashers for DW 1 and DW 2. The DM stated they were both checked off for, .Utilizes test strips and logs appropriately.On 6/4/26 at 10:08 A.M., An interview was conducted with the registered dietitian (RD). The RD stated there should have been no personal food or water bottles in the kitchen refrigerator. The RD stated water pitchers, and any other dishware should not have been stored wet. The RD stated it could harbor bacteria. The RD stated she expected all dishware to be clean and dry before storing. The RD stated there should have been a thermometer in the dry storage room and the temperature should have been monitored and recorded. The RD stated all dishwashers should be able to competently test the disinfectant solution used in the dishwashing machine. The RD stated dishwashers should not be testing the disinfectant levels if they could not see colors accurately as the test strip was color based. The RD stated dented cans of food and spoiled food should not have been kept in the dry storage room. The RD stated all food to be served to residents should have had a final temperature taken prior to plating for food safety. The RD stated, It ensures bacteria is killed. The RD stated when staff touched the paper towel dispenser handle with clean hands and dispensed paper towels that touched the trash can, their hands became contaminated.On 6/4/26 at 10:41 A.M., an interview was conducted with the administrator (ADM). The RD was also present. The ADM stated he expected food to be stored safely. The ADM stated storage and resident refrigerated areas should have temperatures monitored and documented on a routine basis. The ADM stated personal food should not have been kept in the dietary kitchen. The ADM stated dishware should not have been stored soiled or wet. The ADM stated the cook should have checked all the temperatures of the food before it was plated. The ADM stated all dishwashers should be able to test the dishwashing solutions competently and anyone who was colorblind should not be asked to use the color testing strips.

Based on interview and record review, the facility failed to obtain admission order from the resident's attending physician for eight of nine sampled residents (6, 10, 14, 17, 19, 25, 94, and 117) as required. Residents 6, 10, 14, 17, 19, 25, 94, and 117 were admitted to the Skilled Nursing Facility's (SNF, provide 24-hour care to residents) secured unit (are intentionally designed spaces that help people with dementia live in a safe environment) without a physician order. This failure had the potential to violate Residents 6, 10, 14, 17, 19, 25, 94, and 117 rights. Findings:1. Resident 6 was admitted to the facility on [DATE], per the facility's admission Record.A review of Resident 6's history and physical (H&P) dated, 11/28/25 was conducted. The physician documented Resident 6 did not have the capacity to understand and make decisions.Resident 6's physician order was reviewed. There was no physician order for Resident 6's SNF placement.2. Resident 10 was admitted to the facility on [DATE], per the facility's admission Record.Resident 10's history and physical (H&P) dated 4/16/26 was conducted. The physician documented Resident 10 had the capacity to understand and make decisions.Resident 10's physician order was reviewed. There was no physician order for Resident 10's SNF placement.3. Resident 14 was readmitted to the facility on [DATE], per the facility's admission Record.Resident 14's history and physical (H&P) dated 4/18/26 was conducted. The physician documented Resident 14 did not have the capacity to understand and make decisions.Resident 14's physician order was reviewed. There was no physician order for Resident 14's SNF placement. 4. Resident 17 was admitted to the facility on [DATE], per the facility's admission Record.Resident 17's history and physical (H&P) dated 1/15/26 was conducted. The physician documented Resident 17 did not have the capacity to understand and make decisions.Resident 17's physician order was reviewed. There was no physician order for Resident 17's SNF placement.5. Resident 19 was readmitted to the facility on [DATE], per the facility's admission Record.Resident 19's history and physical (H&P) dated 1/15/26 was conducted. The physician documented Resident 19 did not have the capacity to understand and make decisions.Resident 19's physician order was reviewed. There was no physician order for Resident 19's SNF placement.6. Resident 25 was admitted to the facility on [DATE], per the facility's admission Record.Resident 25's history and physical (H&P) dated 9/9/25 was conducted. The physician documented Resident 25 did not have the capacity to understand and make decisions.Resident 25's physician order was reviewed. There was no physician order for Resident 25's SNF placement. 7. Resident 94 was readmitted to the facility on [DATE], per the facility's admission Record.Resident 94's history and physical (H&P) dated 5/11/26 was conducted. The physician documented Resident 94 had normal cognition.Resident 94's physician order was reviewed. There was no physician order for Resident 94's SNF placement.8. Resident 117 was admitted to the facility on [DATE], per the facility's admission Record.Resident 117's history and physical (H&P) dated 2/16/26 was conducted. The physician documented Resident 117 was alert and oriented times 2-3 (some parts of their orientation are intact, while others are not. For example, they may know their name and location but be confused about time or situation.)Resident 117's physician order was reviewed. There was no physician order for Resident 117's SNF placement.On 6/4/26 at 10:59 A.M., a joint interview and record review of the resident's clinical record were conducted with Licensed Nurse (LN) 21. LN 21 stated she could find an admission physician's order to admit Residents 6, 10, 14, 17, 19, 25, 94, and 117 to the secured unit for Residents 6, 10, 14, 17, 19, 25, 94, and 117. LN 21 stated there should be a physician's order to admit them to the SNF.On 6/4/26 at 3:21 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated there should be a physician's order to admit residents to the SNF. The DON stated moving forward, the facility would have to enhance the admission process to align with the state and federal regulations.A review of the facility's policy and procedures, titled admission Criteria revised March 2019 was conducted. The policy did not indicate a physician's order for a resident's admission should be obtained prior to the resident's admission into SNF.

Based on observation, interview, and record review, the facility failed to ensure person-centered care plans were developed and interventions were implemented for 5 of 40 sampled residents (Resident 1, 83, 88, 6 and 94) when: A care plan was not developed for Resident 1's prescribed feeding strategies and interventions.A care plan was not implemented for range of motion for Resident 83 and Resident 88.A care plan was not developed to address Resident 6's pain.A care plan was not implemented for Resident 94's falls. These failures had the potential to prevent the residents from receiving care and services specific to the residents' needs. Findings: 1. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include dysphagia (swallowing difficulty) and cerebral infarction (blocked blood flow to the brain). A review of Resident 1's physician's order dated 4/29/26, indicated, . Regular diet Regular texture, Regular/Thin consistency. All plastic utensils.for safe swallowing strategy use. Assist with cutting PO [by mouth] during tray s/u [set/up] as needed. A review of Resident 1's Speech Therapy Treatment Encounter Note dated 5/5/26 indicated, .Summary of Daily Skilled Services.Precautions/Contraindications.[foreign language] speaking.general safe swallowing strategies.Skilled meal observation, trial on plastic utensil.Skilled Instruction Patient and Caregiver Training: Nursing reports recent emergence of shoveling behaviors. Most certainly attributed to decreased impulse control.Response to Session Interventions: All utensil traded out for plastic to ascertain if bolus [food created in the mouth] size and oral management can be facilitated.Reduced bolus providing much needed relief and decreased risk for foreign object aspiration.team notified of change.Swallowing Abilities=Set-up.Current Diet=Regular textures, Moist Puree Consistencies. A review of Resident 1's meal ticket for lunch on 6/1/26, indicated .Adap Equip [adaptive equipment]: Plastic Utensils.Notes: .All plastic utensils as able for safe swallowing strategy use. FEEDER [requiring staff assistance for eating]. A review of Resident 1's speech therapy (ST) Care Plan revised on 3/24/26, indicated, . Goal.will consume safest least restrictive diet texture without overt display s/sx [signs/symptoms] .dysphagia during PO [by mouth] intake.Interventions/Tasks.skilled ST services.for dysphagia.tx[treatment] including diet texture analysis, general safe swallowing strategies and compensatory swallowing strategies. The care plan was not developed to include specific swallowing strategies such as the use of all plastic utensils and the type of supervision or feeding assistance Resident 1 needed. On 6/1/26 at 12:19 P.M., an observation was conducted in the facility's main dining room. Resident 1 was sitting in a wheelchair, feeding himself using plastic utensils. Resident 1 had a whole large piece of chicken breast on his plate. Resident 1's meal ticket indicated resident was a Feeder (a resident who relies entirely on staff). Staff were not providing feeding assistance to Resident 1. Resident 1's meal ticket indicated, All plastic utensils as able for safe swallowing strategy use. Resident 1 continued eating independently and had difficulty cutting up the chicken breast. Later, a licensed nurse (LN) came to assist Resident 1 with cutting the chicken breast then left. On 6/2/26 at 12:31 P.M., another observation was conducted in the facility's main dining room. Resident 1 was sitting in a wheelchair and had his lunch meal tray in front of him. Resident 1 was eating independently using plastic utensils. There were no staff helping the resident. Resident 1's meal ticket indicated, Feeder and All plastic utensils as able for safe swallowing strategy use. LN 60 was in the dining room assisting other residents. LN 60 reviewed Resident 1's meal ticket. LN 60 stated Resident 1 was not a feeder. LN 60 stated the indication for feeder was outdated and the resident's meal ticket was not updated. LN 60 stated Resident 1 needed verbal cues to eat slowly. On 6/2/26 at 12:35 P.M., an interview was conducted with restorative nursing assistant (RNA) 1. RNA 1 stated he was familiar with Resident 1. RNA 1 stated Resident 1 was capable of independently feeding himself. RNA 1 stated Resident 1 had to use plastic utensils to make sure the resident got small portions of food to put into his mouth. RNA 1 stated Resident 1 required verbal cues to slow down with eating. At 12:42 P.M., RNA 2 was then observed sitting next to Resident 1. RNA 2 moved Resident 1's meal tray away from the resident and closer to RNA 2. RNA 2 started feeding Resident 1 using the plastic utensils. RNA 2 fed Resident 1 for the whole meal. On 6/3/26 at 9:05 A.M., an interview and record review was conducted with the speech therapist (ST). The ST stated Resident 1 had received speech therapy services since March 2025. The ST reviewed Resident 1's skilled service summary and clinical orders pertaining to Resident 1's feeding needs. The ST stated Resident 1 was not a feeder. The ST stated the feeder status was outdated and needed to be corrected. The ST stated the current plan for Resident 1 was for compensatory swallowing strategies, to have bite size food pieces and the use of all plastic utensils. The ST stated Resident 1 was in the RNA Dining Program, where the resident would be brought to the dining room and the RNAs would assist and supervise Resident 1's mealtime. The ST stated Resident 1 needed distant supervision to make sure he sat upright on the chair and he needed assistance cutting up his food. The ST stated Resident 1 did not need verbal cues with meals. The ST reviewed Resident 1's speech therapy (ST) Care Plan revised on 3/24/26. The ST stated Resident 1' care plan was not developed to include the prescribed compensatory swallowing strategies, the bite size food pieces, and the use of all plastic utensils. On 6/3/26 at 10:15 A.M., an interview and record review was conducted with LN 48. LN 48 stated she was familiar with Resident 1's care needs. LN 48 reviewed Resident 1's clinical record and the physician's orders. LN 48 stated she did not know why Resident 1 had an order for all plastic utensils with meals. LN 48 stated a care plan should have been developed so the staff would know what feeding assistance and interventions were needed for Resident 1. On 6/3/26 at 12:40 P.M., an interview was conducted with RNA 2. RNA 2 stated she was instructed by LN 60 to sit and feed Resident 1 on 6/2/26. RNA 2 stated she was familiar with Resident 1's care needs. RNA 2 stated Resident 1 always fed himself on his own. RNA 2 stated Resident 1 needed reminders to eat slowly and at times needed assistance with repositioning in his wheelchair. RNA 2 stated Resident 1 had never been a feeder. RNA 2 stated she did not know why Resident 1's meal ticket indicated the resident was a feeder. RNA 2 stated spoon feeding Resident 1 was taking away his independence. RNA 2 stated she did not know why Resident 1 had to use plastic utensils. RNA 2 stated she did not know what an RNA Dining Program was and would need to ask her supervisor. On 6/4/26 at 4:30 P.M., an interview was conducted with the director of nursing (DON). The nurse consultant (NC) was also present in the room. The DON stated there should not have been confusion as to what Resident 1's feeding needs were. The DON stated the confusion could place Resident 1 at risk for aspiration and health decline. The DON stated an individualized care plan should have been developed for Resident 1 regarding compensatory swallowing strategies, to have bite size food pieces, and the use of all plastic utensils. The DON stated it was important to develop an individualized care plan because CNAs followed the Kardex (guide to residents' care and needs) for their residents' care. The DON stated the care plan information would flow into the Kardex and would inform the CNAs of the actual assistance and interventions needed for Resident 1. A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, .3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical.and psychosocial well-being.d. builds on the resident's strengths.11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 2a. A review of Resident 83's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis that included hemiplegia and hemiparesis following cerebral infarction which affected the left non-dominant side (Hemiplegia: Complete paralysis of one side of the body, usually resulting from a stroke or brain injury. Hemiparesis: Weakness or numbness on one side of the body.) 2b. A review of Resident 88's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis that included hemiplegia, unspecified affected the left dominant side. On 6/4/26 at 10:15 A.M., a concurrent interview and record review was conducted with Licensed Nurse 1 (LN1). LN 1 reviewed care plan for Resident 83 and 88. LN 1 reviewed Resident 83's care plan, dated 3/6/26, indicated Resident 83 was at risk for contractures. The intervention was range of motion exercises, both active and passive as tolerated. LN 1 reviewed Resident 88's care plan dated 7/14/25, also indicated Resident 88 was at risk for contractures. Further review indicated the intervention for Resident 88 was range of motion, active or passive, daily am/pm care, daily as indicted. LN 1 stated it was important to implement the care plans for Resident 83 and Resident 88 to prevent the worsening of contractures. LN 1 stated there was no order or documentation that the care plans for either Resident 83 and Resident 88 were implemented, and they should have been. On 6/4/26 at 2:43 P.M., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the care plan for range of motion for Resident 83 and Resident 88 should have been implemented and an order was placed for RNA (restorative nursing assistant). The DON stated the care plan for range of motion was to prevent contractures and to keep use of limbs as much as possible. 3. Resident 6 was admitted to the facility on [DATE], per the facility ' s admission Record. A review of Resident 6's history and physical (H&P) dated 11/28/25 was conducted. The physician documented Resident 6 did not have the capacity to understand and make decisions. On 6/1/26 at 9:41 A.M., an observation and interview were conducted in Resident 6's room. Resident 6 was in bed, rotating his shoulders. Resident 6 stated he had shoulder pain and the staff had not provided interventions to alleviate his pain. On 6/3/26 at 8:23 A.M. a follow-up observation and an interview were conducted in Resident 6's room. Resident 6 was in bed and awake. Resident 6 stated he felt much better regarding his shoulder pain. Resident 6 also stated a couple of days ago, he had pain and only received one dose of his pain medication.On 6/3/26 at 1:21 P.M., a joint interview and record review was conducted with Licensed Nurse (LN) 22. LN 22 stated Resident 6 had pain in his shoulder because he slept on it for long. LN 22 stated Resident 6 expressed his shoulder pain since May 2026 and was prescribed pain medications. LN 22 stated he did not see a care plan in Resident 6's clinical record and a care plan should have been developed to address Resident 6's shoulder pain. On 6/4/26 at 3:21 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the LNs should have developed a care plan to address and alleviate Resident 6's shoulder pain. A review of the facility's policy, titled Care Plan, Comprehensive Person-Centered, revised March 2021, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to [NAME] the resident's physical.and functional needs is developed and implemented for each resident. 4. Resident 94 was readmitted to the facility on [DATE], per the facility ' s admission Record. Resident 94's history and physical (H&P) dated 5/11/26 was conducted. The physician documented Resident 94 had normal cognition. Resident 94's fall risk assessments (A fall risk assessment checks a person's risk of falling) were reviewed. Resident 94's fall risks were as follows: 4/22/26: Fall risk score of 12. Unwitnessed fall, resident lost her balance, reported of left wrist pain. No injury, vitals were normal, and neuro checks initiated. 4/26/26 (7:52 PM): Resident was observed on the floor next to her bed with skin tears on her right forearm. She stated she rolled out of bed while sleeping. She denied pain nor injuries.One fall on 4/26/26, three fall risk assessments were done but only one fall on 4/26/26. 5/21/26: Resident was found on the floor, sitting on her bottom. She denied any pain, neuro checks were initiated. 5/27/26: CNA (certified nursing assistant) reported the resident was seen on the commode, trying to get back in bed, she lost balance, no injury. Responsible Party (RP) notified (witnessed falls) . A review of Resident 94's fall care plan dated 5/27/26 indicated. Place Floor Mats Next To Bed To Reduce The Impact of Falls/Found on Floor Incidents and Safety Devices To Alert Staff of Unassisted Transfers - Bed Alarm, Wheelchair Alarm On 6/3/26 at 11:25 A.M., an observation and an interview was conducted in Resident 94's room. A star was noted by Resident 94's name. There was no bed alarm, no wheelchair alarm (warn caregivers, and in some cases patients themselves, when a patient leaves or attempts to leave the bed or a wheelchair) and no landing mat noted. Resident 94 laid on her right side with her knees bent and were outside the edge of the resident's bed. Resident 94 stated she felt fine. Resident 94 stated she wanted to take a nap. On 6/3/26 at 11:37 A.M., Resident 94 was observed to have a hard time pushing her wheelchair. The wheelchair's right-side wheel was locked. A CNA redirected the resident back to her room. On 6/3/26 at 11:52 A.M., Resident 94 was observed getting up in bed and walking unsteadily while pushing her wheelchair out of her room. A CNA (21) redirected Resident 94 back to her bed. On 6/3/26 at 11:55 A.M., an interview was conducted with CNA 21. CNA 21 stated Resident 94 required visual supervision because she was a fall risk. CNA 21 stated the falling star by the resident's name indicated the resident is at high risk of falling. CNA 21 stated there was no bed alarm, no wheelchair alarm and no landing mat for Resident 94. CNA 21 stated the staff conducted visual checks on Resident 94. On 6/3/26 at 12:03 P.M., an observation was conducted of Resident 94. Resident 94 got up from her bed, and CNA 21 went to assist Resident 94. Resident 94 had a hard time transferring herself to the wheelchair, even with assistance from CNA 21. Resident 94 stated she could not stand to have the wheelchair being locked. CNA 21 assisted Resident 94 back to her bed. On 6/3/26 at 12:08 P.M., Resident 94 was observed trying to get up from the bed. On 6/3/26 at 3:54 P.M., an interview was conducted with CNA 22. CNA 22 stated Resident 94 was confused and a fall risk. CNA 22 stated Resident 94 would get up any time of the day. CNA 22 stated the intervention was to visually check the resident. On 6/4/26 at 9:44 A.M., a joint interview and record review was conducted with LN 21. LN 21 stated Resident 94 was confused, wanted to go to the bathroom and she was confused to use the call lights. LN 21 stated Resident 94 had four falls, and the care plan was to include floor mats, bed alarm, and wheelchair alarms. LN 21 stated there were no floor mats nor alarms for Resident 94. LN 21 stated the care plan should have been implemented for Resident 94's safety and to prevent head injury. On 6/4/26 at 3:21 P.M., an interview was conducted with the DON. The DON stated Resident 94's care plan should have been implemented for Resident 94's safety. A review of the facility's policy, titled Care Plan, Comprehensive Person-Centered, revised March 2021, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to [NAME] the resident's physical.and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services according to professional standards of practice:Random controlled medication (medications with a high abuse potential) use audit for four of five sampled residents (Residents 56, 146, 63, and 91) 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. These failures had the potential for diversion (unlawful distribution or use), inadequate narcotic accountability, and the potential to not meet the needs of the residents in the facility.Licensed Nurse (LN) 51 did not clarify a medication order before medication administration for one of four sampled residents (Resident 87). This failure had the potential for Resident 87 to experience negative health outcomes.Gabapentin (a medication used for various neurological conditions) was not available for administration for one of four sampled residents (Resident 134). This failure had the potential for Resident 134 to not get the full therapeutic benefit of his medication.The instructions of a medication stored in one of four inspected medication carts were not clarified for Resident 135. This failure had the potential for Resident 135 not to receive the full therapeutic benefit of her medication.Medications containing acetaminophen (used for pain or fever) for one of five sampled residents (Resident 76) exceeded the maximum daily dose (highest amount that can be safely consumed in a day) for acetaminophen. This failure had the potential to expose Resident 76 to negative health outcomes, such as liver toxicity.LNs failed to identify residents accurately and consistently prior to medication administration for two of four residents (Residents 134 and 165) sampled for medication administration observation. In addition, one resident (Resident 95) was observed wearing a deceased resident's wristband (ID bracelet). These failures had the potential for misidentifying residents and exposing residents to negative health outcomes from errors, such as receiving another resident's medications.Findings:1. During an inspection of Medication Cart B conducted with LN 53 on 6/1/26 at 3:30 P.M., the CDRs for Residents 56 and 146 receiving PRN (as needed) controlled medications were requested for review. A CDR for Resident 63 from the Station 2 Medication Cart A/B was requested for review on 6/2/26 at 10:24 A.M. from LN 54. A CDR for Resident 91 from the Station 2 Medication Cart C was requested for review on 6/2/26 at 11:14 A.M. from LN 57.a. A review of Resident 56's medical record indicated an order for oxycodone-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 or severe pain, dated 3/24/26.A review of Resident 56's medical record indicated nursing staff signed out of the CDR to acknowledge one tablet of oxycodone-acetaminophen 5/325 mg was taken out of the package for Resident 56's medication administration; there was no documentation of administration for the oxycodone-acetaminophen 5/325 mg tablet on Resident 56's May 2026 MAR for the following dates:5/18/26 at 7 P.M.5/19/26 at 9:25 P.M.5/21/26 at 5 A.M.5/22/26 at 5 A.M.5/28/26 at 5 A.M.During an interview with the Director of Nursing (DON) on 6/4/26 at 3:10 P.M., the DON confirmed the entries on the CDR and that there was no documentation of administration for oxycodone-acetaminophen 5/325mg on Resident 56's May 2026 MAR on the above dates and times.b. A review of Resident 146's medical record indicated an order for morphine sulfate (a controlled medication used to manage pain) 20 mg per mL (milliliters, unit of measure for volume) solution (in liquid form) - give 0.25 mL sublingually (under the tongue) every 4 hours as needed for pain or SOB (shortness of breath), dated 1/5/26. Nursing staff signed out a dose of the morphine sulfate solution on the CDR, but did not document administration on the May 2026 MAR on one occasion: 5/24/26 at 10 P.M.During an interview with the Director of Nursing (DON) on 6/4/26 at 3:10 P.M., the DON confirmed the entry on the CDR and acknowledged there was no documentation of the morphine sulfate solution administration on Resident 146's May 2026 MAR for 5/24/26 at 10 P.M.c. A review of Resident 63's medical record indicated an order for hydrocodone-acetaminophen (a controlled medication used to manage pain) 10/325 mg tablet - give one tablet by mouth every 6 hours as needed for severe pain, dated 1/23/26. Nursing staff signed out a dose of hydrocodone-acetaminophen 10/325 mg tablet on the CDR, but did not document administration on the March 2026 MAR on one occasion: 3/20/26 at 12:45 P.M.During an interview with the Director of Nursing (DON) on 6/4/26 at 3:10 P.M., the DON confirmed the entry on the CDR and acknowledged there was no documentation of the hydrocodone-acetaminophen administration on Resident 63's March 2026 MAR on 3/20/26 at 12:45 P.M.d. A review of Resident 91's medical record indicated an order for oxycodone-acetaminophen 5/325 mg tablet- give 1 tablet by mouth every 6 hours as needed for pain management, dated 12/5/25. Nursing staff signed out a dose of oxycodone-acetaminophen 5/325 mg tablet on the CDR, but did not document administration on the March 2026 MAR on one occasion: 3/29/26 at 6:19 P.M.During an interview with the Director of Nursing (DON) on 6/4/26 at 3:10 P.M., the DON confirmed the entry on the CDR and acknowledged there was no documentation of the oxycodone-acetaminophen administration on Resident 91's March 2026 MAR for 3/29/26 at 6:19 P.M. The DON stated nursing staff were expected to document administration 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, Administering Medications, revised 4/19, indicated, .23. As required.the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered.A review of the facility's 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.i. time of administration.l. signature of nurse administering medication.2. During a medication administration observation on 6/1/26 at 9:32 A.M., LN 51 prepared and administered 16 medications to Resident 87. One of the medications observed was aspirin (used to prevent strokes) 81 mg chewable tablet.A review of Resident 87's medical record indicated an order for aspirin oral tablet - give 81 mg by mouth in the morning for CVA (cerebral vascular accident, stroke) prophylaxis (prevention), started 6/1/26.During a concurrent interview and record review with LN 51 on 6/2/26 at 9:07 A.M., LN 51 acknowledged the bottle used to prepare Resident 87's aspirin dose contained chewable tablets. LN 51 stated the words enteric coated [designed to release in the small intestine] were not on the order.During an interview with the MDS (Minimum Data Set, a mandatory assessment of residents in a nursing home) Coordinator (MDSC) on 6/4/26 at 10:28 A.M., the MDSC stated the facility only carried aspirin in chewable or enteric coated formulations.During an interview with the DON on 6/4/26 at 10:56 A.M., the DON stated nursing staff were expected to clarify orders and not make assumptions.A review of the facility's P&P titled, Administering Medications, revised 4/19, indicated, .10. The individual administering medications checks the label THREE (3) times to verify.right medication.before giving the medication.3. During a medication administration observation on 6/1/26 at 10:12 A.M., LN 52 was observed preparing and administering seven medications for Resident 134. LN 52 stated she did not have Resident 134's eighth medication, gabapentin, on hand to administer to Resident 134.A review of Resident 134's medical record indicated orders for gabapentin, including:gabapentin 100 mg capsule (medication enclosed in a shell) - give 1 capsule by mouth one time a day for neuropathy (nerve damage resulting in pain, tingling or numbness), started 5/5/23. During a concurrent interview and record review of Resident 134's medical record with LN 52 on 6/1/26 at 3:01 P.M., LN 52 stated Resident 134 did not receive his morning gabapentin dose because it was unavailable.During an interview with the DON on 6/4/26 at 10:56 A.M., the DON stated nursing staff were expected to order medications in a timely manner.A review of the facility's P&P titled, Administering Medications, revised 4/19, indicated, .4. Medications are administered in accordance with prescriber orders, including any required time frame.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified.A review of the facility's P&P titled, Pharmacy Services Overview, revised 4/19, indicated, .4. Residents have sufficient supply of their prescribed medications and receive medications.in a timely manner.4. During an inspection of the Medication Cart B with LN 53 on 6/1/26 at 3:30 P.M., a glipizide (a medication used to treat diabetes, a condition characterized by an inability to control blood sugar) bubble pack (a type of packaging for pills that organizes each dose in a clear, plastic bubble) for Resident 135 was observed stored in the medication cart. The glipizide prescription labeling indicated, .*TAKE WITH FOOD*. Additionally, a green auxiliary label indicated, Take This Medicine 1/2 Hour [sic] Before A Meal.A review of Resident 135's medical record indicated an order for glipizide oral tablet 2.5 mg - give 2.5 mg by mouth one time a day for DMII (Type 2 Diabetes Mellitus, a form of diabetes) give with food, started 8/24/25.A drug review of glipizide, of the facility's drug handbook, indicated, Give.about 30 minutes before meals.During a concurrent interview and record review with LN 59 on 6/3/26 at 9:38 A.M., LN 59 stated the instructions on the glipizide bubble pack were contradictory. LN 59 stated the order required clarification.During an interview with the DON on 6/4/26 at 10:56 A.M., the DON nursing staff should have clarified the glipizide order.A review of the facility's P&P titled Charting and Documentation revised 7/17, indicated, .5. All documentation shall be accurate, complete, timely.A review of the facility's P&P titled, Administering Medications, revised 4/19, indicated, .10. The individual administering medications checks the label THREE (3) times to verify.right time.of administration before giving the medication.5. A review of Resident 76's medical record indicated active orders for multiple acetaminophen containing medications, including:acetaminophen ER (extended release, designed to release slowly) 650 mg oral tablet - give 2 tablet [sic] by mouth two times a day for moderate pain. NTE (not to exceed) 3 grams [or 3000 mg] in 24 hours, started 4/13/26,acetaminophen 325 mg oral tablet - give 2 tablet [sic] by mouth every 6 hours as needed for mild pain. Not to exceed 3 grams acetaminophen in 24 hours, started 4/13/26,oxycodone-acetaminophen (a controlled medication used to manage pain) 5/325 mg - give 0.5 tablet by mouth at bedtime for gen[eralized] body pain. NTE 3 grams in 24 hours, started 4/13/26, andoxycodone-acetaminophen 5/325 mg - give 0.5 tablet by mouth every 24 hours as needed for pain, started 4/13/26.A review of Resident 76's medical record indicated the acetaminophen component of her routine acetaminophen containing medication orders totaled 2762.5 mg in a 24-hour period, which left only 237.5 mg of the 3000 mg daily limit. One dose of Resident 76's as needed acetaminophen order was equal to 650 mg, which would exceed Resident 76's 3000 mg daily limit when added to her routine acetaminophen and routine oxycodone-acetaminophen orders.During a telephone interview with the Consultant Pharmacist (CP) on 6/4/26 at 3:22 P.M., the CP stated the total acetaminophen dose from the four orders equaled 5525 mg, or 5.525 grams, per day. The CP stated Resident 76's maximum daily dose of acetaminophen was 3 grams. The CP stated exceeding the maximum daily dose carried the risk of possible liver toxicity. The CP stated nursing staff calculated how much acetaminophen was given.A drug review of acetaminophen on Daily Med (a free drug resource provided by the National Library of Medicine), revised 1/15/25, indicated, Liver warning.Severe liver damage may occur if adult takes more than 4,000 mg [or 4 grams] in 24 hours, which is the maximum daily amount.During an interview with the DON on 6/4/26 at 4:30 P.M., the DON stated nursing staff were expected to calculate the amount of acetaminophen administered to Resident 76.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.attending physician or.medical director to discuss the concerns.6a. During a medication administration observation on 6/1/26 at 10:12 A.M., LN 52 was observed preparing and administering seven medications to Resident 134. LN 52 was not observed or heard verifying Resident 134's identification.During an interview with LN 52 on 6/1/26 at 3:01 P.M., LN 52 stated she recognized Resident 134 from his picture in his medical record and read his name on the sign outside his door. LN 52 stated other identifiers nursing staff used were names listed on residents' footboard or headboard, wristband or asking alert residents to verbalize their names. LN 52 stated she asked for residents to state their names and dates of birth if she had just met them.During an interview with the Director of Staff Development (DSD) on 6/2/26 at 9:40 A.M., the DSD stated nursing staff were to identify residents using their pictures in their medical records, wristbands and asking for their full names. The DSD stated all three identifiers were to be used. The DSD stated the names on the door and on the bed (footboard or headboard) were not appropriate identifiers because residents could move rooms and the signage may not move with them.On 6/2/26 at 10:12 A.M., when asked what identifiers were to be used if a resident refused to wear a wristband or take a photograph, the DSD stated staff were to get a second staff member to identify the resident, call the resident's RP (responsible party, someone responsible for making decisions on the resident's behalf) and to ask the resident for their name, date of birth and social security number. The DSD stated residents who were not alert should automatically have a wristband. The DSD stated the information on the wristband included the resident's first and last names and date of birth .6b. During a medication administration observation on 6/2/26 at 11:43 A.M., LN 58 was observed preparing and administering one medication to Resident 165. LN 58 was not observed or heard verifying Resident 165's identification.During a concurrent observation and interview with Resident 165 on 6/2/26 at 12:29 P.M., Resident 165's wristband was observed attached to his bed. Resident 165 stated he did not know who put it there.During an interview with LN 58 on 6/2/26 at 12:37 P.M., LN 58 stated she verified Resident 165's identity using his picture in his medical record. LN 58 stated she identified Resident 165 earlier in the day. LN 58 acknowledged nursing staff were expected to verify resident identification prior to each medication administration, not once per shift. LN 58 stated she only used residents' names and dates of birth if they were new to her. LN 58 stated it was standard practice to use two identifiers.6c. During an observation on 6/1/26 at 9:48 A.M., Resident 95 was observed wearing someone else's wristband. Certified Nursing Assistant (CNA) 76 confirmed Resident 95 was wearing a former roommate's wristband.During an observation on 6/2/26 at 12:53 P.M., Resident 95 was observed wearing the wrong wristband (her former roommate's wristband).During a concurrent observation and interview with LN 57 on 6/2/26 at 1 P.M., LN 57 was asked how she verified resident identification. LN 57 stated forms of identification included the photograph in the medical record, wristband, the resident's full name and the resident's date of birth . LN 57 stated she used Resident 95's photograph and wristband to verify Resident 95's identification prior to the morning medication administration on 6/2/26. LN 57 was asked to read the wristband Resident 95 had on. LN 57 stated, this isn't hers. LN 57 stated it was not appropriate for a resident to wear someone else's wristband. LN 57 acknowledged she only used Resident 95's photograph to identify her. LN 57 stated the wristband Resident 95 was wearing belonged to her former roommate who was no longer at the facility. LN 57 stated she did not know how long Resident 95 had been wearing the wrong wristband. LN 57 stated she did not know how Resident 95 obtained the wrong wristband.A record review of the resident whose name was on the wristband indicated she was discharged from the facility on 3/2/26 to a mortuary (a place where dead bodies are stored before they are buried or cremated).During a concurrent observation and interview with LN 79 on 6/3/26 at 9:08 A.M., Resident 95 was observed in bed without a wristband on. LN 79 stated she identified Resident 95 by using her photograph and asking for her name. LN 79 stated the wrong wristband belonged to Resident 95's former roommate, who expired months ago.During an interview with LN 57 on 6/3/26 at 9:23 A.M., LN 57 stated she removed the wrong wristband Resident 95 had been wearing. LN 57 stated admissions staff were aware of the removal and were making a new wristband for Resident 95.During an observation on 6/3/26 at 3:59 P.M., Resident 95 was observed without a wristband on.During an interview with the Admissions Coordinator (AC) on 6/4/26 at 10:14 A.M., the AC stated he made the wristbands for residents. The AC stated wristbands had the residents' names, the facility name and facility address. The AC stated he put wristbands on wheelchairs or beds if residents did not wear the wristbands. When asked if that was a safe practice, the AC stated he understood the potential risk, but because he had not seen it occur, he viewed it as a safe practice. When asked about Resident 95's new wristband, the AC stated he did not remember being asked for a new wristband.During an interview with the DON on 6/4/26 at 10:56 A.M., the DON stated nursing staff were expected to use at least two resident identifiers for every medication administration. The DON stated some residents refused wristbands or photographs, so nursing staff were to get another staff member to identify those residents. The DON stated residents who could speak should be asked to state their full names. The DON stated there was no need for nursing staff to request a resident's social security number or call the resident's RP prior to each medication administration. The DON stated nursing staff were to ask residents to verify their full names and dates of birth instead. The DON stated Resident 95 should have had her own wristband. The DON stated Resident 95 wearing the wrong wristband could have confused registry (work for a staffing agency and pick up shifts at facilities on a short-term or as needed basis) nurses such that they would not have been able to administer Resident 95's medications to her.A review of the facility's 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 include: a. checking identification band; b. checking photograph attached to medical record; and c. if necessary, verifying resident identification with other facility personnel.A review of the facility's P&P titled, Resident Identification System, revised 12/07, indicated, .1. Our facility has adopted a photo and/or wristband identification system to help assure that medication and treatments are administered to the right resident.

Based on observation, interview, and record review, the facility failed to maintain infection control practices for one of 35 sampled residents (90) when an incentive spirometer (a handheld plastic device that acts like an exercise machine for the lungs) was found on top of a bedside drawer, not inside a plastic bag or container.This failure had the potential for an increased risk spread of infection. Resident 90 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a long-term lung disease that makes it hard to breathe). On 6/1/26, at 8:10 A.M., an observation was conducted of Resident 90 in his room. An incentive spirometer was observed on top of the resident's bedside drawer not inside a plastic bag or container.On 6/2/26, at 7:30 A.M., an observation was conducted of Resident 90 in his room. An incentive spirometer was observed on top of the resident's bedside drawer not inside a plastic bag or container. On 6/3/26, at 11:00 A.M, a concurrent interview and observation was conducted with director of nursing (DON) inside Resident 90's room. The DON observed an incentive spirometer on top of Resident 90's bedside drawer, not inside a plastic bag or container. The DON stated Resident 90's incentive spirometer should have been kept inside a plastic bag or container. The DON stated the importance of keeping it in a plastic bag or container was to help prevent the spread of infection. A review of the facility policy titled Departmental (Respiratory Therapy) - Prevention of Infection, dated November 2022, indicated that .Incentive spirometers .must be stored in a clean plastic bag or covered container when not in use .

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5%, when four medication errors occurred out of 37 opportunities during the medication administration for two of four sampled residents (Residents 87 and 134). The medication error rate was 10.81%. These failures resulted in Residents 87 and 134 not receiving medications as ordered and had the potential for Resident 134 not to get the full therapeutic benefit of his medications.Findings:During a medication administration observation on 6/1/26 at 9:11 A.M., Licensed Nurse (LN) 51 was observed preparing and administering one medication to Resident 87. On 6/1/26 at 9:32 A.M., LN 51 prepared and administered 16 more medications to Resident 87.A review of Resident 87's medical record indicated active orders due at 9 A.M. for two medications that were not observed during the medication administration observation. The medications were the following:miconazole (a medication used to treat fungal infections) external powder 2% (strength) (topical) - apply to R[ight] arm topically two times a day for fungal rash for 14 days, started 6/1/26,Novolog (brand name for insulin aspart, a medication used to lower blood sugar) 100 units per mL (milliliter, unit of measure for volume) - inject as per sliding scale (a predetermined dose based on a current blood sugar level) subcutaneously (into the fat under the skin) in the morning for DM2 (Type 2 Diabetes Mellitus, a condition characterized by an impaired ability to control blood sugar), started 6/1/26.A review of Resident 87's medical record indicated LN 51 documented miconazole as administered on 6/1/26 on his Medication Administration Record (MAR, section of the medical record where all medications given to the resident are recorded to ensure patient safety). LN 51 documented, 2 on the MAR for the Novolog dose on 6/1/26. The chart code on the MAR indicated, 2 = Med[ication] Refused/Declined. LN 51 documented in a note, dated 6/1/26 at 10:14 A.M., Novolog.stated he does [sic] not eat breakfast today, does not want.During a concurrent interview and record review of Resident 87's medical record on 6/2/26 at 9:07 A.M., LN 51 stated both Novolog and miconazole powder were due at 9 A.M. LN 51 was asked when Resident 87 was offered his Novolog dose and refused it. LN 51 acknowledged it was not observed during medication administration. LN 51 stated she offered the Novolog dose after the medication administration observation.When asked about the miconazole powder topical dose, LN 51 stated she applied it. LN 51 stated she documented the administration at 12:22 P.M., but administered it at 9:21 A.M.During a concurrent interview and record review on 6/4/26 at 9:39 A.M., with the Medical Records Director (MRD) and the Minimum Data Set (MDS, a federally mandated assessment of all residents in nursing homes) Coordinator (MDSC), a review of Resident 87's medical record was conducted. The MDSC stated the administration time (under the heading, Effective Date) was timestamped when nursing staff clicked on the medication. For the first medication observed being administered, LN 51 entered documentation on 6/1/26 at 9:20 A.M. Under that documentation, the administration time was 6/1/26 at 9:11 A.M. The remaining 16 medications observed during medication administration were documented on 6/1/26 at 9:51 A.M., as administered on 6/1/26 between 9:31 A.M. through 9:41 A.M.During a concurrent interview and record review with LN 51 on 6/4/26 at 10:35 A.M., Resident 87's medical record was reviewed. LN 51 stated miconazole powder was administered after the medication administration observation. LN 51 was asked about the documentation from 6/1/26 at 12:22 P.M., indicating miconazole powder was administered topically at 9:21 A.M. LN 51 stated the miconazole powder dose was administered around the documented time of 12:22 P.M. on 6/1/26. LN 51 stated she did not know where the 9:21 A.M. timestamp came from.During an interview with the Director of Nursing (DON) on 6/4/26 at 10:56 A.M., the DON stated nursing staff were expected to prepare all medications due at that time.A review of the facility's policy and procedure (P&P) titled Charting and Documentation revised 7/17, indicated, .5. All documentation shall be accurate, complete, timely.2. During a medication administration observation on 6/1/26 at 10:12 A.M., LN 52 was observed preparing and administering seven medications for Resident 134. One of the medications LN 52 prepared and administered to Resident 134 was the following:sennosides (a laxative, used to stimulate bowel movements) 8.6 mg (milligrams, unit of measure) - two tablets.LN 52 stated she did not have Resident 134's eighth medication, gabapentin (a medication used for various neurological conditions), on hand to administer to Resident 134.A review of Resident 134's medical record indicated active orders for the following:sennosides-docusate (docusate is a stool softener) 8.6 mg-50 mg - 2 tablets by mouth every morning and at bedtime, started 10/21/24 andgabapentin 100 mg capsule (medication enclosed in a shell) - give 1 capsule by mouth one time a day for neuropathy (nerve damage resulting in pain, tingling or numbness), started 5/5/23. During a concurrent interview and record review of Resident 134's medical record with LN 52 on 6/1/26 at 3:01 P.M., LN 52 stated Resident 134 did not receive his morning gabapentin dose because it was unavailable. LN 52 was asked about Resident 134's laxative order and the bottle used to prepare his morning dose. LN 52 acknowledged the bottle differed from the order. LN 52 stated the order and the bottle used to prepare Resident 134's morning dose did not match.During an interview with the DON on 6/4/26 at 10:56 A.M., the DON stated nursing staff were expected to read the medication, compare it to the order on the screen and read the medication again. The DON stated nursing staff were expected to order medications in a timely manner.A review of the facility P&P titled, Administering Medications, revised 4/19, indicated, .4. Medications are administered in accordance with prescriber orders, including any required time frame.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified.10. The individual administering medications checks the label THREE (3) times to verify.right medication.right time.of administration before giving the medication.23.the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered.A review of the facility's P&P titled, Pharmacy Services Overview, revised 4/19, indicated, .4. Residents have sufficient supply of their prescribed medications and receive medications.in a timely manner.

Based on interview and record review, the facility failed to ensure acceptable standards of practice were followed for one of 40 sampled residents (Resident 16), when Resident 16's blood glucose checks (blood test) were performed without a physician's order and without parameters for diabetic interventions.This had the potential to negatively affect Resident's 16's care and safety. Findings: A review of Resident 16's admission Record indicated the resident was admitted on [DATE] with diagnoses to include type 2 diabetes mellitus (inability to regulate blood sugar). A review of Resident 16's minimum data set assessment (MDS, a comprehensive assessment tool) dated 5/15/26, section I, indicated the resident had a medically complex condition of type 2 diabetes mellitus. A review of Resident 16's Order Summary Report dated 6/4/26, indicated, .Insulin Glargine [medication to manage blood sugar]-yfgn[sic] Subcutaneous [under the skin to the fatty layer] Solution Pen-Injector 100 UNIT/ML [milliliters] (Insulin Glargine-yfgn) Inject 10 unit subcutaneously two times a day for DM [diabetes mellitus] .active.order date 2/6/26.There was no order for blood glucose checks and parameters for when to provide interventions.A review of Resident 16's Medication Administration Record for May 2026 indicated blood glucose levels were taken twice a day at 9 A.M. and at 9 P.M.On 6/4/26 at 2:46 P.M., a joint interview and record review were conducted with licensed nurse (LN) 45. LN 45 reviewed Resident 16's clinical record. LN 45 stated Resident 16 had a diagnosis of diabetes. LN 45 reviewed Resident 16's insulin order and medication administration record for the month of May 2026. LN 45 stated blood glucose levels were documented with each insulin administration at 9 A.M. and 9 P.M. from 5/1/26 to 5/31/26. LN 45 stated there was no order for blood glucose checks. LN 45 stated the standards of practice was to have a physician's order for blood sugar checks before any checks could be performed. LN 45 stated the nurse should have called the physician to obtain an order for the blood glucose checks and parameters for when to provide interventions. On 6/4/26 at 4:30 P.M., an interview was conducted with the director of nursing (DON). The nurse consultant (NC) was also present in the room. The DON stated it was not acceptable for blood glucose checks to be performed on Resident 16 without a physician's order. The DON stated it was her expectation that LNs obtained an order and followed the standards of practice for blood glucose checks. The DON stated there should have been an order for blood glucose parameters and interventions.A review of the facility's policy titled, Obtaining a Fingerstick Glucose Level revised October 2011, indicated, Purpose.The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level.1. Verify that there is a physician's order for this procedure.Documentation.6. The blood sugar results. Follow.for appropriate nursing interventions regarding blood sugar results.and/or physician intervention is needed to adjust insulin.Reporting.1. Report results promptly.the Attending Physician.3. Report.in accordance with facility policy and professional standards of practice.

Based on observation, interview, and record review, the facility failed to provide routine nail care to one of one resident (Resident 23) reviewed for Activities of Daily Living (ADLs, activities related to personal care) for dependent residents. As a result, Resident 23 was at risk for skin injury and infection. Findings: Resident 23 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (complete weakness of one side of the body and weakness on one part of the body following a stroke) and diabetes (increase blood sugar) per the facility admission Record. A record review of Resident 23's physician history and physical examination (H&P) on 11/14/25 indicated Resident 23 had capacity to make medical decisions. On 6/4/26 at 9: 51 AM, a concurrent observation and interview was conducted with LN 11. Resident 23 was observed with long and thick fingernails on his left hand, with left hand in a closed fist position. Resident 23 had left sided weakness. LN 11 stated Resident 23 had long and thick fingernails on the left hand. LN 11stated Resident 23's fingernails should have been cut or trimmed to prevent skin injury. Resident 23 stated his left fingernails were last cut six (6) months ago and requested to have them trimmed. On 6/4/26 at 10:18 A.M. a concurrent observation, interview, and record review was conducted with Assistant Director of Nursing (ADON. The ADON stated nail care was done by Certified Nursing Assistants (CNAs), and that when residents were diabetic, nail care should be done by LNs. During this interview and record review, there was no documented evidence to indicate nail care was performed on Resident 23's left fingernails. Shower sheets reviewed with the ADON did not indicate whether the right or left fingernail was cut or trimmed. An observation of Resident 23 was conducted with the ADON and the Director of Staff Development (DSD) at Resident 23's bedside. Resident 23 was observed with long, thick fingernails on his left hand with left hand, with the left hand in a closed fist position. The DSD stated fingernails were done during the facility's Sunday nail care, and that resident nails should be checked daily, during showers, and on Sundays. On 6/4/26 at 11:14 A.M., an interview was conducted with LN 12. LN 12 stated resident's fingernails were cut as needed, usually during shower days. LN 12 also stated LNs should trim the fingernails of residents with diabetes. On 6/4/26 at 11:43 A.M., an interview was conducted with CNA 11. CNA 11 stated she provided care for Resident 23 two or three times this week. CNA 11 stated she did not check Resident 23's fingernails today but planned to cut them. CNA 11 stated she cut Resident 23's right fingernails nails last week, but Resident 23 did not want his left fingernails cut at that time. CNA 11 stated Resident 11 was not diabetic, she would ask the LNs if a resident had diabetes before cutting his fingernails. CNA 11 stated CNAs were not allowed to cut resident fingernails of diabetic residents. However, CNA 11 stated she did not ask Resident 23 if he was diabetic before cutting Resident 23's fingernails. On 6/4/26 at 4:01P.M. an interview was conducted with the Director of Nursing (DON). The DON stated Resident 23 had long and thick left fingernails with indentions on his palms. The DON was aware Resident 23 was diabetic and that a CNA had cut Resident 23's fingernails. The DON stated CNAs should not cut or trim the fingernails of diabetic residents. The DON stated nail care was done every Sunday except for those residents with diabetes. The DON stated Resident 23's left fingernail was not cut or trimmed. The DON stated Resident 23's fingernail nail should have been trimmed to prevent skin injury since Resident 23 had contractures on his left hand. Per the facility policy titled Fingernails/Toenails, Care of, revision ate February 2018, .The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .General guidelines 1. Nail care includes daily cleaning and regular trimming .

Based on observation, interview, and record review, the facility failed to ensure three of three kitchen staff (cook [CK] and dishwashers [DW 1 and DW 2]) had the appropriate skill sets and were competent to carry out the functions of food and nutrition services when:A cook (CK) was not competent to calibrate a thermometer that was used to measure safe food temperatures. 2. Dishwashers (DW 1 and DW 2) were not competent in using test strips to determine accurate disinfectant levels used to sanitize dishware.These failures had the potential to expose residents to bacterial contamination that could result in foodborne illnesses for all residents who consumed food from the kitchen.FINDINGS:1. On 6/3/26 at 11:43 A.M., a joint observation and interview was conducted with CK. The dietary manager (DM) was also present. CK began calibrating a thermometer that would be used during meal service to take food temperatures. CK placed ice water in a paper cup and then placed the thermometer probe into the cup. CK stated the thermometer had been calibrated when the temperature was fluctuating between 37 and 38 degrees Fahrenheit. CK was asked what temperature the thermometer needed to reach in order to be calibrated. CK stated the temperature should not be more than 41 degrees. CK was asked the question again to ensure he understood the question. CK again the calibration had to be less than 41 degrees Fahrenheit. The DM stated during thermometer calibration, [the thermometer] should reach 32 degrees or it's a problem. The DM stated CK should know that since he was responsible for calibrating the thermometer.A review of the document titled Competency Form for Cook/Chef dated 4/8/26, indicated, Purpose: To ensure cooks demonstrate competency in.food safety. 4. Food safety, Storage, and Handling.Properly uses and calibrates thermometers. The document indicated CK had been checked off as competent related to calibrating a thermometer.On 6/4/26 at 8:58 A.M., a joint interview and record review was conducted with the DM. The DM stated CK needed more training on calibration of the thermometer. DM stated the thermometers were calibrated whenever they got a new thermometer. The DM stated it was best practice for thermometers to be calibrated at least weekly.A review of the facility's policy titled Calibrating a Probe or Digital Thermometer dated 2018, indicated, Probe and digital food thermometers should be calibrated weekly to ensure accuracy. Procedure.3. Place thermometer in middle of the glass of ice water.6. After three (3) minutes, thermometer should read 32 degrees [Fahrenheit]).2. On 6/3/26 at 1:09 P.M., an observation of the kitchen and interview was conducted with DW 1, DW 2, and the DM. DW 1 was observed running the dishwasher. DW 1 then tested the dishwasher disinfectant level (low temp machine) using chlorine test paper. The chlorine test paper had different shades of purple that would indicate different disinfectant levels present in the dishwashing water. DW 1 was hesitant to test the dishwasher. DW 1 placed the chlorine test paper into the dishwasher water. DW 1 then stated he could not see the test strip because he was tired. At 1:19 P.M., DW 2 was observed running the dishwasher. DW 2 then tested the disinfectant level using the chlorine test paper. DW 2 stated he could not read the test strip because he was color blind. The DM stated this was a concern.On 6/4/26 a record review was conducted. The facility's document titled Dish Machine Temperature Log for April and May 2026 indicated DW 1 tested the dishwashing disinfectant level using the chlorine test paper on 5/28/26. The document further indicated DW 2 tested the dishwashing disinfectant level using the chorine test paper on 4/4/26, 4/5/26, 4/25/26, 4/26/26, 5/2/26, 5/3/26, 5/10/26, 5/16/26, 5/17/26, 5/23/26, 5/28/26, and 5/31/26.On 6/4/26 at 8:58 A.M., a joint interview and record review was conducted with the DM stated both DW 1 and DW 2 should have been competent to test the sanitation chemical in the dishwasher. The DM stated new hires were not asked about color blindness, but they should include it in their new hire process. The DM stated she did not think DW 1 knew how to use the test strips as someone else usually tested it for him. The DM stated it was her expectation that all dishwashers knew how to test the dishwasher disinfectant levels. The DM stated DW 2 should not have been testing dishwashing disinfectant levels since he was color blind. The DM reviewed the Competency Form for Dietary Aides and Dishwashers for DW 1 and DW 2. The DM stated they were both checked off for, .Utilizes test strips and logs appropriately.On 6/4/26 at 10:08 A.M., An interview was conducted with the registered dietitian (RD). The RD stated all dishwashers should be able to competently test the disinfectant solution used in the dishwashing machine. The RD stated dishwashers should not be testing the disinfectant levels if they could not see colors accurately as the test strip was color based.On 6/4/26 at 10:41 A.M., an interview was conducted with the administrator (ADM). The RD was also present. The ADM stated all dishwashers should be able to test the dishwashing solutions competently and anyone who was colorblind should not be asked to use the color testing strips.

Based on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling in accordance with acceptable standards of practice when:Medications which required storage between 68-77 degrees Fahrenheit (F, a unit of measure for temperature) were stored inside one of one inspected medication rooms (Station 1 Medication Room), which had a room temperature of 84 degrees F. Medications for Residents 20 and 167 stored in one of four inspected medication carts (Medication Cart B) did not have an open date.These failures had the potential to negatively alter the drugs' stability, physical properties, and potency, which may cause adverse side effects to residents.Findings:On 6/1/26 at 10:36 A.M., a concurrent observation and interview was conducted with Licensed Nurse (LN) 60 inside the Station 1 Medication Room. LN 60 confirmed the Station 1 Medication Room temperature was 84 degrees F.The following medications, which had specific manufacturer storage instructions, were observed stored inside the medication room:- Five boxes of Mucus Relief DM (a medication used to control coughs and loosen mucus) tablets with manufacturer instructions that indicated, store at.68 [degrees] to 77 F. on the back of the medication carton.- One box of omeprazole (a medication used to treat heartburn) with manufacturer instructions on the back of the medication carton that indicated, .store at.68-77 F.keep product out of high heat. - Two boxes of preservative-free (does not contain added chemicals to extend the shelf life) Refresh Classic Lubricant Eye Drops (a medication used to treat dry eyes) with manufacturer instructions on the back of the medication carton that indicated, Store at 59 -77 F.- Five bottles of Lactulose (a medication used to treat constipation or complications in severe liver disease) Solution (in liquid form) 10 g (grams, a unit of measure) per 15 ml (milliliters, unit of measure for volume) 16 fluid ounces (size of the bottle) with product labeling that indicated storage between 68-77 degrees F.Three of the bottles were for Resident 26.One bottle was for Resident 90.One bottle was for 7.- One bottle of Lactulose Solution 10g/15 ml 8 fluid ounces for Resident 59 with product labeling on the front of the bottle that indicated, .Store at.68 to 77 F.- One box of loperamide HCl (a medication used to treat diarrhea) 2 mg (milligram, unit of measure) tablets, with manufacturer instructions on the side of the medication carton, which indicated, .store between.68 -77 F.- One bottle of acetaminophen (a medication used to relieve pain or fever) 325 mg tablets, with manufacturer instructions that indicated storage temperature should be between 68-77 degrees F.-One box of bisacodyl (a laxative) suppositories (medications designed to be inserted into a body cavity, such as the rectum), which had product labeling on the medication carton that read, .store at temperatures below.77 F. -One nicotine (used to quit smoking cigarettes) 21 mg patches (applied to the skin), which had manufacturer instructions that read, .store at.68 F-77 F.LN 60 stated it was not appropriate for these medications to be stored at 84 degrees F. LN 60 stated the Station 1 Medication Room temperature exceeded the storage requirements for several medications stored there.A review of the facility's policy titled, Medication Labeling and Storage, revised February 2023, indicated, . Drugs shall be stored at appropriate temperatures. 2. On 6/1/26 at 3:30 P.M., a concurrent observation and interview was conducted with LN 53 at Station 1 Medication Cart B. Resident 20's umeclidinium and vilanterol ELLIPTA (a medication that helps with breathing) 62.5 mcg (microgram, unit of measure)/25 mcg inhaler was opened, but did not have an open date. LN 53 stated he did not see a date open label to indicate when the medication was opened. Manufacturer instructions on the medication indicated, Discard the inhaler 6 weeks after opening. The prescription label on the outer carton indicated, .EXPIRES 6 WEEKS AFTER OPENING. LN 53 stated there should have been a label which indicated when the medication was opened.On 6/1/26 at 3:49 P.M., a concurrent observation and interview was conducted with LN 53. A box containing Resident 167's preservative-free dorzolamide hydrochloride and timolol maleate (used to treat glaucoma, elevated pressure in the eyes) 2%/0.5% (strength) eye drops were observed stored in Medication Cart B. There were two open pouches in the box. The medications did not have a date open label to indicate when the medications were opened. The manufacturer instructions on the pouch indicated, .Throw away.15 days after.opening the pouch. LN 53 stated there should have been a date open label. LN 53 stated directions needed to be adhered to.On 6/4/26 at 10:56 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated medications had to be stored according to the manufacturer guidelines on the medication packaging to ensure safety. The DON stated nursing staff were expected to label opened medications with the date they were opened. On 6/4/26 at 4:30 P.M., an interview was conducted with the DON. The DON stated the medications that did not have an open date should have been thrown away because it was unknown when they were opened. A review of the facility's policy titled, Administering Medications, revised April 2019, 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.

Based on observation, interview, and record review, the facility failed to ensure garbage was contained in the two dumpsters. This deficient practice had the potential to cause health hazards by attracting disease carrying pests and providing a breeding ground for harmful bacteria. Findings: On 6/2/26 at 11:05 A.M., an observation was conducted at the facility's dumpster area. The dietary manager (DM) and the registered dietitian (RD) were present. There were two open dumpsters with the covers pushed up by the contents inside the dumpster. There were two large black garbage bags with kitchen waste inside that were on the ground in front of one of the dumpsters. The DM stated the garbage bags were too heavy for some staff to throw into the dumpster. The DM stated they were waiting for staff strong enough to throw the garbage bags into the dumpster. On 6/2/26 at 12:45 P.M., an observation was conducted at the facility's dumpster area. The two dumpsters continued to be overfilled and uncovered. There was a large clear garbage bag with resident care items inside that was on the ground in front of one of the dumpsters. An observation was conducted at the facility's dumpster area. Both dumpsters were overfilled and uncovered. A large, clear garbage bag containing resident care items was found lying on the ground in front of one of them. On 6/2/26 at 4:15 P.M., another observation was conducted at the facility's dumpster area. The two dumpsters remained overfilled and uncovered. There were six clear garbage bags with resident care items inside them and five black trash bags with kitchen waste inside them on the ground next to a dumpster. One of the black garbage bags was ripped, with food items spilled from the bag onto the ground. On 6/4/26 at 8:50 AM, an interview was conducted with the DM. The DM stated all kitchen garbage should have been placed inside the dumpster bins and should not have been left on the ground. The DM stated the area where the dumpsters were located was also the area used for food delivery. The DM stated garbage on the ground could attract pests. On 6/4/26 at 10:08 A.M., an interview was conducted with the RD. The RD stated the garbage should have been contained inside the dumpster bins with the dumpster lids closed. The RD stated garbage should not have been left on the ground. On 6/4/26 at 10:41 A.M., an interview was conducted with the administrator (ADM). The ADM stated it was important to keep the facility's garbage contained inside the dumpsters.A review of the facility's policy titled, Garbage and Trash Cans, last reviewed 5/30/2020, indicated, .1. All food waste must be placed in covered garbage and trashcans.5. The dumpster area must be free of debris on the ground and the lid must be closed.

Based on interview and record review, the facility failed to offer an influenza vaccine (flu shot - medication that provides protection against the flu illness) to one of five sampled residents (35) during during the flu season (the time of year when the highly contagious influenza virus spreads easily and rapidly among people, usually surging in the fall and winter). This failure had the potential for Resident 35 highly vulnerable to severe flu complications. Per the facility admission record, Resident 35 was admitted to the facility on [DATE] with diagnoses that included vascular dementia (a decline in thinking skills caused by blocked or damaged blood vessels in the brain). On 6/4/26 at 8:19 A.M., a concurrent interview and record review was conducted with the infection preventionist nurse (IPN). A review of Resident 35's clinical records indicated the resident was last given the flu shot on 1/19/24. The IPN stated there was no documentation of Resident 35 being offered or refusing the flu shot for the 2025 flu season. The IPN stated that Resident 35 should have been offered the flu shot. On 6/4/26 at 2:35 P.M., an interview was conducted with the director of nursing (DON). The DON stated all residents need to be offered the flu shot during the flu season. A review of the facility policy titled Influenza Vaccine, dated March 2022, indicated that .Between October 1st and March 31st each year, the influenza vaccine should be offered to residents .

Based on observations, interview and record review, the facility failed to reschedule a missed appointment for one of four sampled residents (36) for indwelling urinary catheter (a thin, flexible rubber or plastic tube placed inside the bladder to drain urine when a person cannot pee naturally) when Resident 36's transportation did not transport him to a urology (the branch of medicine focused on the urinary system and the male reproductive system) appointment.This failure had the potential for complications related to indwelling catheters.Per the facility admission record, Resident 36 was admitted to the facility on [DATE] with diagnoses that included neurogenic bladder (a loss of bladder control caused by nerve damage, preventing the brain and bladder muscles from communicating properly).On 6/1/26, at 8:15 A.M., an interview was conducted with Resident 36 in his room. Resident 36 stated he has a suprapubic catheter (a flexible tube inserted directly into your bladder through a small opening in your lower belly, a few inches below your belly button to drain urine) but cannot remember when his last urology appointment was.On 6/3/26, at 8:33 A.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 21. A record review of Resident 36's physician's orders indicated he had a urology appointment on 12/19/25. Further review of Resident 36's progress notes on 12/19/25, at 3:10 P.M., indicated Appointment .will be rescheduled because transport did not pick up resident today. LN 21 stated that the appointment was not rescheduled by the staff, but it should have been. On 6/4/26, at 2:30 P.M., an interview was conducted with the director of nursing (DON). The DON stated that Resident 36's urology appointment should have been rescheduled. The DON stated that medical specialist appointments were important to prevent long-term complications. The facility policy titled Appointments and Transportation, dated December 2026, indicated that .missed appointments.the facility will assist with rescheduling as appropriate.

Based on observation, interview, and record review, the facility failed to provide adequate monitoring and supervision to a known high-risk resident (1) for elopement (an unsupervised, undetected, and unauthorized departure from the facility). As a result, Resident 1 left the facility unnoticed through the room window for the second time. This failure exposed Resident 1 to potential harm, including cold weather environmental exposure, physical injuries from accidents, and medical emergencies. Findings: Resident 1 was admitted to the facility on [DATE] in the secured unit, with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), bipolar disorder (a mental health condition that causes extreme mood swings), opioid dependence ( uncontrollable need to use drugs such as prescription pain relievers, heroin, or fentanyl) ,and alcohol dependence ( uncontrollable need to drink alcohol) , per the facility's admission record. A review of Resident 1's admission elopement risk score was 14, based on the assessment dated [DATE]. An updated elopement risk assessment was completed on 12/30/25, after his first elopement, and the score was 16. Per the facility's Skilled Nursing Risk Determination Evaluation, if the total score is 10 or greater, the resident was considered an elopement risk. A review of Resident 1's BIMS (Brief Interview for Mental Status- screening tool used to evaluate a patient's cognitive function) dated 3/6/26, indicated Resident 1 had a score of 15. A score of 15 indicated that Resident 1 demonstrated full cognitive function. A review of the IDT (Interdisciplinary Team - different types of staff work together to share expertise, knowledge, and skills to impact on patient care) meeting dated 3/16/26, indicated on 3/13/26 at approximately 11:55 P.M., Resident 1 was not in his room and the window was found open and screen was removed. A review of Resident 1' care plan was conducted.On 7/23/25, an initial wandering/elopement care plan was created, related to attempts to exit unit unattended, ETOH (alcohol abuse), and mental health illness. Interventions included: Resident educated on notification and supervision if needed to go outside of the unit, safe and hazard free environment, and structured activities provided. On 12/3/25, an actual elopement care plan for first elopement was created when Resident 1 exited through the window in his room. Interventions included discharged planning, 1:1sitter until evaluated by the psychiatrist nurse practitioner, every 30 minutes monitoring, moved to another room, social services to discuss elopement, and on going assessment and evaluation by the psychiatrist nurse practitioner. On 3/13/26, an actual elopement care plan for second elopement was created when Resident 1 exited through the window in his room. Interventions included alarms installed inside and outside windows, room door to remain open at all times, every 30 minutes check, social services to discuss elopement, and on going assessment and evaluation by the psychiatrist nurse practitioner. On 3/23/26 at 1:40 P.M., an interview was conducted with Resident 1. Resident 1 was in his room, lying on his bed. Resident 1 was alert and oriented. Resident 1 acknowledged that he left the facility through the window for the second time. Resident 1 stated he waited and left after the staff made their rounds. Resident 1 stated he left at around 11 P.M. Resident 1 stated I will not be able to leave the facility through the window next time since they put an alarm in the window. Resident 1 stated the police found him in the nearby [name of the store] convenience store and brought him back to the facility. Resident 1 stated he was only out for a short time. Resident 1 stated he might have come back around midnight On 3/23/26 at 4:54 P.M., a telephone interview was conducted with LN1 (Licensed Nurse). LN 1 stated Resident 1 was alert and oriented. Resident 1 was ambulatory but at times would use a walker. LN 1 reported at midnight on 3/13/26, Resident 1 was not on his room and found the window was open. On 3/23/26 at 5:30 P.M., an interview was conducted with the DON (Director of Nursing) and BHD (Behavioral Health Director). Both the DON and BHD stated Resident 1 was alert and oriented. The DON stated every 30 minutes monitoring was discontinued after the team developed a plan. On 4/1/26 at 5:40 P.M., a telephone interview was conducted with LN 2. LN 2 stated, on 3/13/26 at 11 P.M., Resident 1 was in his room. Around 11:30 P.M., Resident 1 was not in his room and found the window was open. LN 2 stated she contacted law enforcement. The police found Resident 1 in the nearby [name of the store] convenience store. LN 2 stated Resident 1 came back around midnight. LN 2 stated when Resident 1 came back in his room, he put back the screen in the window and closed the window. On 4/1/26 at 6:46 P.M., a telephone interview was conducted with CNA 2 (certified nursing assistant). CNA 2 stated he worked on 3/13/26 and was assigned to Resident 1. CNA 2 stated that around 11- 11:20 P.M., he saw Resident 1 walking in the hallway near his room. CNA 2 stated he stationed himself in the hallway near Resident 1's room. CNA 2 stated LN 3 went to Resident 1's room around midnight and found Resident 1 was not in his bed and room. CNA 2 stated he entered the room and found the window open. CNA 2 stated Resident 1 came back around 1 A.M. and that CNA 2 stated he was stationed at Resident 1 for the rest of his shift. A review of the facility's policy and procedures titled, Wandering and elopement, dated 3/19, indicated .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring for one resident (1) who was a known high risk for elopement (an unsupervised, undetected, and unauthorized departure from the facility). As a result, Resident 1 left the facility unnoticed and was gone for seven days. This failure had the potential harm for Resident 1 from environmental exposure from cold weather, physical injuries from accidents, and medical emergencies. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar type (mental health condition that is marked by a mix of schizophrenia (a severe mental disorder affecting a person's thoughts, feelings, and behavior, often leading to a disconnection with reality) symptoms, such as hallucinations (a false or distorted perception of sensory experiences- seeing, hearing, smelling, tasting, or feeling things that are not present), delusions (false belief that is not based in reality and remains unchanged despite clear contradictory evidence), and mood disorders and epilepsy (brain condition that causes recurring seizures), per the facility's admission record.A review of Resident 1's admission elopement assessment dated [DATE] indicated, Resident 1 was categorized as a high risk for elopement. The assessment indicated, Resident 1 was fully ambulatory and had expressed desire to leave the facility. A review of LN (licensed nurse) 1 progress note, dated 12/28/25 at 10:50 A.M., indicated LN 1 was unable to locate Resident 1 in assigned room. LN1 conducted a search of the dining area and common spaces with negative results. LN 1 notified the assigned CNA (certified nursing assistant) 1 of the inability to locate Resident 1. CNA 1 reported to LN 1 that Resident 1 frequently ambulates independently throughout the facility and typically returns on his own. A review of the IDT (Interdisciplinary Team) meeting notes, dated 12/29/25 at 2 P.M., indicated Resident 1's prior elopement risk score was 18 based on the assessment dated [DATE]. An updated elopement risk assessment was completed on 12/28/25 and remained at 18. Per the facility's Skilled Nursing - admission Initial Eval, If Total Score was 10 or greater, Resident was considered an Elopement Risk. A review of LN 2 progress note, dated 12/29/25 at 3:06 P.M., indicated Resident 1 had a known history of leaving AWOL (absence without leave/notice) from other nursing facilities, board and cares, and Acute care hospitals as reported by Resident 1's Conservator. On 2/2/26 at 11:49 A.M., an interview was conducted with CNA 1. CNA 1 reported that Resident 1 was independent, walked on his own, and frequently moved between the dining room, patio, and his room throughout the day. CNA 1 stated he was assigned to Resident 1 on 12/28/25, from 6:30 A.M. through 2:30 P.M. CNA 1 stated Resident 1 was last seen in his room around 7 A.M., while taking his (Resident 1) vital signs (measuring temperature, pulse, respiratory rate). On 12/28/25 at 11 A.M., CNA 1 was informed by LN1 that Resident 1 could not be located. CNA 1 stated he went to the dining room/activity area but did not see Resident 1. CNA 1 stated he did not look further and went back to complete his assigned scheduled task (residents room sweep on Sundays). CNA 1 stated he finished his scheduled task at approximately 1:30 P.M. CNA 1 stated at approximately 2:15 P.M., Resident 1 was not in his room during his rounds. CNA1 stated he was unaware that Resident 1 was an elopement risk. CNA 1 stated Code [NAME] (missing resident) was activated before he left the faciity on [DATE]. On 2/2/26 at 12:15 P.M., an interview was conducted with CNA 2. CNA 2 stated she was familiar with Resident 1's care and worked on 12/28/25 but not assigned to Resident 1. CNA 2 stated Resident 1 would wander around the building throughout the day. Resident 1 would stay in the dining area and outside patio. CNA 2 stated from the patio a resident could go out to the street through the service/delivery gate. CNA 2 reported that the gate was open during the day. CNA 2 stated that she was not aware that Resident 1 was an elopement risk. CNA 2 stated residents at risk for elopement have their information and picture placed in the elopement binder kept at the nurses' station and front desk. On 2/2/26 at 1:30 P.M., an interview was conducted with the Director of Staff Development (DSD). On 1/4/26 at 3 P.M., a staff member found Resident 1 near the 7/11 store. DSD went to the store and spoke to Resident 1. The DSD stated Resident 1 appeared clean, alert, and responded appropriately. Resident 1 told the DSD that he wanted to go back to the facility but did not know how. Law enforcement was notified, and Resident 1 was transferred to an acute hospital before being readmitted to the facility on [DATE]. On 2/2/26 at 1:55 P.M., an interview was conducted with Resident 1. Resident 1 was re-admitted to a secured unit. Resident 1 was alert and verbally responsive. Resident 1stated he remembered leaving the facility without telling anyone. Resident 1 stated he was at the patio area and went through the opened service/delivery gate to the street. Resident 1 stated he was found by the facility staff, brought to the hospital and came back to the facility.On 2/2/26 at 3:45 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 1 was alert and oriented with a BIM (Brief Interview for Mental Status - cognitive assessment) score of 15. The DON acknowledged Resident 1 was assessed as high risk for elopement on the initial admission assessment, dated 6/5/24. The DON stated residents at high risk for elopement have their pictures and information placed in the elopement binder at the nurses' station and front desk. The DON stated Resident 1 was not listed as a high risk for elopement. The DON stated staff should have visually monitored residents at least every hour. On 2/2/26 at 4 P.M., a concurrent observation of the service/delivery gate and interview was conducted with the Administrator (ADM). The gate was opened. The ADM stated the gate was open during the day and closed at night. The ADM stated the gate should be locked after hours, but during the day time it was open for delivery.A review of the facility's policy and procedures titled, Wandering and elopement, dated 3/19, indicated .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

Based on observation, interview, and record review, the facility failed to ensure 82 residents on the behavioral health unit (BHU, an area of the building that housed residents with mental and psychosocial disorders [syndromes characterized by a clinically significant disturbance in an individual's cognition, emotion, regulation, or behavior]) were protected from physical abuse when:1) Resident 1 stopped taking her Zyprexa (an antipsychotic medication [medication that helps to reduce the symptoms of psychosis, such as hallucinations, delusions, and disorganized thinking]) on 8/25/25 and a written plan of care was not developed to monitor and prevent potential inappropriate and aggressive behaviors resulting from stopping Zyprexa.2) Resident 1 slapped Resident 2 in the face on 9/5/25 and a written plan of care was not developed timely to prevent further incidents of abuse.3) Resident 1 made threatening gestures and threw her lunch tray at her roommate (Resident 3) on 9/9/25 while unsupervised. 4) Resident 1 continued to have escalating physically aggressive and threatening behaviors on 9/7 and 9/9/25 and interventions to closely supervise the resident and prevent further behavioral escalations were not developed and implemented.As a result, Resident 2 and Resident 3 expressed fear of Resident 1 and stated they did not feel safe. Furthermore, these failures to provide adequate supervision to Resident 1 while she experienced escalating behaviors and demonstrated impulsive physical aggression posed an immediate jeopardy to the safety and well-being of the other 82 residents on the BHU. Findings:On 9/10/25 at 9:09 A.M., an onsite visit was conducted to investigate an allegation of physical abuse that occurred on 9/5/25 between Resident 1 and Resident 2. A review of the facility's Census dated 9/10/25, indicated there were 83 residents in the BHU.A review of Resident 1's admission Record dated 9/10/25, indicated the resident was admitted to the facility on [DATE] with diagnosis that included schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder), bipolar type (a chronic mental health condition characterized by extreme mood swings between manic and depressive episodes). A review of Resident 2's admission Record dated 9/10/25, indicated the resident was admitted to the facility on [DATE] with diagnosis that included paranoid schizophrenia (a subtype of schizophrenia characterized by persistent delusions and hallucinations, primarily of a persecutory or threatening nature). A review of Resident 3's admission Record dated 9/11/25, indicated the resident was admitted to the facility on [DATE] with diagnosis that included paranoid schizophrenia and schizoaffective disorder, bipolar type. A review of Resident 1's physician orders indicated the resident was to receive:Zyprexa 20 mg (milligrams) by mouth at bedtime (order dated 2/21/25).Zyprexa 10 mg by mouth twice a day, give intramuscular (IM) injection if resident refused oral dose (order dated 8/28/25).Zyprexa 10 mg to be given IM every 24 hours if resident refuses oral dose (order dated 8/28/25).Zyprexa 10 mg to be given IM every 12 hours if resident refuses oral dose (order dated 9/2/25).A review of Resident 1's Medication Administration Record (MAR) for August and September 2025 for Zyprexa indicated:8/1 through 8/24/25 the resident took her Zyprexa as ordered. 8/25/25 the resident refused her Zyprexa.8/26/25 the resident refused her Zyprexa.8/27/25 the resident refused her Zyprexa.8/28/25 the resident refused her Zyprexa.8/29 through 9/11/25 the resident took some Zyprexa on and off but did not consistently take the full ordered dosage in a 24-hour period. A review of Resident 1's MAR for May, June, and July 2025 indicated the resident was monitored for behavioral manifestations. Resident 1 was monitored for abrupt change in mood (anger outbursts), constant refusal of care, and auditory hallucinations (voices telling to hurt herself). Resident 1 had zero incidents of behavioral manifestations in May, June, July, and August 1 through 27 2025. A review of Resident 1's August and September 2025 MAR indicated the following behavioral manifestations on:8/28/25 Four incidents of constant screaming/yelling profanities at others and two incidents of refusing care. 8/29/25 Four incidents of constant screaming/yelling profanities at others, three incidents of anger outbursts, and five incidents of refusing care. 8/30/25 Two incidents of screaming/yelling profanities and one incident of anger outbursts. 8/31/25 Three incidents of screaming/yelling profanities and two incidents of anger outbursts. 9/1/25 Two incidents of screaming/yelling profanities and two incidents of anger outbursts.9/2/25 One incident of screaming/yelling profanities and one incident of anger outbursts.9/3/25 Three incidents of screaming/yelling profanities and three incidents of anger outbursts.9/4/25 Five incidents of screaming/yelling profanities, six incidents of anger outbursts, and five incidents of refusing care. 9/5/25 Thirteen incidents of screaming/yelling profanities, twelve incidents of anger outbursts, seven incidents of refusing care, and seven incidents of auditory hallucinations.9/6/25 Two incidents of screaming/yelling profanities and four incidents of anger outbursts. 9/7/25 Nine incidents of screaming/yelling profanities and nine incidents of anger outbursts.9/8/25 Two incidents of screaming/yelling profanities and four incidents of anger outbursts.9/9/25 Three incidents of screaming/yelling profanities and two incidents of anger outbursts.9/10/25 Seven incidents of screaming/yelling profanities, seven incidents of anger outbursts, and six incidents of refusing care.9/11/25 Five incidents of screaming/yelling profanities, five incidents of anger outbursts, two incidents of refusing care, and three incidents of combative features striking at others. A review of Resident 1's clinical record indicated the resident did not have a written Plan of Care to address her refusal to take Zyprexa as ordered and interventions that were put in place to monitor and address potential behavioral manifestations resulting from not taking her Zyprexa. A review of Resident 1's Progress Notes indicated:On 8/25/25 at 8:14 A.M., Resident is refusing her medications. On 8/28/25 at 9:57 A.M., (Change of condition note) . [Resident 1] refusing all medications and exhibiting manic behavior, yelling at other residents. On 9/1/25 at 9:16 P.M., Resident noted with increased agitation, yelling and hitting staff, refused her psychotropic medication, Zyprexa, despite of explanation [sic] of risks and benefits. On 9/5/25 at 9:15 P.M., Resident 1 unprovokingly slapped Resident 2 in the face. Resident 1 denied her action to Resident 2. [Resident 1] has been frequently refusing scheduled PO [oral] medications despite education on risks and benefits. On 9/6/25 at 7:19 A.M., . [Resident 1] has calmed down and has stopped harassing patients. On 9/6/25 at 9:57 P.M., Resident refused all medications, remained hostile throughout the shift. On 9/7/25 at 10:43 P.M., Resident 1 struck Certified Nursing Assistant (CNA) 2 with her walker when Resident 1 was by the nurses' station and CNA 2 was trying to exit the nurses' station. Resident 1 was still trying to hit CNA 2 when another employee tried to intervene, putting herself between the two. On 9/8/25 at 2:12 A.M., Resident 1 continued to be aggressive, by throwing cups, yelling, and screaming and had episodes of paranoia (a mental health condition characterized by intense and irrational distrust and suspicion of others, despite a lack of evidence to support these beliefs). On 9/11/25 at 3:11 A.M., [Resident 1] observed with episodes of provoking the MHW [Mental Health Worker], yelling and throwed [sic] her used gloves on him, observed she put her hand on her mouth and removed her glove on her R [right] hand using her teeth and caused her thumb nail to come off and slightly bleeding.advised MHW to avoid resident. On 9/10/25 at 10:35 A.M., a concurrent observation and interview was conducted with Resident 1 on the BHU. Resident 1 walked into the dining area using her walker. Resident 1 acknowledged there was an incident involving Resident 2, but she denied striking Resident 2. Resident 1 stated that Resident 2 threw a punch at her. On 9/10/25 at 10:37 A.M., an interview was conducted with Resident 2 on the BHU. Resident 2 stated Resident 1 was being difficult on 9/5/25. Resident 2 stated she and Resident 1 were in the dining room and sitting next to each other. Resident 2 stated Resident 1 struck her suddenly on her left cheek. Resident 2 stated, She struck me hard. Resident 2 stated it hurt physically but not emotionally because she was used to Resident 1's behavior. Resident 2 stated she was used to seeing Resident 1 get angry multiple times, but this was her first time being struck by Resident 1. Resident 2 stated she did not feel safe. On 9/10/25 at 11:04 A.M., an observation was conducted in the dining hall in the BHU. Resident 1 was observed walking to the dining table where Resident 2 was sitting. Resident 1 yelled at Resident 2. Resident 1's words were incomprehensible. A staff member came from down the hall and separated Resident 1 from Resident 2. On 9/10/25 at 2:51 P.M., an interview was conducted with CNA 1. CNA 1 stated he was working on 9/5/25 during the PM shift. CNA 1 stated he was in the dining hall and saw Resident 1, Resident 2, and another resident sitting at a table. CNA 1 sated he was away from the table and helping another resident when he saw Resident 1 strike Resident 2 across the face with full force. CNA 1 stated he separated Resident 1 from Resident 2. CNA 1 stated Resident 2 seemed to be in shock. CNA 1 stated Resident 1 was mumbling incomprehensively and acted as if nothing had happened. CNA 1 stated he noticed Resident 1's behavior changed about three weeks ago, and during this time he was also pushed by Resident 1. CNA 1 stated Resident 1 was behaving unpredictably and aggressively towards staff and other residents. CNA 1 stated other residents have told him they were afraid of Resident 1. On 9/10/25 at 3:04 P.M., an interview was conducted with CNA 2. CNA 2 stated she was working on 9/5/25 and also witnessed Resident 1 hit Resident 2. CNA 2 stated that she was struck by Resident 1 while working on 9/7/25, two days after the incident between Resident 1 and Resident 2. CNA 2 stated she was exiting the nurses' station and Resident 1 was blocking the way with her walker. CNA 2 stated she positioned the walker away from the exit and Resident 1 used the walker to push CNA 2 back toward the nurses' station. CNA 2 stated a Licensed Nurse (LN) got between her and Resident 1. CNA 2 stated Resident 1 reached around the LN and punched her in the chest and the arm. CNA 2 stated it did not seem like Resident 1's aggressive behavior was being addressed. CNA 2 stated, [Resident 1's] a bully and other residents were afraid of her. On 9/11/25 at 8:35 A.M., a concurrent observation and interview was conducted with Resident 3 (Resident 1's roommate) while inside the resident's room. Resident 3 stated a couple of days ago, Resident 1 came to her bedside, grabbed her lunch tray off her overbed table and threw it at her. Resident 3 appeared fearful while talking about the incident and stated, My stomach moved when Resident 1 did it. Resident 3 stated the tray and food items landed on her bed. Resident 3 stated she put some of the food items back on the tray and reported the incident to LN 7. Resident 3 stated Resident 1 made threatening gestures toward her, and she asked LN 7 to supervise Resident 1 while the resident was in the room with her or to move Resident 1 to another room. Resident 3 stated she felt scared of Resident 1 and did not feel safe in her own room. Resident 3 stated LN 7 told her, We all have to get along. On 9/11/25 at 9:55 A.M., a concurrent interview and record review was conducted with the Nursing Supervisor (NS). The NS reviewed Resident 1's quarterly Minimum Data Set Assessment (MDS, a standardized assessment used to comprehensively evaluate resident health, functional, and cognitive status) dated 8/11/25, and stated that Resident 1 had zero behaviors during that quarterly assessment. The NS stated Resident 1 was not physically aggressive to others until 9/5/25. The NS reviewed Resident 1's Allegation Abuse Care Plan with interventions developed on 9/10/25 and stated the interventions should have been developed on 9/5/25 on the day when Resident 1 slapped Resident 2. The NS was asked if there was a report about Resident 1 throwing Resident 3's lunch tray on 9/9/25. The NS stated she was not aware of that incident. On 9/11/25 at 2:18 P.M., another interview was conducted with the NS. The NS stated Resident 1 did not have behavioral issues until Resident 1 started refusing her Zyprexa recently. The NS stated it was very important for Resident 1 to take her Zyprexa as ordered because without it, Resident 1 would de-stabilize. The NS stated when Resident 1 de-stabilized, she would become loud, aggressive toward others, inappropriate, and her aggressiveness would escalate. The NS stated Resident 1 did not display such behaviors while taking her Zyprexa as ordered. The NS stated that Resident 1's behavior was continuing to escalate, and the resident should have been placed on 1:1 supervision (one staff assigned to closely supervise the resident at all times) until her behavior stabilized. The NS stated Resident 3 was not safe being alone with Resident 1 in their shared room. On 9/11/25 at 2:25 P.M., an interview with Resident 2 was conducted in the dining room on the BHU. Resident 2 stated Resident 1 kept coming back to her room after the incident that occurred on 9/5/25. Resident 2 stated that she told Resident 1 to go away but Resident 1 did not listen. On 9/11/25 at 2:41 P.M., a concurrent interview and record review was conducted with LN 6. LN 6 stated she was familiar with Resident 1 since the resident was admitted to the facility in February 2024. LN 6 stated Resident 1's baseline behavior since admission was calm, nice, and not aggressive until recently. LN 6 reviewed Resident 1's clinical record and stated Resident 1's behavioral episodes increased after 8/25/25 when she stopped taking her Zyprexa. LN 6 stated when Resident 1 started refusing her Zyprexa, there should have been an Interdisciplinary Team (IDT) meeting to discuss the situation. LN 6 stated the IDT should have then developed care plan interventions to monitor for and intervene when Resident 1 decompensated for not taking her Zyprexa or not taking the full therapeutic dosage as ordered. LN 6 stated when Resident 1 decompensated, the care plan should have been developed and revised to focus on potential psychosis or psychotic behaviors and increased aggression especially after incidents on 9/5 and 9/7/25. LN 6 reviewed Resident 1's written care plan for Non-Compliance Care Plan - Declining To Take Medication(s) initiated 8/28/25 with the following interventions: Approach in a non-judgmental manner during conversation with the resident regarding areas of noncompliance, discuss with resident and resident representative the need for and benefits of compliance with care and services, and educate the resident of risk posed by the non-compliance. LN 6 stated the non-compliance care plan was not individualized and did not address the resident's risk for decompensation and destabilization related to not taking Zyprexa. LN 6 stated the care plan did not address monitoring and intervening for Resident 1's inappropriate and aggressive behavior. LN 6 stated after Resident 1 threw Resident 3's lunch tray at the resident on 9/9/25, this should have also been discussed with the IDT because Resident 1's behavior was continuing to escalate and was unsafe. LN 6 stated Resident 1's plan of care should have been reviewed and revised to address this continued escalating behavior. LN 6 stated Resident 1 should not have a roommate, should have eyes on at all times, and other residents should be kept out of Resident 1's striking range. LN 6 stated these things should have been care planned and implemented to keep everyone on the unit safe until Resident 1's behavior returned to her baseline. On 9/11/25 at 3:50 P.M., a telephone interview with LN 7 was conducted. LN 7 stated she was aware of the incident that happened between Resident 1 and Resident 3 on 9/9/25, and that she spoke to both residents that day. LN 7 stated she did not witness the incident. LN 7 stated Resident 3 was upset because she alleged Resident 1 threw her lunch tray at her. LN 7 stated Resident 3 wanted a staff to supervise Resident 1 while they were both in the shared room. LN 7 stated she did not communicate the incident to leadership because the residents were both calm by the time their conversation ended. LN 7 stated some orange juice was spilled on Resident 3's bed so she cleaned it up before she left the room. On 9/11/25 at 5:52 P.M., the administrator (ADM) and Director of Nursing (DON) were informed of Immediate Jeopardy (IJ) related to the facility's failure to provide adequate supervision to Resident 1 and keep other residents in the BHU safe and protected from abuse resulting from Resident 1's physically aggressive behavior. The facility began to develop a plan to remove the IJ. On 9/12/25 at 10:40 A.M., the facility's IJ removal plan was reviewed with ADM, DON, Director of Clinical Services (DCS), Clinical Consultant (CC) 1 and CC 2. The IJ removal plan included: 1. Immediate Actions Taken Resident 1 was placed on 1:1 supervision and moved to an individual room. Resident 1's care plan was revised to address her aggressive behavior and her needs of supervision. Director of Staff Development (DSD) started all staff in-services on abuse prevention, mandatory reporting, and immediate interventions during altercations starting 9/8/25.DON/designee started rounds and interviews in BHU to ensure no other residents were at immediate risk.2. Corrective Measure for the Affected Resident Resident 1's care plan was revised and included 1:1 supervision, alerted triggers, and de-escalation protocol. Resident 1's 1:1 supervision and utilization of the individual room will continue until IDT, attending physician, and/or psychiatrist determined Resident 1 was stabilized. IDT reviewed risks including room safety and potential for further resident - resident abuse. 3. Facility-Wide Systemic Changes Root cause analysis conducted to determine why supervision and interventions were delayed. Implementation of weekly behavioral risk rounds.Implementation of de-escalation protocol included: CNAs to immediately inform LN when a change of condition occurs related to mood, behavior, aggression or psychiatric decompensation including medication refusal, the LN escalates the report to the on-duty Supervisor, and the Supervisor communicates to Manager, Social Services, DON, and ADM. To ensure timely implementation of interventions, the attending physician and/or psychiatrist will be notified simultaneously.Expectations from the Protocol included: Interventions to prevent further harm to others were implemented to prioritize resident safety. Care plans were reviewed and revised to address Resident 1's current conditions, behavioral triggers, and new interventions. The IDT to ensure care plans were individualized to each resident's needs. To prevent the recurrence of abuse, immediate safety action and long-term care plan modifications are expected after all incidents. Collaborating with the DON, the Mental Health Case Manager/Provider and Social Services will oversee the BHU.On 9/12/25 at 3:30 P.M., the IJ was removed, and the ADM, DON, DCS, and CC 1 were notified after verifying the IJ removal plan while on-site. On 9/15/25 at 1:33 P.M., a concurrent interview and record review was conducted with the Mental Health Case Manager (MHCM). The MHCM reviewed Resident 1's clinical record and stated Resident 1 started refusing her Zyprexa on 8/25/25. The MHCM stated stopping Zyprexa would result in inappropriate behavior happening. The MHCM stated this was a change of condition that should have been discussed as an IDT, and the resident's care plan should have been developed to monitor for de-stabilization and to address it. The MHCM reviewed Resident 1's Allegation of Abuse Care Plan interventions dated 9/10/25 and stated that the care plan was not developed timely, but it should have been developed on the day of the incident (9/5/25). The MHCM stated 9/10/25 was too far out and would not prevent further occurrences of potential abuse.The MHCM stated after Resident 1 hit a staff with her walker (9/7/25), she expected an IDT discussion and development of a care plan to address the resident's escalating behavior.The MHCM stated after the incident on 9/9/25 with Resident 1 and Resident 3, the incident should have been discussed as an IDT and the care plan should have been updated with 1:1 supervision so Resident 1 was not alone with another resident. The MHCM stated Resident 1 should have been closely supervised around other residents to prevent further incidents and for the safety of all residents. The MHCM stated everyone on the unit deserved to be safe from another resident who was de-stabilized and decompensating. On 9/24/25 at 1:32 P.M., an interview was conducted with the DON. The DON stated, We could have managed her [Resident 1] better if we addressed her behavior right away to bring her back to baseline. The DON stated when residents had behavioral escalations, the priority was to protect other residents first, staff, and the residents themselves. The DON stated, We didn't ensure the roommate [Resident 3] was safe. The DON stated LN 7 should have reported the allegation of the tray being thrown to the DON. The DON stated, It was a COC [change of condition]. The DON stated the COC should have been discussed as an IDT and care planned. The DON stated, We didn't see how far [Resident 1] spiraled. The DON stated when a resident stopped taking their antipsychotic medications that managed their behavior, their behavior would spiral out of control. The DON stated she was not told Resident 1 had stopped taking her antipsychotic medication right away. The DON stated she should have been told so she could have conducted an IDT and developed a care plan to monitor and address Resident 1's spiraling behavior. On 9/24/25 at 3:34 P.M., an interview was conducted with the ADM. The DON was also present. The ADM stated LNs could implement 1:1 supervision for residents with escalating behaviors that could lead to abuse, if their clinical judgement indicated it was needed. The ADM stated 1:1 should have been done for Resident 1 to keep everyone in the BHU safe. A review of the facility's policy titled Abuse and Neglect - Clinical Protocol revised March 2018, indicated, .Treatment/Management 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse.A review of the facility's policy titled Resident - to - Resident Altercations revised December 2016, indicated, All Altercations, including, those that may represent resident - to - resident abuse shall be investigated and reported to the nursing supervisor, the director of nursing services and to the administrator.1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents. to the staff. Occurrences of such incidents shall be promptly reported to the nurse supervisor, director of nursing services, and to the administrator.A review of the facility's policy titled Unmanageable Residents revised April 2010, indicated, Each resident will be provided with a safe place of residence. 1. Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the nurse supervisor/charge nurse must immediately; a. provide for the safety of all concerned.; b. notify the resident's attending physician for instructions; c. notify the director of nursing services; .7. Complete documentation of the incident must be recorded in the resident's medical record and an incident report must be filed with the administrator.A review of the facility's policy titled Behavioral Assessment, Intervention and Monitoring revised March 2019, indicated, .Management 1.Safety Strategies will be implemented immediately if necessary to protect the resident and others from harm. 8.The care plan will include, as a minimum: .b. targeted in individualized interventions for the behavior and/or psychosocial symptoms; c. the rationale for the interventions and approaches; .e. how the staff will monitor for effectiveness of the interventions.A review of the facility's policy titled Behavioral Health Services revised February 2019, indicated, .4. Staff must promote.safety as appropriate for each resident.5. c. monitoring care plan interventions and reporting changes in condition. A review of the facility's policy titled Care Plans, Comprehensive Person-Centered revised December 2016, indicated, .1. Person-centered care plan for each resident.10.targeted and meaningful to the resident.13. Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition. b. When the desired outcome is not met.

Based on interview and record review, the facility failed to ensure two of three residents' (Resident 1 and Resident 3) clinical records were complete and accurate when: 1. Resident 1's provider progress reports and nursing notes related to the resident's medical condition were not available in the clinical record in a timely manner. 2a. Resident 1 had over 100 blank entries in her Medication Administration Record (MAR) from 5/1/25 through 9/15/25. 2b. Resident 3 had over 20 blank entries in her MAR from 8/1/25 through 9/15/25.3. Resident 1's MAR indicated the resident was at the hospital on 8/31/25 when she was not. 4. Resident 1's Psychiatric Nurse Practitioner's (NP) Psychiatric Assessment Progress Report dated 9/5/25 was inaccurate. As a result, it could not be determined what care and treatment was provided for Resident 1 and Resident 3.Findings:A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder), bipolar type (a chronic mental health condition characterized by extreme mood swings between manic depressive episodes). A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included paranoid schizophrenia and schizoaffective disorder, bipolar type. 1. A review of the provider order for Resident 1 indicated lithium (a medication used to manage acute manic, for the long-term maintenance treatment of bipolar disorder) was discontinued on 8/29/25. On 9/11/25 at 2:41 P.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 6. LN 6 reviewed Resident 1's clinical record and stated Resident 1's refusal of her lithium started on 8/25/25 and the medication was discontinued on 8/29/25. LN 6 stated there was no documentation that indicated a rationale for the discontinuation of lithium. LN 6 stated there was no documentation of who discontinued the lithium. LN 6 stated if a nurse was discontinuing a medication, the nurse was expected to document a note of the provider communication. LN 6 reviewed Resident 1's progress note dated 8/28/25 at 9:57 A.M., which indicated that a nurse notified the primary provider of the resident's change in condition. The note indicated that the resident was refusing all her medications and was exhibiting manic behavior and yelling at other residents. The note indicated that the primary care provider recommended Resident 1 to be seen by the psychiatric NP. LN 6 stated there was no documentation that the resident was seen by the facility's psychiatric NP after Resident 1's change of condition until 9/6/25. LN 6 stated that when there was a change of condition, the resident should be seen by a psychiatric provider within 24 hours.On 9/15/25 at 1:33 P.M., a concurrent interview and record review was conducted with the Mental Health Case Manager (MHCM). The MHCM reviewed Resident 1's Psychiatric Assessment Progress Report dated 8/29/25, .Given her [Resident 1's] repeated refusal of the medication [lithium].the decision was made to discontinue lithium at this time. The MHCM stated this document was uploaded to Resident 1's medical record on the evening of 9/11/25. The MHCM acknowledged Resident 1's psychiatric documentation was not available in the resident's clinical records timely and stated that this was unacceptable. The MHCM stated psychiatric NP's documentation could take up to three weeks for the facility to receive them. The MHCM acknowledged that taking weeks for the facility to receive clinical documentation was unacceptable. The MHCM also stated the nurse who rounded with the psychiatric provider should have documented what took place while rounding. 2a. A review of Resident 1's MAR for Behaviors/ Side Effects Monitoring Record May first through September fifteenth 2025, indicated that the record had over 100 combined blank entries on the following days:5/3, 5/5,5/7,5/20,5/23, 6/3,6/9,6/16,7/1,7/16,7/26,8/7,8/13,8/16,8/20,8/30, 9/1,9/8,9/9, and 9/11/25.On 9/11/25 at 2:41 P.M., a concurrent interview and record review was conducted with LN 6. LN 6 reviewed Resident 1's MAR for Behaviors/ Side Effects Monitoring Record May first through September fifteenth 2025 and stated there should not have been any blanks in resident's monitoring records. 2b. A review of Resident 3's MAR for Behaviors/ Side Effects Monitoring Record August first through September fifteenth 2025 indicated that the record had over 20 combined blank entries on the following days:8/13,8/16,8/21,8/30,9/1,9/11, and 9/15/25.On 9/17/25 at 8:15 A.M., a telephone interview was conducted with the Medical Record Director (MRD). The MRD stated the MAR should not have blanks. The MRD stated the MAR should not have blank entries because the facility would be unable to determine what care and treatment was provided to the residents. 3. A review of Resident 1's August 2025 MAR for Zyprexa (antipsychotic medication) was coded 6 which meant that the resident was hospitalized on 8/31/25. On 9/15/25 at 1:33 P.M., a concurrent interview and record review was conducted with the MHCM. The MHCM stated the MAR coding number 6 meant the resident was hospitalized . The MHCM reviewed Resident 1's clinical record and stated there was no documentation that the resident was hospitalized on [DATE]. 4. On 9/24/25 at 11:41 A.M., a concurrent interview and record review was conducted with the MHCM. The MHCM reviewed Resident 1's Psychiatric Assessment Progress Report dated 9/5/25 and stated that she rounded with the psychiatric NP that day. The MHCM stated the psychiatric NP was at the facility from 9 A.M. to 12 P.M. The MHCM reviewed Resident 1's progress note dated 9/5/25 at 9:15 P.M., which indicated Resident 1 unprovokingly slapped Resident 2 in the face. Resident 1 denied her action to Resident 2. [Resident 1] has been frequently refusing scheduled PO [oral] medications despite education on risks and benefits. The MHCM stated the psychiatric NP would not have known about the incident that occurred later in the evening. The MHCM stated the document seemed to be copied and pasted from Resident 1's Psychiatric Assessment Progress Report dated 9/6/25. The MHCM stated the psychiatric NP's note on 9/5/25 was not accurate. On 9/24/25 at 1:32 P.M., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON reviewed Resident 1's Psychiatric Assessment Progress Report dated 9/5/25 and stated the provider documented about the incident between Resident 1 and Resident 2 before it happened. The DON stated it was not accurate. The DON also stated provider progress notes should have been uploaded in a timely manner and readily available within 72 hours after their visit. The DON stated when a nurse was rounding with a provider a progress note should have been made regarding the round. The DON also stated the nurse who was taking a verbal order from the provider should document the discussion in the resident's clinical record. The DON reviewed Resident 1's MAR for Behaviors/ Side Effects Monitoring Record May first through September fifteenth 2025 and Resident 3's MAR for Behaviors/ Side Effects Monitoring Record August first through September fifteenth 2025 and stated having blank entries in residents' MAR was not acceptable. The DON stated the documentation in residents' clinical records should be complete and accurate. A review of the facility's policy titled Charting and Documentation revised July 2017, indicated, .3. Documentation in the medical record will be. complete, and accurate.

Based on interview and record review, the facility failed to: 1. Have resident - specific and appropriate indications for behavior monitoring for two of three residents' (Resident 1 and Resident 3) antipsychotic medications (a medication used to control thoughts, mood, and behavior).2. Administer Resident 1's PRN (as needed) Intramuscular (IM) Zyprexa (antipsychotic medication) at the correct times as ordered nine times. As a result, the residents were at risk for receiving unnecessary antipsychotic medications. In addition, there was the potential for Resident 1 and Resident 3 to not have their right to refuse care be respected. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder), bipolar type (a chronic mental health condition characterized by extreme mood swings between manic depressive episodes). A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included paranoid schizophrenia and schizoaffective disorder, bipolar type. 1. A review of Resident 1's physician order dated 10/7/24, indicated Behaviors/ Side Effects Monitoring Record for Zyprexa: Monitor Episodes of Schizoaffective as evidenced by constant refusal of care every shift. A review of Resident 3's physician order dated 5/3/25, indicated Behaviors/ Side Effects Monitoring Record for Haldol (antipsychotic medication): Monitor episodes of schizoaffective, manifested by refusal of care every shift.On 9/11/25 at 2:41 P.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 6. LN 6 reviewed Resident 1's physician order dated 10/7/24, indicated Behaviors/ Side Effects Monitoring Record for Zyprexa: Monitor Episodes of Schizoaffective as evidenced by constant refusal of care every shift. LN 6 stated behavior monitoring was used to determine the effectiveness of antipsychotic medications. LN 6 stated all residents had the right to refuse care. LN 6 stated antipsychotic medications should not be given to make residents comply with care as this would be a potential chemical restraint. LN 6 stated it was not appropriate to monitor the resident's refusal of care as an indication of Resident 1's antipsychotic effectiveness. LN 6 stated it would have been more appropriate to monitor Resident 1 for aggression and agitation related to the resident's psychosis (a mental health state where a person has a lost touch with reality, making it difficult to think, behave, or understand what is real). On 9/15/25 at 1:33 P.M., a concurrent interview and record review was conducted with the Mental Health Case Manager (MHCM). The MHCM reviewed Behaviors/ Side Effects Monitoring Record for Resident 1's Zyprexa. The MHCM stated that behavior monitoring was used to determine the effectiveness of antipsychotic medications and if the medication needed to be increased or decreased. The MHCM stated residents had the right to refuse care, we can't force anyone, and it should not be used to determine if antipsychotic medications were working. On 9/24/25 at 1:32 P.M., a concurrent interview and record review was conducted with the DON. The DON reviewed Resident 1's Behaviors/ Side Effects Monitoring Record for Zyprexa: Monitor Episodes of Schizoaffective as evidenced by constant refusal of care every shift and Resident 3's Behaviors/ Side Effects Monitoring Record for Haldol: Monitor episodes of schizoaffective, manifested by refusal of care every shift. The DON stated refusing care was a resident's right. The DON stated Resident 1 and Resident 3's behavior monitoring was too broad and should have been resident specific as to what care refusal was being monitored. A review of the facility's policy titled Psychotropic Medication Use revised July 2022, indicated, 3.d. adequate monitoring for efficacy.A review of the facility's policy titled Resident Rights revised December 2016, did not provide guidance on refusal of care. 2. A review of Resident 1's physician orders indicated:Zyprexa oral tablet 10 MG (milligrams) twice a day at 9A.M. and 6 P.M. for psychotic disorder and to give IM if the resident refuses (order dated 8/28/25).Zyprexa 10 MG IM every 24 hours PRN if the resident refused the oral Zyprexa dose (order dated 8/28/25).Zyprexa 10 MG IM every 12 hours PRN if the resident refused the oral Zyprexa dose (order dated 9/2/25).A review of Resident 1's Medication Administration Records (MAR) for August and September 2025 for Zyprexa indicated:8/29 the resident refused her oral Zyprexa at 9 A.M. and 6 P.M. and Zyprexa 10 MG IM was administered at 4:26 A.M. 9/1 the resident refused her oral Zyprexa at 9 A.M. but took her 6 P.M. dose. Zyprexa 10 MG IM was administered at 8 P.M. 9/2 the resident refused her oral Zyprexa at 9 A.M. and 6 P.M. and Zyprexa 10 MG IM was administered at 11:49 A.M. 9/4 the resident refused her oral Zyprexa at 9 A.M. and 6 P.M. and Zyprexa 10 MG IM was administered at 1:07 P.M. 9/5 the resident refused her oral Zyprexa at 9 A.M. and 6 P.M. and Zyprexa 10 MG IM was administered at 11:57 A.M. 9/6 the resident refused her oral Zyprexa at 9 A.M. and 6 P.M. and Zyprexa 10 MG IM was administered at 12:34 A.M. and 11:45 A.M.9/7 the resident took her oral Zyprexa at 9 A.M. and 6 P.M., and Zyprexa 10 MG IM was administered at 1:03 A.M. 9/9 the resident refused her oral Zyprexa at 9 A.M. and 6 P.M. and Zyprexa 10 MG IM was administered at 12:19 A.M. and 12:13 P.M. 9/10 the resident refused her oral Zyprexa at 9 A.M. and 6 P.M. and Zyprexa 10 MG IM was administered at 12:14 A.M. On 9/11/25 2:41 P.M., a concurrent interview and record review was conducted with LN 6. LN 6 reviewed Resident 1's August and September 2025 MAR for Zyprexa oral and IM. LN 6 stated Zyprexa PRN IM was to be given when the oral Zyprexa was refused within the scheduled administration time (9 A.M. and 6 P.M.). LN 6 reviewed Resident 1's Zyprexa on 8/29/25, the resident refused her oral Zyprexa at 9 A.M. and 6 P.M. and Zyprexa 10 MG IM was administered at 4:26 A.M. LN 6 stated that the IM was given outside the scheduled time and the order was not followed. LN 6 reviewed Resident 1's oral and IM Zyprexa orders and stated the order for the Zyprexa IM was confusing and should have been clarified.On 9/15/25 at 1:33 P.M., a concurrent interview and record review was conducted with the MHCM. The MHCM reviewed Resident 1's August and September 2025 MAR for both oral and IM Zyprexa and stated the Zyprexa IM should have been given in the medication administration window of one hour before and after the scheduled administration time. The MHCM stated the Zyprexa IM should coincide with the oral Zyprexa schedule. The MHCM stated the Zyprexa order indicated the IM was to be given when the resident refused the oral Zyprexa dose. The MHCM stated if Zyprexa IM administrations were entered late, the progress notes should explain the reason for the late entry. The MHCM reviewed Resident 1's progress notes and stated no documentation was found that supported any late entries. The MHCM stated the administration of IM Zyprexa at 4:26 A.M. on 8/29/25 was nowhere near the oral Zyprexa scheduled time and appeared to be given at the LN's discretion. The MHCM stated the physician's orders were not followed. The MHCM reviewed all August and September 2025 Zyprexa IM administration times and stated they did not consistently match with administration time of the oral Zyprexa and they should have matched.On 9/24/25 at 1:32 P.M., a concurrent interview and record review was conducted with the DON. The DON reviewed Resident 1's August and September 2025 MAR for Zyprexa oral and IM. The DON stated Resident 1's Zyprexa IM was to replace the oral dose within an hour before or an hour after the scheduled times of 9 A.M. and 6 P.M. The DON stated Resident 1's Zyprexa IM order was confusing, because it contained the word PRN. The DON stated the order should have been clarified. The DON acknowledged Resident 1's IM Zyprexa physician order was not followed.A review of the facility's policy titled Administering Medications revised April 2019, indicated, .4. Medications are administered in accordance with prescriber orders, including required time frame.7. Medications are administered within one (1) hour of their prescribed time.A review of the facility's policy titled Psychotropic Medication Use revised July 2022 did not provide guidance related to IM antipsychotic medications.

Based on interview and record review, the facility failed to develop two residents' (Resident 1 and Resident 2) care plan in a timely manner after an incident of physical abuse on 9/5/25. As a result, Resident 1 and Resident 2 were at risk for potential delays of treatment and care.Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder), bipolar type (a chronic mental health condition characterized by extreme mood swings between manic depressive episodes). A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included paranoid schizophrenia (a subtype of schizophrenia characterized by persistent delusions and hallucinations, primarily of a persecutory or threatening nature). A review of Resident 1's progress note dated 9/5/25 at 9:15 P.M., indicated that Resident 1 unprovokingly slapped Resident 2 in the face. Resident 1's Abuse Allegation Care Plan was reviewed on 9/10/25 and indicated that the care plan category of alleged abuse was started on 9/5/25 while the care plan goals and interventions were created on 9/10/25, five days after Resident 1 slapped Resident 2. Resident 2's Abuse Allegation Care Plan was reviewed on 9/10/25 and indicated that the care plan category of alleged abuse was started on 9/5/25 while the care plan goals were created on 9/10/25 and interventions were blank. On 9/11/25 at 9:55 A.M., a concurrent interview and record review was conducted with the Nursing Supervisor (NS). The NS reviewed Resident 1's Abuse Allegation Care Plan and stated that the care plan category alleged abuse was developed on 9/5/25 while the care plan goals and interventions were created on 9/10/25. The NS stated the interventions should have been developed and started on 9/5/25 when Resident 1 slapped Resident 2. The NS stated the care plan interventions were to be used to address the protection of other residents from Resident 1 after the incident. On 9/11/25 at 10:41 A.M., a concurrent interview and record review was conducted with Assistant Director of Nursing (ADON). The ADON reviewed Resident 1's Allegation Abuse Care Plan started on 9/5/25 and stated she started the resident's care plan with interventions the night of 9/5/25 while teleworking. The ADON stated the interventions in the care plan did not save in the electronic medical record (EMR). On 9/15/25 at 1:33 P.M., a concurrent interview and record review was conducted with the Mental Health Case Manager (MHCM). The MHCM reviewed Resident 1's Allegation of Abuse Care Plan created on 9/5/25 and interventions that were created on 9/10/25. The MHCM stated the care plan interventions were not developed timely and they should have been developed and implemented on the day of the incident (9/5/25). The MHCM stated 9/10/25 was too far out and would not prevent further occurrences of potential abuse. The MHCM reviewed Resident 2's Allegation of Abuse Care Plan created on 9/5/25 and interventions dated 9/10/25. The MHCM stated the care plan was developed late, and it should have been developed on the day of the incident (9/5/25). The MHCM stated the incident could cause Resident 2 to be triggered and act out. The MHCM stated this was developed late and maybe it's a [computer] glitch, too. On 9/17/25 at 8:15 A.M., a telephone interview was conducted with the Medical Record Director (MRD). The MRD stated any EMR glitches or problems with medical record must be reported to the Information Technology department to resolve the problems. The MRD stated she should have been made aware of any issues and glitches in their EMR that affected the residents' care plans. The MRD stated she was not aware of any recent issues with the EMR or glitches with resident care plans. On 9/24/25 at 1:32 P.M., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated after the incident on 9/5/25, there should have been Interdisciplinary Team (IDT) discussion and monitoring of Resident 1's behavior. The DON care plan should have been developed and implemented on the day of the incident. A review of the facility's policy titled Care Plans, Comprehensive Person-Centered revised December 2016, indicated, .1. Person-centered care plan for each resident.10.targeted and meaningful to the resident.13. Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition.

Based on interview and record review, the facility failed to provide the necessary behavioral health care and services to one of three residents (Resident 1) when: 1) Resident 1 stopped taking her Zyprexa (an antipsychotic medication [medication that helps to reduce the symptoms of psychosis, such as hallucinations, delusions, and disorganized thinking]) on 8/25/25 and a written plan of care was not developed to monitor and prevent potential inappropriate and aggressive behaviors resulting from stopping Zyprexa.2) Resident 1 continued to have escalating physically aggressive and threatening behaviors on 9/5, 9/7, and 9/9/25 and interventions to closely supervise the resident and prevent further behavioral escalations were not developed and implemented.As a result, Resident 1 was unable to maintain her highest practicable physical, mental, and psychosocial well-being. Cross reference F600. Findings: A review of Resident 1's admission Record dated 9/10/25, indicated the resident was admitted to the facility on [DATE] with diagnosis that included schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder), bipolar type (a chronic mental health condition characterized by extreme mood swings between manic and depressive episodes). A review of Resident 1's physician orders indicated the resident was to receive:Zyprexa (antipsychotic medication used to control thoughts, mood, and behavior) 20 mg (milligrams) by mouth at bedtime (order dated 2/21/25).Zyprexa 10 mg by mouth twice a day, give intramuscular (IM) injection if resident refused oral dose (order dated 8/28/25).Zyprexa 10 mg to be given IM every 24 hours if resident refused oral dose (order dated 8/28/25).Zyprexa 10 mg to be given IM every 12 hours if resident refused oral dose (order dated 9/2/25).A review of Resident 1's Medication Administration Records (MAR) for August and September 2025 for Zyprexa indicated:8/1 through 8/24/25 the resident took her Zyprexa as ordered. 8/25/25 the resident refused her Zyprexa.8/26/25 the resident refused her Zyprexa.8/27/25 the resident refused her Zyprexa.8/28/25 the resident refused her Zyprexa.8/29 through 9/11/25 the resident took some Zyprexa on and off but did not consistently take the full ordered dosage in a 24-hour period. A review of Resident 1's MAR for May, June, and July 2025 indicated the resident was monitored for behavioral manifestations. Resident 1 was monitored for abrupt change in mood (anger outbursts), constant refusal of care, and auditory hallucinations (voices telling to hurt herself). Resident 1 had zero incidents of behavioral manifestations in May, June, July, and August 1 through 27 of 2025. A review of Resident 1's August and September 2025 MAR indicated the following behavioral manifestations on:8/28/25 Four incidents of constant screaming/yelling profanities at others and two incidents of refusing care. 8/29/25 Four incidents of constant screaming/yelling profanities at others, three incidents of anger outbursts, and five incidents of refusing care. 8/30/25 Two incidents of screaming/yelling profanities and one incident of anger outbursts. 8/31/25 Three incidents of screaming/yelling profanities and two incidents of anger outbursts. 9/1/25 Two incidents of screaming/yelling profanities and two incidents of anger outbursts.9/2/25 One incident of screaming/yelling profanities and one incident of anger outbursts.9/3/25 Three incidents of screaming/yelling profanities and three incidents of anger outbursts.9/4/25 Five incidents of screaming/yelling profanities, six incidents of anger outbursts, and five incidents of refusing care. 9/5/25 Thirteen incidents of screaming/yelling profanities, twelve incidents of anger outbursts, seven incidents of refusing care, and seven incidents of auditory hallucinations.9/6/25 Two incidents of screaming/yelling profanities and four incidents of anger outbursts. 9/7/25 Nine incidents of screaming/yelling profanities and nine incidents of anger outbursts.9/8/25 Two incidents of screaming/yelling profanities and four incidents of anger outbursts.9/9/25 Three incidents of screaming/yelling profanities and two incidents of anger outbursts.9/10/25 Seven incidents of screaming/yelling profanities, seven incidents of anger outbursts, and six incidents of refusing care.9/11/25 Five incidents of screaming/yelling profanities, five incidents of anger outbursts, two incidents of refusing care, and three incidents of combative features striking at others. A review of Resident 1's clinical record indicated the resident did not have a written Plan of Care to address her refusal to take Zyprexa as ordered and interventions that were put in place to monitor and address potential behavioral manifestations resulting from not taking her Zyprexa. A review of Resident 1's Progress Notes indicated:On 8/25/25 at 8:14 A.M., Resident is refusing her medications. On 8/28/25 at 9:57 A.M., (Change of condition note) . [Resident 1] refusing all medications and exhibiting manic behavior, yelling at other residents. On 9/1/25 at 9:16 P.M., Resident noted with increased agitation, yelling and hitting staff, refused her psychotropic medication, Zyprexa, despite of explanation [sic] of risks and benefits. On 9/5/25 at 9:15 P.M., Resident 1 unprovokingly slapped Resident 2 in the face. Resident 1 denied her action to Resident 2. [Resident 1] has been frequently refusing scheduled PO [oral] medications despite education on risks and benefits. On 9/6/25 at 7:19 A.M., . [Resident 1] has calmed down and has stopped harassing patients. On 9/6/25 at 9:57 P.M., Resident refused all medications, remained hostile throughout the shift. On 9/7/25 at 10:43 P.M., Resident 1 struck Certified Nursing Assistant (CNA) 2 with her walker when Resident 1 was by the nurses' station and CNA 2 was trying to exit the nurses' station. Resident 1 was still trying to hit CNA 2 when another employee tried to intervene, putting herself between the two. On 9/8/25 at 2:12 A.M., Resident 1 continued to be aggressive, by throwing cups, yelling, and screaming and had episodes of paranoia (a mental health condition characterized by intense and irrational distrust and suspicion of others, despite a lack of evidence to support these beliefs). On 9/11/25 at 3:11 A.M., [Resident 1] observed with episodes of provoking the MHW [Mental Health Worker], yelling and throwed [sic] her used gloves on him, observed she put her hand on her mouth and removed her glove on her R [right] hand using her teeth and caused her thumb nail come off and slightly bleeding.advised MHW to avoid resident. On 9/11/25 at 2:18 P.M., an interview was conducted with the Nursing Supervisor (NS). The NS stated Resident 1 did not have behavioral issues until Resident 1 started refusing her Zyprexa recently. The NS stated it was very important for Resident 1 to take her Zyprexa as ordered because without it, Resident 1 would de-stabilize. The NS stated when Resident 1 de-stabilized, she would become loud, aggressive toward others, inappropriate, and her aggressiveness would escalate. The NS stated Resident 1 did not display such behaviors while taking her Zyprexa as ordered. The NS stated that Resident 1's behavior was continuing to escalate, and the resident should have been placed on 1:1 supervision (one staff assigned to closely supervise the resident at all times) until her behavior stabilized. The NS further stated Resident 1 should not be alone with her roommate in their shared room. On 9/11/25 at 3:50 P.M., a telephone interview with LN 7 was conducted. LN 7 stated she was aware of the incident that happened between Resident 1 and Resident 3 on 9/9/25 and that she spoke to both residents that day. LN 7 stated she did not witness the incident. LN 7 stated Resident 3 was upset because she alleged Resident 1 threw her lunch tray at her. LN 7 stated Resident 3 wanted a staff to supervise Resident 1 while they were both in the shared room. LN 7 stated she did not communicate the incident to leadership because the residents were both calm by the time their conversation ended. LN 7 stated some orange juice was spilled on Resident 3's bed so she cleaned it up before she left the room. On 9/11/25 at 2:41 P.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 6. LN 6 stated she was familiar with Resident 1 since the resident was admitted to the facility in February 2024. LN 6 stated Resident 1's baseline behavior since admission was calm, nice, and not aggressive until recently. LN 6 reviewed Resident 1's clinical record and stated Resident 1's behavioral episodes increased after 8/25/25 when she stopped taking her Zyprexa. LN 6 stated when Resident 1 started refusing her Zyprexa, there should have been an Interdisciplinary Team (IDT) meeting to discuss the situation. LN 6 stated the IDT should have then developed interventions to monitor for and intervene when Resident 1 decompensated for not taking her Zyprexa or not taking the full therapeutic dosage as ordered. LN 6 stated when Resident 1 decompensated the care plan should have been developed and revised to focus on potential psychosis or psychotic behaviors and increased aggression especially after incidents on 9/5 and 9/7/25. LN 6 reviewed Resident 1's written care plan for Non-Compliance Care Plan - Declining To Take Medication(s) initiated 8/28/25 with the following interventions: Approach in a non-judgmental manner during conversation with the resident regarding areas of noncompliance, discuss with resident and resident representative the need for and benefits of compliance with care and services, and educate the resident of risk posed by the non-compliance. LN 6 stated the non-compliance care plan was not individualized and did not address the resident's risk for decompensation and destabilization related to not taking Zyprexa. LN 6 stated the care plan did not address monitoring and intervening for Resident 1's inappropriate and aggressive behavior. LN 6 stated after Resident 1 threw Resident 3's lunch tray at the resident on 9/9/25, this should have also been discussed with the IDT because Resident 1's behavior was continuing to escalate and was unsafe. LN 6 stated Resident 1's plan of care should have been reviewed and revised to address this continued escalating behavior. LN 6 stated Resident 1 should not have a roommate, should have eyes on at all times, and other residents should be kept out of Resident 1's striking range. LN 6 stated these things should have been care planned and implemented to keep everyone on the unit safe until Resident 1's behavior returned to her baseline. On 9/15/25 at 1:33 P.M., a concurrent interview and record review was conducted with the Mental Health Case Manager (MHCM). The MHCM reviewed Resident 1's clinical record and stated Resident 1 started refusing her Zyprexa on 8/25/25. The MHCM stated stopping Zyprexa would result in inappropriate behavior happening. The MHCM stated this was a change of condition that should have been discussed as an IDT, and the resident's care plan should have been developed to monitor for de-stabilization and to address it. The MHCM reviewed Resident 1's Allegation of Abuse Care Plan interventions dated 9/10/25 and stated that the care plan was not developed timely, but it should have been developed on the day of the incident (9/5/25). The MHCM stated 9/10/25 was too far out and would not prevent further occurrences of potential abuse.The MHCM stated after Resident 1 hit a staff with her walker (9/7/25), she expected an IDT discussion and development of a care plan to address the resident's escalating behavior.The MHCM stated after the incident on 9/9/25 with Resident 1 and Resident 3, the incident should have been discussed as an IDT and care plan should have been updated with 1:1 supervision so Resident 1 was not alone with another resident. The MHCM stated Resident 1 should have been closely supervised around other residents to prevent further incidents and for the safety of all residents. The MHCM stated everyone on the unit deserved to be safe from another resident who was de-stabilized and decompensating. On 9/24/25 at 1:32 P.M., an interview was conducted with the DON. The DON stated, We could have managed her [Resident 1] better if we addressed her behavior right away to bring her back to baseline. The DON stated LN 7 should have reported the allegation of the tray being thrown to the DON. The DON stated, It was a COC [change of condition]. The DON stated the COC should have been discussed as an IDT and care planned. The DON stated, We didn't see how far [Resident 1] spiraled. The DON stated when a resident stopped taking their antipsychotic medications that managed their behavior, their behavior would spiral out of control. The DON stated she was not told Resident 1 had stopped taking her antipsychotic medication right away. The DON stated she should have been told so she could have conducted an IDT and developed a care plan to monitor and address Resident 1's spiraling behavior. A review of the facility's policy titled Unmanageable Residents revised April 2010, indicated, Each resident will be provided with a safe place of residence. 1. Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the nurse supervisor/charge nurse must immediately; a. provide for the safety of all concerned.; b. notify the resident's attending physician for instructions; c. notify the director of nursing services; .7. Complete documentation of the incident must be recorded in the resident's medical record and an incident report must be filed with the administrator.A review of the facility's policy titled Behavioral Assessment, Intervention and Monitoring revised March 2019, indicated, .Management 1.Safety Strategies will be implemented immediately if necessary to protect the resident and others from harm. 8.The care plan will include, as a minimum: .b. targeted in individualized interventions for the behavior and/or psychosocial symptoms; c. the rationale for the interventions and approaches; .e. how the staff will monitor for effectiveness of the interventions.A review of the facility's policy titled Behavioral Health Services revised February 2019, indicated, .4. Staff must promote.safety as appropriate for each resident.5. c. monitoring care plan interventions and reporting changes in condition.A review of the facility's policy titled Care Plans, Comprehensive Person-Centered revised December 2016, indicated, .1. Person-centered care plan for each resident.10.targeted and meaningful to the resident.13. Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition. b. When the desired outcome is not met.

Based on observation, interview, and record review, the facility failed to ensure staff working on the facility's behavioral health unit (BHU, an area of the building that housed residents with mental and psychosocial disorders [syndromes characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior]) had appropriate training, skill sets, and competencies (measurable pattern of knowledge, skills, abilities, and behaviors, and other characteristics in order to perform occupational functions successfully) to provide appropriate care to the 54 residents on the BHU with mental and psychosocial disorders, and residents experiencing suicidal ideation (SI- thoughts of self-harm and/or the killing oneself). In addition, the facility failed to have a system in place wherein staff were knowledgeable to respond immediately and efficiently to behavioral emergencies/crisis (when a resident was posing a danger to self and/or others). As a result: 1. Resident 1 verbalized to staff on several occasions that she wanted to kill herself, told certified nursing assistant (CNA) 3 that she would swallow glass; and was left alone in her room. Resident 1 successfully executed her plan. Resident 1 was sent to the hospital on [DATE] and later died due to sustained shards of glass throughout the gastrointestinal tract (GI tract, path where food travels through the body) that cut the organs of the GI tract, developed sepsis (infection in the blood). 2. Resident 2 who had a history of SI, verbalized to staff on [DATE] his plan to hang himself with his oxygen tubing (tube delivering oxygen to a resident). This failure placed Resident 2 and other 54 residents in the BHU in immediate danger of serious injury, harm, impairment, or death. On [DATE] at 5:37 P.M., the ADM and DON were informed of Immediate Jeopardy (IJ) related to the facility's failure to ensure staff were adequately trained and competent in providing care to residents with SI and responding to behavioral emergencies/crisis. The facility began to develop a plan to remove the immediacy. On [DATE] at 3:28 P.M., the IJ was removed, and the ADM, DON, and director of clinical operations were notified after verifying the facility's Plan of Action while on-site. Cross reference F740 and F838. Findings: On [DATE] at 1:48 P.M., an on-site visit was conducted at the facility to investigate a facility reported incident related to Resident 1 had swallowed glass on [DATE]. The administrator (ADM) and director of nursing (DON) were interviewed. The ADM stated he was still conducting an investigating into the incident. The ADM and DON both stated they were recently informed that Resident 2 had died at the hospital on [DATE]. A review of facility document titled Daily Census dated, [DATE], indicated, there were 152 residents in the facility, and 65 residents on the BHU (Station 2). Of the 65 residents on the BHU, 10 residents were identified as being part of the County Patch program (county funded program aiming to provide specialized care for residents with mental disorders). According to Optum, undated, online document titled San Diego County funded Skilled Nursing Facility (SNF) Patch Criteria, .An additional daily rate paid by San Diego County to contracted SNFs that have agreed to provide additional mental health services to San Diego County beneficiaries . The client must meet the following criteria for San Diego County funded SNF Patch: . 4. Cannot be safely managed in a less restrictive level of care . 8. Is gravely disabled as determined by the establishment of .Conservatorship [a legally appointed person who makes decisions on behalf of another individual deemed unable to] by the Superior Court . 10. Has an adequately documented .primary diagnosis of a serious, persistent, major mental disorder . a. The client's psychosocial functioning has deteriorated to the degree that the client is at risk for being unable to safely and adequately care for themselves in the community or at a less restrictive setting [such as assisted living facility] . https://www.optumsandiego.com A review of facility document titled Diagnosis Report dated [DATE], indicated: Eighteen residents on the BHU had a diagnosis of schizophrenia (a mental disorder characterized by a break from reality, paranoia, delusions, and hallucinations). Thirty-one residents on the BHU had a diagnosis of depression and/or major depression (a mood disorder that caused persistent feelings of sadness, hopelessness, and loss of interest). Five residents on the BHU had a diagnosis of bipolar disorder (mental disorder with extreme changes in mood, thought, energy, and behavior and characterized by periods of mania and depression). According to the National Institute of Mental Health's online article titled Depression, dated [DATE], .Depression is a serious mood disorder . What are the signs and symptoms of depression? . Feelings of guilt, worthlessness, or helplessness . Increased irritability or anger . becoming withdrawn, negative, or detached .Thoughts of death, suicide, or suicide attempts . Bipolar disorder . also experience depressive episodes . also experiences .unusually elevated moods, in which they might feel very happy, irritable, or up with a marked increase in activity level A review of Resident 2's facility Admission Record indicated, the resident was admitted to the facility on [DATE] with diagnoses to include acute respiratory failure, major depressive disorder (major depression), and SI. A review of Resident 2's admitting paperwork from the general acute care hospital (GACH) 1 dated, [DATE] indicated, the resident was identified to have suicidal thoughts and had expressed SI to the licensed nurse during his hospital course. A review of Resident 2's facility nursing progress notes, dated [DATE], indicated, Resident verbalized to nursing staff I don't want to live, I want to die, What is there to live for. [sic] When asked if the resident had a plan, resident stated he will hang himself with O2 [oxygen] tubing A review of Resident 2's facility clinical record dated, [DATE] indicated, the resident's suicide risk had not been assessed and there was no written plan of care developed with person-centered interventions to address the resident's major depressive disorder and SI until [DATE]. A review of Resident 1's facility Admission Record indicated the resident was admitted on [DATE] with diagnoses to include bipolar disorder and depression. A review of Resident 1's Minimum Data Set Assessment (MDS- a comprehensive assessment tool) dated [DATE] indicated, the resident scored 15 on the brief interview of mental status (a score of 15 meant the resident was cognitively intact). A review of Resident 1's facility History and Physical exam, signed by the physician on [DATE], indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 1's admitting paperwork from the GACH 2 dated [DATE], indicated the resident had a history of SI. Review of Resident 1's facility nursing progress notes indicated on: [DATE], The resident became very upset during the medication administration and was yelling at the licensed nurse (LN). [DATE], Pt [patient] presented with behavioral problems today demanding to be discharged , aggressive, calling nurses out their name or title with bad language and profanity, slammed telephone and slammed door. She demanded to speak to social services to be discharged . [DATE], Resident .started yelling and demanded me to go out from her room. She wants to go home. No one paying attention to her. Resident left alone. [DATE], .Pt stated she was very upset with her care here and feels like she is in prison. Pt is very upset with [family members] for putting her here and they don't come and visit her. Pt refusing medications at this time and believes that if she stops taking her medications she will die faster .asked pt if she has thoughts of hurting herself and pt denies .will follow up with doctor [DATE], Late entry for [DATE]: .Pt was sitting in room with [family member, FM 1] laughing and eating chips [DATE], At 12:05 AM Resident came out from the room and stating she swallowed a glass. We would like to come to the room she wont [sic] let us in and she pushed the bed at the door .physician notified . Resident hold the phone and saying you are not my [expletive] doctor .911 called and with difficulty evaluating her and took her at 110 AM. Room has been assessed broken glass found at the window. A review of Resident 1's facility clinical record indicated, the resident's suicide risk had not been assessed upon admission and there was no written plan of care developed with person-centered interventions to address the resident's bipolar disorder, depression, and/or SI until [DATE] (the resident did not return to the facility after leaving via 911 on [DATE]). A review of Resident 1's GACH 1 physician documentation dated, [DATE], indicated, .Patient was seen and evaluated by writer and the SW [social worker] at the ED [emergency department]. Pt appears to be restless, maintained no eye contact, report feeling depressed, overwhelmed and frustrated which has been getting worse in the last few days to week and started feeling increasingly irritable and has been feeling on edge. Report that she has been feeling worthless, useless and she had been feeling suicidal and decided to swallow some glasses with the intention to hurt herself. Report poor sleep for days and loss of appetite. Pt remain guarded and refused to elaborate further. Pt report that [family member] put her in a nursing home and she would rather kill herself than staying in the nursing home A review of Resident 1's GACH 1 physician documentation dated [DATE], indicated, . [Resident 1] tried to kill herself by swallowing broken glass; I screwed up now I have pain at the back of my throat; c/o [complained of] not liking the living facility; also CT [computerized tomography, machine able to visualize inside the body] chest pneumomediastinum [air in the chest cavity near the esophagus (tube connecting mouth to the stomach)] and possible foreign body glass at the upper pharynx [throat] and smaller pieces in small intestine A review of Resident 1's GACH 1 physician documentation dated [DATE], indicated, .Patient currently endorsing pain over her throat and abdominal area A review of Resident 1's GACH 1 physician documentation dated [DATE], indicated, .Patient states that she is in severe pain in her lower neck and upper chest and now wishes that she did not swallow the class [sic] because of the pain and also reports right lower quadrant pain that started after swallowing glass A review of Resident 1's GACH 1 physician documentation, discharge summary, dated [DATE], indicated the resident had a 3.5 by 4 cm (centimeter) slightly curved piece of glass with sharp edges removed that had caused a 2 cm tear the resident's esophagus. Resident 1 was transferred to GACH 2 with physician's recommendation to keep sedated and intubated (breathing with a breathing tube). A review of Resident 1's GACH 2 documentations dated, [DATE] indicated, the resident had prior suicide attempts on [DATE] and [DATE]. A review of Resident 1's GACH 2 documentation, Admission History and Physical, dated [DATE], indicated, .Patient was at [SNF] .when she was found to have swallowed about 5 handfuls of broken glass from a vase .She had severe pain in her neck and upper chest. Reported to be remorseful for her actions . CT [computerized tomography, machine able to visualize inside the body] showed extensive shards of glass from the proximal esophagus [upper part/near the mouth of the tube connecting the mouth to the stomach] through the colon [large intestine]. She had subcutaneous emphysema [air that's trapped under the skin] near her cricopharynx [in the throat area]. Underwent direct esophagoscopy [scope that goes in the esophagus] . which revealed a 3x4 cm [centimeter] shard of glass which was removed. There was a 2-centimeter tear posterior wall of the esophagus and into the prevertebral fascia [layer of tissue surrounding the spine] as well as a small laceration in the posterior oropharynx [back of the throat directly behind the roof of the mouth] that was thought to be the source of subcutaneous emphysema . She remained intubated [with a breathing tube] for safety. Transferred to [GACH 2] for further care . Found to have glass shards throughout the GI [gastrointestinal] tract .Patient is septic [blood infection] by SIRS [systemic inflammatory response in the presence of a known or suspected source] and GI/oral source . Apparent suicide attempt A review of Resident 1's GACH 2 documentation, Discharge Summary, dated [DATE], .Following admission, the patient was initially cared for in the ICU [intensive care unit] and then transitioned to comfort care. Active hospital problems .Severe sepsis, esophageal perforation [tear], foreign body in digestive tract . Prognosis felt to be guarded to poor [not likely to recover] .She passed away in the hospital on [DATE] at 0758 [7:58 AM] On [DATE] at 2:45 P.M., an observation of the BHU was conducted. The double entry doors to the unit alarmed when opened. Approximately, 24 residents were observed siting closely together at several tables or were walking around the tables in the open space located in front of the nurses' station. A resident seated at one of the tables near the entry doors was making yelling and screaming sounds. Another resident was heard screaming unintelligibly from down the west hall. Two residents at one of the tables were playing cards. One resident at a table was rocking back and forth. One staff was observed sitting at the resident table and another staff was observed standing near a table. Two staff were observed in the nurses' station. On [DATE] at 3 P.M., an interview was conducted with certified nursing assistant (CNA) 3. CNA 3 stated she often provided care to Resident 1 and the resident made statements like, I want to go home and I don't belong here. CNA 3 stated Resident 1 would frequently yell and cuss at the nurses and had a behavior of putting herself on the floor for attention. CNA 3 stated Resident 1 had told her, I want to kill myself, on three different occasions since admission to the facility. CNA 3 was asked what she had done when the resident verbalized that. CNA 3 stated she kept a closer eye on the resident. CNA 3 stated she began her shift at 2:30 P.M. on [DATE], and had worked double shift (from 2:30 P.M. on [DATE] to 7 A.M. on [DATE]). CNA 3 stated at the start of the shift, Resident 1 was at the nurses' station yelling and cussing at the nurse. CNA 3 stated Resident 1 went to her room after a while and seemed calm. CNA 3 stated sometime around midnight, Resident 1's call light went off and she responded to it. CNA 3 stated she asked Resident 1 what she needed, and the resident told her, Get the [expletive] out of here. CNA 3 stated she reminded Resident 1 that she had the call light on, and the resident told her, I'm going to swallow glasses. CNA 3 stated the resident normally spoke with a slightly slurred speech. CNA 3 stated she checked the resident's room and inside the resident's mouth. CNA 3 stated she did not see any glass or broken glass anywhere. CNA 3 stated, when Resident 1 noticed that she (CNA 3) did not find anything and told her, You can't find it. CNA 3 stated she left resident's room to get LN 4 and that Resident 1 wanted her to close the door and she closed it. CNA 3 stated, [Resident 1] wants me to slam the door so it closes tight. CNA 3 stated when she located LN 4, they both heard the sound of glass breaking. CNA 3 stated they went to Resident 1's room and the resident was closing her door and pushing her body against the door, and they could not open it. CNA 3 stated when she was able to open the door, Resident 1 was seated in her wheelchair and a broken glass vase on the floor next to the resident. CNA 3 stated the resident was strong enough to move fast and without the need of an assistive device. CNA 3 stated the glass vase had been at the resident's bedside and the resident had kept artificial flowers in it. CNA 3 stated Resident 1 made pushing motions toward her that ushered her out of the resident's room and then the resident closed the door. CNA 3 stated she remained outside Resident 1's closed door and did not open the door because the resident would become upset. CNA 3 stated she remained outside Resident 1's closed door for approximately two minutes while LN 4 called the physician. CNA 3 stated Resident 1 had been alone in her room with broken glass on the floor. CNA 3 stated she was afraid the resident was going to swallow the glass. CNA 3 stated LN 4 returned with the physician on the mobile phone, and LN 4 was able to get the resident's door open enough to pass the phone through the door to the resident. CNA 3 stated Resident 1 said, You're not my [expletive] doctor, and threw the phone into the hallway. CNA 3 stated 911 came and took Resident 1 to the hospital. CNA 3 stated the incident with Resident 1 had been a behavioral emergency. CNA 3 stated the facility did not have a protocol to handle behavioral emergencies and that she had not known what to do during the incident. CNA 3 stated she had needed help with Resident 1 and had not been able to handle the situation alone. CNA 3 stated there should be a process like a code (a systematic, organized emergency response) called so other staff can help in a behavioral emergency. CNA 3 stated she had not received any facility training for residents with SI. CNA 3 stated, I didn't know what to do in that situation. CNA 3 further stated the BHU did not feel safe without more training and a system in place to respond to emergencies. CNA 3 further stated the Station 2 used to be a dementia unit (residents with cognitive and memory issues), but It's gotten worse since they mixed psych [mental disorders] with the dementia. CNA 3 stated there was too much screaming on the unit now. CNA 3 stated staff received some training about residents who scream, but nothing on SI or psychiatric/behavioral emergencies. On [DATE] at 4 P.M., an interview was conducted with CNA 5. CNA 5 stated Station 2 used to be a dementia unit but recently it turned into a psych unit. CNA 5 stated, Mixing psych [residents] and dementia's [residents] not working. Lots of screaming from psych [residents] that upsets those with dementia. CNA 5 stated staff received in-services from the psychologist about behavior, But we still don't know how to deal with them. CNA 5 stated the staff training was rushed and there were no skills checks or competency evaluation done. CNA 5 stated he would not know how to respond in a behavioral emergency or if a resident had SI or threatened suicide. CNA 5 stated there should be training about SI and behavioral emergencies so everyone knows what to do and could form a coordinated response. CNA 5 stated staff often got hurt on the BHU and that he had been hit, kicked, and scratched by the psychiatric residents. CNA 5 stated, It's been a mess in there [BHU] . and unsafe. CNA 5 stated, We need better training . CNA 5 further stated that he was working the night of Resident 1's incident, but he did not know a behavioral emergency had taken place until the LN asked him to open the door for 911 responders. On [DATE] at 9:32 A.M., a telephone interview was conducted with LN 4. LN 4 stated she worked regularly on Station 2. LN 4 stated Station 2 used to be a dementia unit but now had a lot of psych residents and were adding Patch residents. LN 4 stated the Patch residents were difficult to manage and frequently screamed and yelled on the unit. LN 4 stated staff were getting hurt because the psych residents tried to fight with the staff. LN 4 stated mixing dementia residents with psych/behavioral residents made the unit chaotic. LN 4 stated she was providing care to Resident 1 during the NOC shift (10:30 P.M. on [DATE] to 7 A.M. on [DATE]) and she had seen Resident 1 around 10:45 P.M., at which the resident seemed calm. LN 4 stated she was unaware of Resident 1 having had any history of SI or making SI statements. LN 4 stated, I would have wanted to know that .I didn't know. LN 4 stated it was important to know a resident had SI to monitor for that. LN 4 stated all staff should have known of Resident 1's SI to keep the resident safe from self-harm. LN 4 stated there had not been any training for providing care to residents with SI and that there should have been training provided. LN 4 stated SI training was needed because any resident could begin to experience SI. LN 4 stated she first became aware of the incident with Resident 1 because the resident came up to the nurses' station and told her, I swallowed glass. LN 4 stated she did not recall CNA 3 informed her that Resident 1 had threatened to swallow glass. LN 4 stated she remembered hearing of glass breaking prior to Resident 1 informing her that she had swallowed glass. LN 4 stated both her and CNA 3 tried to get into Resident 1's room and that the resident had closed the door and place herself against the door. LN 4 stated she left CNA 3 at the resident's closed door and went to call the physician. LN 4 stated CNA 3 tried to get back inside the resident's room while they waited for the physician to return the call. LN 4 stated she brought the mobile phone to Resident 1 and the resident threw it into the hall and said, That's not my [expletive] doctor. LN 4 stated she called 911 and they came right away for the resident. LN 4 stated the incident with Resident 1 was considered a behavioral emergency and had been a suicide threat. LN 4 stated the facility did not have a procedure for behavioral emergencies and that there should be one. LN 4 stated, We needed more help, and could not get inside the resident's room. LN 4 stated if she had known Resident 1 verbalized the threat of swallowing glass, she would have had a staff remained inside the resident's room. LN 4 stated the resident should have been placed on 1:1 supervision (one staff to remain with the resident) as soon as the suicide threat was made. LN 4 stated the resident's room would have been thoroughly searched until all dangers were removed. LN 4 stated doing those things could have prevented Resident 1 from swallowing glass. LN 4 stated, Training could have prevented this. LN 4 stated the number of staff on the unit had been enough but that there needed to be an organized, systematic response during a behavioral emergency and staff who were competent. On [DATE] at 10:43 A.M., an interview was conducted with CNA 6. CNA 6 stated the facility had not provided any staff training related to SI or behavioral emergency response. CNA 6 stated there should have been training so we all know what to do and could act quickly. On [DATE] at 10:57 A.M., an interview was conducted with LN 7. LN 7 stated she was familiar with Resident 1 and that the resident would scream and had, Lots of suicidal ideation. LN 7 stated Resident 1 would speak negatively about herself and would say things such as certain family members did not like her, she was not worthy of living, and that she would rather die. LN 7 stated Resident 1 often said, I just want to die. LN 7 stated Resident 1's verbalizations of SI were not a change of condition and did not required intervention. LN 7 stated, [Resident 1] was on the psych unit and not everything residents [on the BHU] say makes sense. LN 7 stated Resident 1's frequency of verbalizing SI was increasing prior to the incident ([DATE]). LN 7 stated it would be a change reportable to the physician if the resident had a plan. LN 7 stated there was currently a resident on the BHU, Resident 2, and he would say that he wants to die, too. LN 7 stated that she had not received training related to providing care to residents with SI. LN 7 stated she thought SI training would be beneficial. LN 7 stated an actual suicide threat was an emergency and it deserved an emergency response like calling a code. LN 7 stated the facility did not have a procedure or code for responding to behavioral emergencies. LN 7 stated training and competency evaluation was important for everyone involved to ensure, We know what to do. On [DATE] at 11:45 A.M., an interview was conducted with the director of staff development (DSD). The DSD stated she was responsible for staff training. The DSD stated there had not been any training provided to staff related to providing care to residents with SI. The DSD stated that there should have been SI training given to staff especially to those that worked in the BHU. The DSD stated corporate did staff trainings about residents with behaviors but there was no competency evaluation done. The DSD stated for a behavioral emergency such as what took place with Resident 1, a Code Grey (situational emergency response) should have been called. The DSD stated a Code Grey was called for combative residents which also included a resident trying to do self-harm. The DSD stated Code Grey training was mandatory for all staff in the facility especially before any staff worked in the BHU. The DSD stated she had not done staff knowledge checks or competencies after the Code Grey training was done and should have. The DSD stated what happened to Resident 1, Comes down to a lack of staff knowledge. On [DATE] at 12:05 P.M., the lesson plans and attendance sheets for Code Grey training was requested from the DSD. On [DATE] at 12:20 P.M., a joint interview and record review was conducted with the DSD. The facility's Lesson plan for CPI- Crisis, Prevention, Intervention Code Grey, dated [DATE] was reviewed. The training did not include SI, had de-escalation tips, and Code Grey paging overhead for any behavioral occurrence where immediate available staff were needed promptly. A review of the sign in sheet for the CPI training dated [DATE], did not have LN 4, LN 7, CNA 3, CNA 4, and CNA 6 in the attendance. The DSD stated they should have had the mandatory training. The DSD stated that knowledge checks and competency evaluations had not been done. The DSD stated competency evaluation should have been done to ensure the training was learned and the staff were deemed competent. The DSD stated she was unsure what training was required to work competently and safely in the BHU. The DSD stated the BHU training automatically came from corporate and that she was not part of any discussion or planning of that staff training. The DSD stated facility staff should have been part of analyzing and planning the BHU training since they were most familiar with the facility and residents' needs. On [DATE] at 2:05 P.M., a joint interview and record review was conducted with the DON. The DON reviewed Resident 1's clinical record and stated on [DATE], after the resident made a statement of wanting to stop taking medications so she would die faster, she had instructed nursing staff to do a change of condition report and to closely monitor the resident. The DON stated there was no documentation nursing staff had carried out her directions, or that Resident 1 had received increased monitoring. The DON stated this should have been done. The DON stated as soon as Resident 1 threatened to swallow glass, the resident should not have been left alone at any time, should have been placed on 1:1 supervision, and the entire room swept for the removal of all glass objects and any other suicide hazards. The DON stated if this had been done, it could have prevented Resident 1 from being able to swallow glass. The DON stated a Code Grey should have been implemented immediately and that staff should have gained access to the resident's room by any means necessary to separate the resident from broken glass that was on the floor. The DON stated all staff should have been trained on how to deal with residents who have SI and how to respond to a Code Grey in an organized and immediate fashion. The DON stated staff competencies should have been evaluated. The DON further stated the residents housed in BHU with higher level of psychiatric diagnoses and mental disorders required more competency training for staff. The DON stated both Resident 1 and Resident 2 should have had their SI history assessed and mental disorders care planned with resident-specific interventions since their admission to the facility. The DON stated Resident 2 was still in the BHU and there were staff providing care to the resident who may not have been trained for SI and behavioral emergencies. The DON further stated the facility stopped admitting residents with mental disorders and Patch program as of [DATE] until all staff were trained and competent. The DON stated, We don't admit those residents [with SI history] here. The DON stated Resident 1 and Resident 2 should not have been admitted to the facility. The DON stated, [We] Shouldn't have admitted residents that we were not fully able to provide care to. On [DATE] at 5:30 P.M., an interview was conducted with the administrator (ADM). The DON was also present. The ADM stated he did not understand what the concern was about Patch residents in the BHU. The ADM stated they had the same needs as any other resident in the BHU only the funding was different. The ADM did not provide an answer related to staff training and competencies. On [DATE] at 5:37 P.M., the ADM and DON were informed of Immediate Jeopardy (IJ) related to the facility's failure to ensure staff were adequately trained and competent in providing care to residents with SI and responding to behavioral emergencies/crisis. The facility began to develop a plan to remove the immediacy. On [DATE] at 6:42 P.M., a telephone interview was conducted with the facility's medical director (MDR). The MDR stated he expected staff to be fully trained and knowledgeable in providing care to residents with SI. The MDR stated when Resident 1 verbalized SI, staff should have responded immediately by notifying the physician and psychiatrist, assess the resident, and develop a care plan. The MDR stated when Resident 1 threatened to swallow glass, the resident should have been placed on immediate 1:1 supervision and all glass removed from the resident's room. The MDR stated a Code Grey should have been called and carried out. The MDR stated staff should have been trained and competent to respond in a behavioral emergency. On [DATE] at 8:05 P.M., the facility's Plan of Action was reviewed with the DON. The Plan of Action included: Immediate corrective action and identification of residents affected: 1. [Resident 2] had verbalized hanging himself with oxygen tubing. Suicide risk assessment done, placed resident on 1:1 supervision with safety precautions in place and care planned. 2. Suicide risk assessment and high-risk assessment are in process and are being completed on all and was done on all residents in station 2 and all PATCH residents in the facility. Immediate systemic changes: 1. All staff tonight were given in-service on code gray and training how to respond to crisis in station 2 by DSD. A. Code gray in-service included how to call the code and the expectation. B. Blast text was sent to all staff on OnShift to notify of Code gray expectations and response for Code gray. 2. Inservice will be given to NOC [11 P.M. to 7 A.M.] shift tonight, on code gray and training on how to respond to crisis. 3. Residents who were identified with suicidal ideation on suicidal risk assessment will be care planned and will be provided with safety precaution and 1:1 supervision. Monitoring process: 1 [TRUNCATED]

Based on interview and record review, the facility failed to ensure the necessary behavioral healthcare and services were provided to one of three residents (Resident 1) who was diagnosed with mental disorders (a syndrome characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior) when: 1. Resident 1's mental disorders and history of suicidal ideation (SI, thoughts of self-harm or of killing oneself), identified upon admission, were care planned with resident-specific interventions to include providing an environment free of items that could be used to inflict self-harm. 2. A written care plan to address Resident 1's depression (a mood disorder that caused persistent feelings of sadness, hopelessness, and loss of interest) was developed after the resident's Minimum Data Set Assessment (MDS, a comprehensive assessment) was completed to indicate the resident was showing signs/symptoms of depression. 3. Resident 1's verbalizations and increased frequency of SI were promptly acted upon by nursing staff or reported to the physician and/or psychiatrist (physician who specialized in mental disorders). As a result of these deficient practices, most of the staff providing care to Resident 1 were aware of the resident's history of SI and did not have a plan of care to follow for providing resident-centered mental and behavioral health services. In addition, on [DATE], Resident 1 verbalized to staff on several occasions that she wanted to kill herself, told certified nursing assistant (CNA) 3 that she would swallow glass. Resident 1 was left alone in her room with a glass vase which the resident then broke and ingested. Resident 1 was sent out to the hospital on [DATE], experienced pain, sustained shards of glass throughout the gastrointestinal tract (GI tract, path where food travels through the body) that cut the organs of the GI tract, developed sepsis (infection in the blood) and later died at the hospital on [DATE]. Cross reference F741 and F838. Findings: On [DATE] at 1:48 P.M., an on-site visit was conducted at the facility to investigate a facility reported incident alleging Resident 1 had swallowed glass on [DATE]. The administrator (ADM) and director of nursing (DON) were interviewed at this time. The ADM stated he was still conducting an investigation into the incident. The ADM and DON both stated they were recently informed that Resident 1 had died at the hospital. A review of Resident 1's facility Admission Record indicated, the resident was admitted on [DATE] with diagnoses to include bipolar disorder (mental disorder with extreme changes in mood, thought, energy, and behavior and characterized by periods of mania and depression) and depression (a mood disorder that caused persistent feelings of sadness, hopelessness, and loss of interest). A review of Resident 1's Minimum Data Set assessment dated [DATE], indicated, the resident scored 15 on the brief interview of mental status (a score of 15 meant the resident was cognitively intact). A review of Resident 1's facility History and Physical exam, signed by the physician on [DATE], indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 1's admitting paperwork from the general acute care hospital (GACH) 2 dated [DATE], indicated, the resident had a history of SI. A review of Resident 1's facility nursing progress notes indicated, on: [DATE], The resident became very upset during the medication administration and was yelling at the licensed nurse (LN). [DATE], Pt [patient] presented with behavioral problems today demanding to be discharged , aggressive, calling nurses out their name or title with bad language and profanity, slammed telephone and slammed door. She demanded to speak to social services to be discharged . [DATE], Resident .started yelling and demanded me to go out from her room. She wants to go home. No one paying attention to her. Resident left alone. [DATE], .Pt stated she was very upset with her care here and feels like she is in prison. Pt is very upset with [family members] for putting her here and they don't come and visit her. Pt refusing medications at this time and believes that if she stops taking her medications she will die faster .asked pt if she has thoughts of hurting herself and pt denies .will follow up with doctor [DATE], Late entry for [DATE]: .Pt was sitting in room with [family member, FM 1] laughing and eating chips [DATE], At 12:05 AM Resident came out from the room and stating she swallowed a glass. We would like to come to the room she wont [sic] let us in and she pushed the bed at the door .physician notified . Resident hold the phone and saying you are not my [expletive] doctor .911 called and with difficulty evaluating her and took her at 110 AM. Room has been assessed broken glass found at the window. A review of Resident 1's facility clinical record indicated, the resident's suicidal risk had not been assessed upon admission and there was no written plan of care developed with person-centered interventions to address the resident's bipolar disorder (a mental illness that can be chronic (persistent or constantly recurring) or episodic (occurring occasionally and at irregular intervals), depression, and SI until [DATE]. A review of Resident 1's GACH 1 physician documentation dated [DATE], indicated, .Patient was seen and evaluated by writer and the SW [social worker] at the ED [emergency department]. Pt appears to be restless, maintained no eye contact, report feeling depressed, overwhelmed and frustrated which has been getting worse in the last few days to week and started feeling increasingly irritable and has been feeling on edge. Report that she has been feeling worthless, useless and she had been feeling suicidal and decided to swallow some glasses with the intention to hurt herself. Report poor sleep for days and loss of appetite. Pt remain guarded and refused to elaborate further. Pt report that [family member] put her in a nursing home and she would rather kill herself than staying in the nursing home A review of Resident 1's GACH 1 physician documentation dated [DATE], indicated, . [Resident 1] tried to kill herself by swallowing broken glass; I screwed up now I have pain at the back of my throat; c/o [complained of] not liking the living facility; also CT [computerized tomography, machine able to visualize inside the body] chest pneumomediastinum [air in the chest cavity near the esophagus (tube connecting mouth to the stomach)] and possible foreign body glass at the upper pharynx [throat] and smaller pieces in small intestine A review of Resident 1's GACH 1 physician documentation dated [DATE], indicated, .Patient currently endorsing pain over her throat and abdominal area .Patient states that she is in severe pain in her lower neck and upper chest and now wishes that she did not swallow the class [sic] because of the pain and also reports right lower quadrant pain that started after swallowing glass A review of GACH 1 discharge summary dated [DATE], physician documentation, indicated, the resident had a 3.5 by 4 cm (centimeter) slightly curved piece of glass with sharp edges removed that had caused a 2 cm tear the resident's esophagus. Resident 1 was transferred to GACH 2 with physician's recommendation to keep sedated and intubated (breathing with a breathing tube). A review of Resident 1's GACH 2 documentations dated [DATE], indicated, the resident had prior suicide attempts on [DATE] and [DATE]. The Admission History and Physical, dated [DATE], indicated, .Patient was at [SNF] .when she was found to have swallowed about 5 handfuls of broken glass from a vase .She had severe pain in her neck and upper chest. Reported to be remorseful for her actions . CT [computerized tomography, machine able to visualize inside the body] showed extensive shards of glass from the proximal esophagus [upper part/near the mouth of the tube connecting the mouth to the stomach] through the colon [large intestine]. She had subcutaneous emphysema [air that's trapped under the skin] near her cricopharynx [in the throat area]. Underwent direct esophagoscopy [scope that goes in the esophagus] . which revealed a 3x4 cm [centimeter] shard of glass which was removed. There was a 2 centimeter tear posterior wall of the esophagus and into the prevertebral fascia [layer of tissue surrounding the spine] as well as a small laceration in the posterior oropharynx [back of the throat directly behind the roof of the mouth] that was thought to be the source of subcutaneous emphysema . She remained intubated [with a breathing tube] for safety. Transferred to [GACH 2] for further care . Found to have glass shards throughout the GI [gastrointestinal] tract .Patient is septic [blood infection] by SIRS [systemic inflammatory response in the presence of a known or suspected source] and GI/oral source . Apparent suicide attempt GACH 2 discharge Summary, dated [DATE] indicated, .Following admission, the patient was initially cared for in the ICU [intensive care unit] and then transitioned to comfort care. Active hospital problems .Severe sepsis, esophageal perforation [tear], foreign body in digestive tract . Prognosis felt to be guarded to poor [not likely to recover] .She passed away in the hospital on [DATE] at 0758 [7:58 AM] According to the National Institute of Mental Health's online article titled Depression, dated [DATE], .Depression is a serious mood disorder . What are the signs and symptoms of depression? . Feelings of guilt, worthlessness, or helplessness . Increased irritability or anger . becoming withdrawn, negative, or detached .Thoughts of death, suicide, or suicide attempts . bipolar disorder . also experience depressive episodes . also experiences .unusually elevated moods, in which they might feel very happy, irritable, or up with a marked increase in activity level On [DATE] at 3 P.M., an interview was conducted with certified nursing assistant (CNA) 3. CNA 3 stated she often provided care to Resident 1 and the resident made statements like, I want to go home and I don't belong here. CNA 3 stated Resident 1 would frequently yell and cuss at the nurses and had a behavior of putting herself on the floor for attention. CNA 3 stated Resident 1 had told her, I want to kill myself, on three different occasions since her admission. CNA 3 was asked what she had done when the resident verbalized that. CNA 3 stated she kept a closer eye on the resident. CNA 3 stated she began her shift at 2:30 P.M. on [DATE] and had worked double shift (from 2:30 P.M. on [DATE] to 7 A.M. on [DATE]). CNA 3 stated at the start of the shift, Resident 1 was at the nurses' station yelling and cussing at the nurse. CNA 3 stated Resident 1 went to her room after a while and seemed to calm down. CNA 3 stated sometime around midnight, Resident 1's call light went off and she responded to it. CNA 3 stated that she asked Resident 1 what she needed, and the resident told her to, Get the [expletive] out of here. CNA 3 stated she reminded Resident 1 that she had the call light on, and the resident told her, I'm going to swallow glasses. CNA 3 stated the resident normally spoke with a slightly slurred speech. CNA 3 stated she checked the resident's room and inside the resident's mouth. CNA 3 stated she did not see any glass or broken glass anywhere. CNA 3 stated Resident 1 noticed that she did not find anything and told her, You can't find it. CNA 3 stated she left the resident's room to get LN 4 and that Resident 1 wanted her (CNA 3) to close the door to the room and she closed it. CNA 3 stated, [Resident 1] wants me to slam the door so it closes tight. CNA 3 stated when she located LN 4, and they were speaking, they both heard the sound of glass breaking. CNA 3 stated they went to Resident 1's room and the resident was closing her door and pushing her body against the door, and they could not open it. CNA 3 stated when she was able to open the door, Resident 1 was seated in her wheelchair and there was a broken glass vase on the floor next to the resident. CNA 3 stated the resident was strong enough to move fast without the need of an assistive device. CNA 3 stated the glass vase had been at the resident's bedside that the resident had kept with artificial flowers in it. CNA 3 stated Resident 1 made pushing motions toward her that ushered her out of the resident's room and the resident closed the door. CNA 3 stated she remained outside Resident 1's closed door and did not open the door because the resident would become upset. CNA 3 stated she remained outside Resident 1's closed door for approximately two minutes while LN 4 called the physician. CNA 3 stated Resident 1 had been alone in her room with broken glass on the floor. CNA 3 stated she was afraid the resident was going to swallow the glass. CNA 3 stated LN 4 returned with the physician on the mobile phone, and LN 4 was able to get the resident's door open enough to pass the phone through the door to the resident. CNA 3 stated Resident 1 said, You're not my [expletive] doctor, and threw the phone into the hallway. CNA 3 stated 911 came and took Resident 1 to the hospital. CNA 3 stated she had not received any facility training for residents with SI. CNA 3 stated, I didn't know what to do in that situation. On [DATE] at 9:32 A.M., a telephone interview was conducted with LN 4. LN 4 stated she worked regularly on Station 2. LN 4 stated she was providing care to Resident 1 during the NOC shift (10:30 P.M. on [DATE] to 7 A.M. on [DATE]) and she had seen Resident 1 around 10:45 P.M., at which point the resident seemed calm. LN 4 stated she was unaware of Resident 1 having had any history of SI or making SI statements. LN 4 stated, I would have wanted to know that .I didn't know. LN 4 stated it was important to know how to monitor a resident who had SI. LN 4 stated all staff should have known of Resident 1's SI to keep the resident safe from self-harm. LN 4 stated residents with mental disorders should have a written plan of care with individualized interventions to include suicide prevention if resident had a history of SI. LN 4 stated she became aware of the incident with Resident 1 when the resident came up to the nurses' station and told her, I swallowed glass. LN 4 stated she did not recall CNA 3 informed her that Resident 1 had threatened to swallow glass. LN 4 stated she remembered hearing the sound of glass breaking prior to Resident 1 informing her that she had swallowed glass. LN 4 stated both her and CNA 3 tried to get into Resident 1's room, and that the resident had closed the door and place herself against the door. LN 4 stated she left CNA 3 outside of the resident's closed door and went to call the physician. LN 4 stated CNA 3 tried to get back inside the resident's room while they waited for the physician's call. LN 4 stated she brought the mobile phone to Resident 1 and the resident threw it into the hall and said, That's not my [expletive] doctor. LN 4 stated she called 911 and they came right away for the resident. LN 4 stated if she had known Resident 1 verbalized the threat of swallowing glass, she would have had a staff remain inside the resident's room. LN 4 stated the resident should have been placed on 1:1 supervision (one staff to remain with the resident) as soon as the suicide threat was made. LN 4 stated the resident's room would have been thoroughly searched until all dangers were removed. LN 4 stated doing those things could have prevented Resident 1 from swallowing glass. On [DATE] at 10:57 A.M., an interview was conducted with LN 7. LN 7 stated she was familiar with Resident 1 who would scream and had, Lots of suicidal ideation. LN 7 stated Resident 1 would speak negatively about herself and would say things like certain family members did not like her, she was not worthy of living, and that she would rather die. LN 7 stated Resident 1 often said, I just want to die. LN 7 stated Resident 1's verbalizations of SI were not a change of condition and did not required intervention. LN 7 stated, [Resident 1] was on the psych unit [residents with mental disorders] and not everything residents say makes sense. LN 7 stated Resident 1's frequency of verbalizing SI was increasing prior to the incident ([DATE]). LN 7 stated it would be a change of condition reportable to the physician if the resident had a plan. LN 7 stated she had not received training related to providing care to residents with SI. On [DATE] at 11:22 A.M., an interview was conducted with Resident 1's family member (FM) 1. FM 1 stated that they visited Resident 1 nearly every day. FM 1 stated Resident 1 had their mind made up that they were not going to remain in this world. FM 1 stated Resident 1 had felt that way for a while and would appear happy at times even though the resident did not truly feel happy. FM 1 stated to their knowledge, Resident 1 did not have a formal suicide plan, but Resident 1 did not want to live. FM 1 stated Resident 1 had expressed wanting to talk to someone about how they felt. FM 1 stated it may have helped Resident 1 to speak to a psychologist or someone. FM 1 stated if Resident 1 was verbalizing SI, that would have been a warning the resident was thinking of committing suicide. FM 1 stated facility staff told them that Resident 1, Never said anything about wanting to die so they [facility staff] didn't know. FM 1 stated they worried something like this would have happened to Resident 1 eventually because the resident had made it clear that they no longer wanted to live. On [DATE] at 2:05 P.M., a joint interview and record review was conducted with the director of nursing (DON). The DON reviewed Resident 1's clinical record and stated the resident was admitted with mental disorders and a history of SI and that this should have been care planned upon admission. The DON stated Resident 1's suicide risk should have also been assessed upon admission. The DON stated when Resident 1 made statements on [DATE] about wanting to stop taking her medications so she would die faster, she had instructed her staff to do a change of condition report and frequent monitoring. The DON stated her directions had not been followed. The DON stated a written plan of care should have been developed immediately to address Resident 1's current mood and SI. The DON stated when LN 7 noticed Resident 1's increased frequency of verbalizing SI, this was a change in the resident's condition and should have been reported to the physician. The DON stated when Resident 1 threatened to swallow glass on [DATE], the resident should have been placed on 1:1 supervision right away, the room should have been swept for anything that could be used for self-harm and any glass removed. The DON stated this could have prevented the resident from swallowing glass. On [DATE] at 6:42 P.M., a telephone interview was conducted with the facility's medical director (MDR). The MDR stated he expected staff to be fully trained and knowledgeable in providing care to residents with SI. The MDR stated when Resident 1 verbalized SI, staff should have responded immediately by notifying the physician and psychiatry, assessing, and care planning to include the removal of objects that could be used for self-harm as an intervention. The MDR stated when Resident 1 threatened to swallow glass, the resident should have been placed on immediate 1:1 supervision and all glass removed from the resident's room. On [DATE] at 9:30 A.M., a joint interview and record review was conducted with LN 9. LN 9 stated the purpose of developing a plan of care for residents was to alert the LN to any problems and provide resident-specific interventions to prevent the problem from occurring or reoccurring. LN 9 stated when the LN admitted a resident, the past medical history on the admitting paperwork should be reviewed and start a baseline care plan to guide the resident's care. LN 9 stated residents with mental disorders should have individualized care plans developed to identify what services were required to address the disorder, and to include non-pharmacological interventions (not using medications). LN 9 stated SI was a problem area that required an individualized care plan to keep the resident safe from self-harm. LN 9 stated residents with a history of SI should be assessed for suicide risk upon admission in order to develop a personalized care plan. LN 9 reviewed Resident 1's clinical record and stated the resident was admitted with a documented history of SI and that the resident had not been assessed for suicide risk upon admission. LN 9 stated Resident 1 had depression and bipolar disorder, there should have been a written care plan developed specific to mental disorders. LN 9 stated when Resident 1 verbalized SI, the written care plan should have included interventions to prevent the resident from being able to act upon the SI, and remove any objects in the resident's room that could be used to cause self-harm, frequent monitoring, or 1:1 supervision. LN 9 further stated when Resident 1 verbalized SI, the psychiatrist (physician who specialized in mental disorders) should have been notified and evaluated Resident 1 and may have ordered the resident to be transferred to the acute care. LN 9 stated when the LN noticed Resident 1's SI increasing in frequency, that was considered a change in the resident's mental and psychosocial condition, and the resident should have been promptly assessed and reported to the psychiatrist right away. LN 9 stated Resident 1's increased frequency of verbalizing SI, should have been treated seriously as it indicated the resident was becoming unstable and further mental health services were needed. LN 9 stated when the LN communicated with a physician or other provider, it had to be documented in the resident's clinical record. LN 9 reviewed Resident 1's nursing progress notes dated [DATE], .Pt refusing medications at this time and believes that if she stops taking her medications she will die faster . will follow up with doctor LN 9 stated there was no documentation this incident had been followed up or reported to the doctor. LN 9 stated this, and other verbalizations of SI, should have been reported to the facility's psychiatrist, medical doctor (MD) 8. On [DATE] at 11:33 A.M., a joint interview and record review was conducted with the MDS coordinator (MDSC). The MDSC stated she would review hospital admission paperwork to check the residents' diagnosis and problem areas as part of completing residents' MDS assessments. The MDSC stated the admission MDS assessment was considered the final catch to develop resident care plans based off document review and the comprehensive (evaluation of the patient's current condition as well as any changes since the last assessment) assessment. The MDSC stated care plan development was important to make sure problem areas were addressed with appropriate services and personalized, non-pharmacological interventions. The MDSC stated resident care plans communicated any problem areas and how to provide resident-centered care to all staff taking care of the resident. The MDSC reviewed Resident 1's clinical record and stated the resident's mental disorders: depression and bipolar disorder should have been care planned upon admission. The MDSC stated Resident 1's SI history was a problem area and that the resident should have been assessed for suicidal risk upon admission. The MDSC stated after the suicide risk assessment was completed, a care plan should have been developed for the resident's SI. The MDSC stated they could not say what services and non-pharmacological interventions had been provided to Resident 1 to manage the resident's disorders and behaviors because there was no written plan of care. The MDSC reviewed Resident 1's admission MDS assessment Section D, Mood, dated [DATE]. The assessment indicated: Resident 1 experienced little interest or pleasure in doing things for ,d+[DATE] days (several days); felt down, depressed, or hopeless for ,d+[DATE] days (half or more of the days); felt tired or had little energy for ,d+[DATE] days (several days); had poor appetite or overeating for ,d+[DATE] days (half or more of the days); felt bad about themselves or that they were a failure or have let themselves or family down for ,d+[DATE] days (half or more of the days); and moved slowly so others could have noticed or have been fidgety or restless for ,d+[DATE] days (several days). The Mood assessment had a total severity score of 09. The MDSC stated Resident 1's MDS assessment captured the resident's mood from admission on [DATE] through [DATE]. The MDSC stated based off Resident 1's Mood assessment score of 09, [Resident 1's] depressed. The MDSC stated after the Mood assessment was completed, Resident 1's care plan should have been developed to address the resident's depression. The MDSC stated the care plan should have been developed by the social services department. The MDSC stated some possible interventions based off Resident 1's Mood assessment would have been to refer to psychiatry services, daily visits by social services, visits or calls with family, resident-specific activities, clergy visits, and increased monitoring. The MDSC stated Resident 1's verbalizations of SI to staff should have been identified on the resident's written care plan with interventions in place to remove any items from the resident's room that could cause self-harm. The MDSC further stated when the LN noticed the frequency of Resident 1's SI was increasing, that required immediate action and the psychiatrist should have been notified right away. The MDSC stated there was no documentation Resident 1's verbalizations of SI had been reported to the psychiatrist. On [DATE] at 2 P.M., a joint interview and record review was conducted with the DON. The DON reviewed Resident 1's clinical record and stated she had signed the resident's MDS assessment dated [DATE]. The DON stated based off Resident 1's Mood assessment, a care plan should have been developed and completed by the social services director to address the resident's symptoms of depression. The DON stated there had been multiple occasions where a plan of care should have been developed to manage Resident 1's mental disorders and SI. The DON further stated the social services director was unavailable for interview. On [DATE] at 2:17 P.M., an interview was conducted with the facility's psychiatrist, MD 8. MD 8 stated he saw Resident 1 during an initial visit and the resident had depression, bipolar disorder and a borderline personality disorder (a disorder with unstable moods, behavior, and relationships). MD 8 stated these diagnoses posed an increased risk of suicide for Resident 1. MD 8 stated residents with prior suicide attempts also ran a higher risk of attempting suicide again. MD 8 stated residents with a history of SI should have their suicide risk assessed and a plan of care in place upon admission. MD 8 stated when Resident 1 verbalized SI, he should have been notified. MD 8 stated when Resident 1's verbalizations of SI increased in frequency, it was a, Definite warning sign that the resident was focusing on SI or beginning to formulate a plan. MD 8 stated when LN 7 noticed Resident 1's SI increasing in frequency, he should have been notified right away and this should always be taken seriously. MD 8 stated he had not been aware that Resident 1 had verbalized SI to staff and it was something he would have wanted to know, notified right away to evaluate the resident. MD 8 stated when Resident 1 made the suicide threat of swallowing glass, the resident should not have been left alone for any length of time, other staff should have responded, the entire room should have been thoroughly searched for glass, and other dangers and hazards should have been removed. MD 8 stated in crisis, staff had to get inside the resident's room even if the resident did not want staff inside the room. MD 8 stated if the facility had adequately trained and evaluated the competencies of their staff and had systems in place to respond to SI and behavioral emergencies, including the written care plan, that addressed the resident's mental disorders and SI, a good chance the outcome for Resident 1 would have been different. On [DATE] at 3:06 P.M., an interview was conducted with LN 10. LN 10 stated her background was psychiatric nursing. LN 10 stated she was familiar with Resident 1 and had not known the resident had a history of SI, suicide attempts, or had been verbalizing SI to nursing staff. LN 10 stated Resident 1's depression and bipolar disorder should have been care planned to include the resident's verbalizing of SI. LN 10 stated everyone providing care to Resident 1 should have known of her SI history so the resident could have been monitored appropriately. LN 10 stated increased verbalization of SI meant the resident's mental condition was worsening and that should have been reported to the psychiatrist immediately. LN 10 further stated when Resident 1 threatened to swallow glass, that was considered a suicide threat, and the resident should not have been left alone. LN 10 stated other staff should have responded to the situation, resident's room should have been thoroughly searched for items that could have been used to inflict self-harm. LN 10 stated the glass vase that had been in Resident 1's room was given to Resident 1 by another resident. LN 10 stated there should not have been any glass items allowed on the behavioral health unit (unit housing residents with mental disorders, and where Resident 1 resided) as they posed a general safety hazard. LN 10 stated as a standard, residents with verbalizations of SI should have had their rooms checked for items that could have been used for self-harm should be removed. LN 10 stated what happened to Resident 1 (on [DATE]) could have been prevented had those things been done. On [DATE] at 1:18 P.M., a telephone interview was conducted with MD 13. MD 13 stated she treated Resident 1 at GACH 2 when the resident was placed on terminal comfort care. MD 13 stated Resident 1 sustained a lot of damage to her GI tract after swallowing glass. MD 13 stated resident 1 had developed sepsis from the cuts to her GI tract. MD 13 stated, The patient's swallowing of glass contributed to her demise. MD 13 was asked it Resident 1's swallowing glass on [DATE] was a substantial factor causing the resident's death. MD 13 stated, Yes, it was. MD 13 further stated, It was the direct cause of the patient's death. A review of the facility's policy titled Behavioral Health Services, revised February 2019, indicated, . The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care . 2. Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care . 5. Staff training regarding behavioral health services includes, but is not limited to: a. recognizing changes in behavior that indicated psychological distress; b. implementing care plan interventions that are relevant to the resident's diagnosis and appropriate to his or her needs; c. monitoring care plan interventions and reporting changes in conditions A review of the facility's policy titled Suicide Threats, revised [DATE], indicated, Resident suicide threats shall be taken seriously and addressed appropriately .1. Staff shall report any resident threats of suicide immediately to the nurse supervisor/charge nurse .3. A staff member shall remain with the resident until the nurse supervisor/charge nurse arrives to evaluate the resident .5. All nursing personnel and other staff involved in c [TRUNCATED]

Based on observation, interview, and record review, the facility's Facility Assessment (determines the resources and training necessary to care for residents competently during the day-to-day operations) failed to: 1. Thoroughly assess its resident population and its ability to provide care for residents with suicidal ideation (SI, thoughts of self-harm or of killing oneself). 2. Evaluate and identify the needs of the resident in the behavioral health unit (BHU- section of the facility's building designated for residents with mental disorders [syndromes characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior] and memory care issues) located in Station 2 and the provision of behavioral health services to residents with suicidal ideation (SI, thoughts of self-harm or of killing oneself), mental and psychosocial disorders, and Patch program residents (county funded program aiming to provide specialized care for residents with mental disorders). 3. Evaluate and provide adequate training and competencies to staff (measurable pattern of knowledge, skills, abilities, and behaviors, and other characteristics in order to perform occupational functions successfully) required to appropriately deliver care to residents with mental and psychosocial disorders, SI, and to respond to behavioral emergencies/crisis (such as harm to self and/or others). As a result, two residents (1, 2) were identified to have history of SI and mental disorders. Resident 1, verbalized to staff on several occasions that she wanted to kill herself, told certified nursing assistant (CNA) 3 that she would swallow glass. Resident 1 was left alone in her room with a glass vase which the resident then broke and ingested. Resident 1 was sent to the hospital, experienced pain, and later died at the hospital due to sustained shards of glass throughout the gastrointestinal tract (GI tract, path where food travels through the body) that cut the organs of the GI tract, developed sepsis (infection in the blood). These failures put Resident 2 and other residents with mental disorders, SI or the potential for SI, and/or behavioral emergencies at risk of serious injury, harm, impairment, or death. Cross reference F740 and F741. Findings: On [DATE] at 1:48 P.M., an on-site visit was conducted at the facility to investigate a facility reported incident alleging Resident 2 had swallowed glass on [DATE]. The administrator (ADM) and director of nursing (DON) were interviewed at this time. The ADM and DON both stated they were recently informed that Resident 2 had died at the hospital. A review of facility document titled Daily Census dated [DATE], indicated, there were 152 residents in the facility, and 65 residents on the BHU (Station 2). Of the 65 residents on the BHU, 10 residents were identified as being part of the County Patch program. According to Optum, undated, online document, titled San Diego County funded Skilled Nursing Facility (SNF) Patch Criteria, .An additional daily rate paid by San Diego County to contracted SNFs that have agreed to provide additional mental health services to San Diego County beneficiaries . The client must meet the following criteria for San Diego County funded SNF Patch: . 4. Cannot be safely managed in a less restrictive level of care . 8. Is gravely disabled as determined by the establishment of .Conservatorship [a legally appointed person who makes decisions on behalf of another individual deemed unable to] by the Superior Court . 10. Has an adequately documented .primary diagnosis of a serious, persistent, major mental disorder . a. The client's psychosocial functioning has deteriorated to the degree that the client is at risk for being unable to safely and adequately care for themselves in the community or at a less restrictive setting [such as assisted living facility] . https://www.optymsandiego.com A review of facility document titled Diagnosis Report dated [DATE], indicated: Eighteen residents in the BHU had a diagnosis of schizophrenia (a mental disorder characterized by a break from reality, paranoia, delusions, and hallucinations). Thirty-one residents in the BHU had a diagnosis of depression and/or major depression (a mood disorder that caused persistent feelings of sadness, hopelessness, and loss of interest). Five residents in the BHU had a diagnosis of bipolar disorder (mental disorder with extreme changes in mood, thought, energy, and behavior and characterized by periods of mania and depression). A review of Resident 2's facility Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include acute respiratory failure (lungs cannot release enough oxygen), major depressive disorder, and SI. A review of Resident 2's admitting paperwork from the general acute care hospital (GACH) 1 dated [DATE], indicated the resident had a diagnosis of suicidal thoughts and expressed SI to the licensed nurse during his hospital course. A review of Resident 2's facility nursing progress notes, dated [DATE], indicated, Resident verbalized to nursing staff I don't want to live, I want to die, what is there to live for. [sic] When asked if the resident had a plan, resident stated he will hang himself with O2 [oxygen] tubing A review of Resident 1's facility Admission Record indicated, the resident was admitted on [DATE] with diagnoses to include bipolar disorder and depression. A review of Resident 1's admitting paperwork from the general acute care hospital (GACH) 2 dated [DATE], indicated, the resident had a history of SI. A review of Resident 1's facility nursing progress notes dated [DATE], indicated, At 12:05 AM Resident came out from the room and stating she swallowed a glass. We would like to come to the room she wont [sic] let us in and she pushed the bed at the door .physician notified . Resident hold the phone and saying you are not my [expletive] doctor .911 called and with difficulty evaluating her and took her at 110 AM. Room has been assessed broken glass found at the window. A review of Resident 1's GACH 1 physician documentation dated [DATE], indicated, .Patient was seen and evaluated by writer and the SW [social worker] at the ED [emergency department]. Pt appears to be restless, maintained no eye contact, report feeling depressed, overwhelmed and frustrated which has been getting worse in the last few days to week and started feeling increasingly irritable and has been feeling on edge. Report that she has been feeling worthless, useless and she had been feeling suicidal and decided to swallow some glasses with the intention to hurt herself. Report poor sleep for days and loss of appetite. Pt remain guarded and refused to elaborate further. Pt report that [family member] put her in a nursing home and she would rather kill herself than staying in the nursing home A review of Resident 1's GACH 1 physician documentation dated [DATE], indicated, . [Resident 1] tried to kill herself by swallowing broken glass; I screwed up now I have pain at the back of my throat; c/o [complained of] not liking the living facility; also CT [computerized tomography, machine able to visualize inside the body] chest pneumomediastinum [air in the chest cavity near the esophagus (tube connecting mouth to the stomach)] and possible foreign body glass at the upper pharynx [throat] and smaller pieces in small intestine A review of Resident 1's GACH 1 physician documentation dated [DATE], indicated, .Patient currently endorsing pain over her throat and abdominal area A review of Resident 1's GACH 1 physician documentation dated [DATE], indicated, .Patient states that she is in severe pain in her lower neck and upper chest and now wishes that she did not swallow the class [sic] because of the pain and also reports right lower quadrant pain that started after swallowing glass A review of Resident 1's GACH 1 physician documentation, discharge summary, dated [DATE], indicated the resident had a 3.5 by 4 cm (centimeter) slightly curved piece of glass with sharp edges removed that had caused a 2 cm tear the resident's esophagus. Resident 1 was transferred to GACH 2 with physician's recommendation to keep sedated and intubated (breathing with a breathing tube). A review of Resident 1's GACH 2 documentations dated [DATE], indicated the resident had prior suicide attempts on [DATE] and [DATE]. A review of Resident 1's GACH 2 documentation, Admission History and Physical, dated [DATE], indicated, .Patient was at [SNF] .when she was found to have swallowed about 5 handfuls of broken glass from a vase .She had severe pain in her neck and upper chest. Reported to be remorseful for her actions . CT [computerized tomography, machine able to visualize inside the body] showed extensive shards of glass from the proximal esophagus [upper part/near the mouth of the tube connecting the mouth to the stomach] through the colon [large intestine]. She had subcutaneous emphysema [air that's trapped under the skin] near her cricopharynx [in the throat area]. Underwent direct esophagoscopy [scope that goes in the esophagus] . which revealed a 3x4 cm [centimeter] shard of glass which was removed. There was a 2 centimeter tear posterior wall of the esophagus and into the prevertebral fascia [layer of tissue surrounding the spine] as well as a small laceration in the posterior oropharynx [back of the throat directly behind the roof of the mouth] that was thought to be the source of subcutaneous emphysema . She remained intubated [with a breathing tube] for safety. Transferred to [GACH 2] for further care . Found to have glass shards throughout the GI [gastrointestinal] tract .Patient is septic [blood infection] by SIRS [systemic inflammatory response in the presence of a known or suspected source] and GI/oral source . Apparent suicide attempt A review of Resident 1's GACH 2 documentation, Discharge Summary, dated [DATE], .Following admission, the patient was initially cared for in the ICU [intensive care unit] and then transitioned to comfort care. Active hospital problems .Severe sepsis, esophageal perforation [tear], foreign body in digestive tract . Prognosis felt to be guarded to poor [not likely to recover] .She passed away in the hospital on [DATE] at 0758 [7:58 AM] On [DATE] at 2:45 P.M., an observation of the BHU was conducted. The BHU was separated from the rest of the building by double entry doors that alarmed when opened. Approximately, there were 24 residents in the BHU. Some residents were sitting closely at the tables, other residents were walking around the tables in the open space located in front of the nurses' station. Another resident was seated at the table near the entry door and making yelling and screaming sounds. Another resident was heard screaming unintelligibly from down the west hall. Two residents at one of the tables were playing cards. One resident at a table was rocking back and forth. One of the staff was sitting at the resident table and another staff was standing near a table. Two staff were in the nurses' station. On [DATE] at 3 P.M., an interview was conducted with CNA 3. CNA 3 stated she often provided care to Resident 1 and the resident made statements such as, I want to go home and I don't belong here. CNA 3 stated Resident 1 would frequently yell and cuss at the nurses and had a behavior of laying on the floor for attention. CNA 3 stated Resident 1 had told her, I want to kill myself, on three different occasions since admission to the facility. CNA 3 was asked what she had done when the resident verbalized that. CNA 3 stated she kept a closer eye on the resident. CNA 3 stated she began her shift at 2:30 P.M. on [DATE] and had worked a double shift (from 2:30 P.M. on [DATE] to 7 A.M. on [DATE]). CNA 3 stated at the start of the shift, Resident 1 was at the nurses' station yelling and cussing at the nurse. CNA 3 stated Resident 1 went to her room after a while and seemed to calm down. CNA 3 stated sometime around midnight, Resident 1's call light went off and she responded to it. CNA 3 stated that she asked Resident 1 what she needed, and the resident told her to, Get the [expletive] out of here. CNA 3 stated she reminded Resident 1 that she had the call light on, and the resident told her, I'm going to swallow glasses. CNA 3 stated the resident normally spoke with a slightly slurred speech. CNA 3 stated she checked the resident's room and inside the resident's mouth. CNA 3 stated she did not see any glass or broken glass anywhere. CNA 3 stated Resident 1 noticed that she did not find anything and told her, You can't find it. CNA 3 stated she left to get LN 4 and that Resident 1 wanted her to close the door to the room and she closed it. CNA 3 stated, [Resident 1] wants me to slam the door so it closes tight. CNA 3 stated when she located LN 4, they both heard the sound of glass breaking. CNA 3 stated they went to Resident 1's room and the resident was closing her door and pushing her body against the door, and they could not open it. CNA 3 stated when she was able to open the door, Resident 1 was seated in her wheelchair and a broken glass vase on the floor next to the resident. CNA 3 stated the resident was strong enough to move fast and without the need of an assistive device. CNA 3 stated the glass vase had been at the resident's bedside and the resident had kept artificial flowers in it. CNA 3 stated Resident 1 made pushing motions toward her that ushered her out of the resident's room and then the resident closed the door. CNA 3 stated she remained outside Resident 1's closed door and did not open the door because the resident would become upset. CNA 3 stated she remained outside Resident 1's closed door for approximately two minutes while LN 4 called the physician. CNA 3 stated Resident 1 had been alone in her room with broken glass on the floor. CNA 3 stated she was afraid the resident was going to swallow the glass. CNA 3 stated LN 4 returned with the physician on the mobile phone, and LN 4 was able to get the resident's door open enough to pass the phone through the door to the resident. CNA 3 stated Resident 1 said, You're not my [expletive] doctor, and threw the phone into the hallway. CNA 3 stated 911 came and took Resident 1 to the hospital. CNA 3 stated the incident with Resident 1 had been a behavioral emergency. CNA 3 stated the facility did not have a protocol to handle behavioral emergencies and that she had not known what to do during the incident. CNA 3 stated she had needed help with Resident 1 and had not been able to handle the situation alone. CNA 3 stated there should be a process like a code (a systematic, organized emergency response) called so other staff can help in a behavioral emergency. CNA 3 stated she had not received any facility training for residents with SI. CNA 3 stated, I didn't know what to do in that situation. CNA 3 stated the BHU did not feel safe without more training and a system in place to respond to emergencies. CNA 3 further stated the Station 2 used to be a dementia unit (residents with cognitive and memory issues), but It's gotten worse since they mixed psych [mental disorders] with the dementia. CNA 3 stated there was too much screaming in the unit. CNA 3 stated staff received some training about residents who scream, but nothing on SI or psychiatric/behavioral emergencies. On [DATE] at 4 P.M., an interview was conducted with CNA 5. CNA 5 stated Station 2 used to be a dementia unit but recently it turned into a psych unit. CNA 5 stated, Mixing psych [residents] and dementia's [residents] not working. Lots of screaming from psych [residents] that upsets those with dementia. CNA 5 stated staff received in-services from the psychologist about behavior, But we still don't know how to deal with them. CNA 5 stated the staff training was rushed and there were no skills checks or competency evaluation done. CNA 5 stated he would not know how to respond in a behavioral emergency or if a resident had SI or threatened suicide. CNA 5 stated there should be training about SI and behavioral emergencies so everyone knows what to do and could form a coordinated response. CNA 5 stated staff often got hurt on the BHU and that he had been hit, kicked, and scratched by the psychiatric residents. CNA 5 stated, It's been a mess in there [BHU] . and unsafe. CNA 5 stated, We need better training . CNA 5 further stated that he was working the night of Resident 1's incident, but he did not know a behavioral emergency had taken place until the LN asked him to open the door for 911 responders. On [DATE] at 9:15 A.M., the Facility Assessment was requested from the DON. On [DATE] at 9:20 A.M., an interview was conducted with the DON. The DON stated the Facility Assessment was kept in the ADM's office and it would be available upon the ADM's arrival to the facility. On [DATE] at 9:32 A.M., a telephone interview was conducted with LN 4. LN 4 stated she worked regularly on Station 2. LN 4 stated Station 2 used to be a dementia unit but now had a lot of psych residents and were adding Patch residents. LN 4 stated the Patch residents were difficult to manage and frequently screamed and yelled in the unit. LN 4 stated staff were getting hurt because the psych residents tried to fight with the staff. LN 4 stated mixing dementia residents with psych/behavioral residents made the unit chaotic. LN 4 stated she was providing care to Resident 1 during the NOC shift (10:30 P.M. on [DATE] to 7 A.M. on [DATE]) and she had seen Resident 1 around 10:45 P.M., at which the resident seemed calm. LN 4 stated she was unaware of Resident 1 having had any history of SI or making SI statements. LN 4 stated, I would have wanted to know that .I didn't know. LN 4 stated it was important to know a resident had SI to monitor for that. LN 4 stated all staff should have known of Resident 1's SI to keep the resident safe from self-harm. LN 4 stated there had not been any training for providing care to residents with SI and that there should have been training provided. LN 4 stated SI training was needed because any resident could begin to experience SI. LN 4 stated she first became aware of the incident with Resident 1 because the resident came up to the nurses' station and told her, I swallowed glass. LN 4 stated she did not recall CNA 3 informed her that Resident 1 had threatened to swallow glass. LN 4 stated she remembered hearing glass breaking prior to Resident 1 informed her that she had swallowed glass. LN 4 stated that both her and CNA 3 tried to get into Resident 1's room and that the resident had closed the door and place herself against the door. LN 4 stated she left CNA 3 at the resident's closed door and went to call the physician. LN 4 stated CNA 3 tried to get back inside the resident's room while they waited for the physician to return the call. LN 4 stated she brought the mobile phone to Resident 1 and the resident threw it into the hall and said, That's not my [expletive] doctor. LN 4 stated she called 911 and they came right away for the resident. LN 4 stated the incident with Resident 1 was considered a behavioral emergency and had been a suicide threat. LN 4 stated the facility did not have a procedure for behavioral emergencies and that there should be one. LN 4 stated, We needed more help, and could not get inside the resident's room. LN 4 stated if she had known Resident 1 verbalized the threat to swallow glass, she would have had a staff remain inside the resident's room. LN 4 stated the resident should have been placed on 1:1 supervision (one staff to remain with the resident) as soon as the suicide threat was made. LN 4 stated the resident's room would have been thoroughly searched until all dangers were removed. LN 4 stated doing those things could have prevented Resident 1 from swallowing glass. LN 4 stated, Training could have prevented this. LN 4 stated the number of staff on the unit had been enough but that there needed to be an organized, systematic response during a behavioral emergencies and staff who were competent. On [DATE] at 10:10 A.M., the DON provided a copy of the facility assessment titled, Facility Assessment Tool, dated [DATE]. A review of the facility document titled Facility Assessment Tool, dated [DATE], indicated, .Part 1: Our Resident Profile .Psychiatric/Mood Disorders: Depression disorder, anxiety disorder, schizophrenia, PTSD [post-traumatic stress disorder, anxiety and flashbacks triggered by traumatic event], co-occurring disorders, trauma, dementia, bipolar, ADHD [attention-deficit/hyperactivity disorder, characterized by attention difficulty, hyperactivity, and impulsiveness] .During a typical month the facility could provide services to the number of residents noted .Mental Health Behavioral health 15, Substance Abuse 6 .Part 2: Services and Care We Offer Based on our Resident's Needs . Mental health and behavior: Medications as ordered, Counseling services as ordered . Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies . Staff training/education and competencies . All staff receive the required orientation to their position, department and facility emergency procedures with annual review as well. Competencies reviewed annually usually during annual performance reviews The facility assessment did not provide a clear description and assessment for residents with SI potential, the facility's participation in the Patch program, Station 2's designation as a BHU, the acuity of residents and staff needed on the BHU, nor the training and competencies required for staff to provide care to residents with mental and psychosocial disorders, SI, or to respond to a behavioral emergency. On [DATE] at 10:57 A.M., an interview was conducted with LN 7. LN 7 stated she was familiar with Resident 1 and that the resident would scream and had, Lots of suicidal ideation. LN 7 stated Resident 1 would speak negatively about herself and would say things such as certain family members did not like her, she was not worthy of living, and that she would rather die. LN 7 stated Resident 1 often said, I just want to die. LN 7 stated Resident 1's verbalizations of SI were not a change of condition and did not required intervention. LN 7 stated, [Resident 1] was on the psych unit and not everything residents [on the BHU] would say makes sense. LN 7 stated Resident 1's frequency of verbalizing SI was increasing prior to the incident ([DATE]). LN 7 stated it would be a change reportable to the physician if the resident had a plan. LN 7 stated there was currently a resident on the BHU, Resident 2, and he would say that he wants to die, too. LN 7 stated that she had not received training related to providing care to residents with SI. LN 7 stated she thought SI training would be beneficial. LN 7 stated an actual suicide threat was an emergency and it deserved an emergency response like calling a code. LN 7 stated the facility did not have a procedure or code for responding to behavioral emergencies. LN 7 stated training and competency evaluation was important for everyone involved to ensure, We know what to do. On [DATE] at 11:45 A.M., an interview was conducted with the director of staff development (DSD). The DSD stated she was responsible for staff training. The DSD stated there had not been any training provided to staff related to providing care to residents with SI. The DSD stated that there should have been SI training given to staff especially to those that worked in the BHU. The DSD stated corporate did staff trainings about residents with behaviors but that there was no competency evaluation done. The DSD stated for a behavioral emergency such as what took place with Resident 1, a Code Grey (situational emergency response) should have been called. The DSD stated a Code Grey was called for combative residents which also included a resident trying to do self-harm. The DSD stated Code Grey training was mandatory for all staff in the facility, especially before any staff worked on the BHU. The DSD stated she had not done staff knowledge checks or competencies after the Code Grey training was done and should have. The DSD stated what happened to Resident 1, Comes down to a lack of staff knowledge. On [DATE] at 12:20 P.M., a joint interview and record review was conducted with the DSD. The DSD stated she was unsure what training was required to work competently and safely in the BHU. The DSD stated the BHU training automatically came from corporate and that she was not part of any discussion or planning of that staff training. The DSD stated facility staff should have been part of analyzing and planning the BHU training since they were most familiar with the facility and residents' needs. The DSD stated she did not recall working on the facility assessment. On [DATE] at 2:05 P.M., a joint interview and record review was conducted with the DON. The DON stated as soon as Resident 1 threatened to swallow glass, the resident should not have been left alone at any time, should have been placed on 1:1 supervision, and the entire room swept for the removal of all glass objects and any other object that could be used for self-harm. The DON stated if this had been done, it could have prevented Resident 1 from being able to swallow glass. The DON stated a Code Grey should have been implemented immediately and staff should have gained access to the resident's room by any means necessary to separate the resident from broken glass that was on the floor. The DON stated all staff should have been trained on how to deal with residents who have SI and how to respond to a Code Grey in an organized and immediate fashion. The DON stated staff competencies should have been evaluated. The DON further stated the residents housed in the BHU with higher level psychiatric diagnoses and mental disorders required more training for staff. The DON stated both Resident 1 and Resident 2 were admitted with a history of SI on their admission paperwork. The DON reviewed the Facility Assessment Tool dated [DATE] and stated it should have assessed their Patch program and BHU more thoroughly to include the training staff required to be competent to provide care to those residents. The DON stated the facility stopped admitting residents with mental disorders and Patch program as of [DATE] until all staff were trained and competent. The DON stated residents with SI were not identified on the Facility Assessment Tool because, We don't admit those residents [with SI history] here. The DON stated Resident 1 and Resident 2 should not have been admitted to the facility. The DON stated, [We] Shouldn't have admitted residents that we were not fully able to provide care to. On [DATE] at 5:30 P.M., an interview was conducted with the ADM. The DON was also present. The ADM stated he did not know when the facility began admitting Patch residents. The ADM stated he did not understand what the concern was about Patch residents on the BHU. The ADM stated they had the same needs as any other resident on the BHU only the funding was different. The ADM did not provide an answer related to what additional mental health services were being provided to Patch residents or staff training and competencies. On [DATE] at 6:42 P.M., a telephone interview was conducted with the facility's medical director (MDR). The MDR stated he expected staff to be fully trained and knowledgeable in providing care to residents with SI. The MDR stated staff should have been trained and competent to respond in a behavioral emergency. On [DATE] at 11:40 A.M., a joint interview and record review was conducted with the DON. The DON reviewed the Facility Assessment Tool dated [DATE]. The DON, ADM, DSD, and others were listed as Persons (names/titles) involved in completing the assessment. The medical director was not listed. The DON stated she had been part of the discussion the team held when completing the facility assessment. The DON stated the team's discussions of the type of residents the facility admitted , essential training, and staff competencies had not been rigorous enough. On [DATE] at 10:45 A.M., an interview was conducted with the admissions marketer (AM) and admissions coordinator (AC). The AM stated they reviewed resident admissions and determined if a resident was appropriate to be admitted to the facility. The AM stated they would then bring their recommendation to the morning meetings where it was discussed with some members of the interdisciplinary team (facility leadership from different disciplines). The AM stated Resident 1 and Resident 2's history of SI got missed during her admissions review. The AM and AC both stated there was no document that guided admission criteria. At [DATE] at 11:13 A.M., an interview was conducted with CNA 11. CNA 11 stated they had a background working in behavioral health. CNA 11 stated the facility's BHU had residents with dementia and psych diagnoses and that was, Not the best mix. CNA 11 stated when the psych residents yell and make bizarre statements, the residents with dementia do not understand what was happening and become distressed and agitated. CNA 11 stated, The milieu [social environment/open space] is frequently disturbed because the yelling spreads. CNA 11 stated the facility's BHU did not feel well-planned out. CNA 11 stated they noticed an influx of psych residents being placed on the dementia unit when the current ADM started working at the facility sometime last year. CNA 11 stated the staff who had worked on the dementia unit did not know what to do or how to provide care to the new psych residents. CNA 11 stated an in-service was not sufficient and that there needed to be a more in-depth training for taking care of residents with mental disorders and SI. On [DATE] at 2:17 P.M., an interview was conducted with the facility's psychiatrist (physician who specialized in mental disorders), medical doctor (MD) 8. MD 8 stated he saw Resident 1 during an initial visit and the resident had depression, bipolar disorder, and a borderline personality disorder (a disorder with unstable moods, behavior, and relationships). MD 8 stated these diagnoses posed an increased risk of suicide for Resident 1. MD 8 stated residents with mental disorders had an increased suicide risk compared to that of the general population. MD 8 stated residents with prior suicide attempts also ran a higher risk of attempting suicide again. MD 8 stated residents with a history of SI should have their suicide risk assessed and a plan of care in place beginning upon admission. MD 8 stated when Resident 1 verbalized SI, he should have been notified. MD 8 stated when Resident 1's verbalizations of SI increased in frequency, it was a, Definite warning sign that the resident was focusing on SI or beginning to formulate a plan. MD 8 stated when LN 7 noticed Resident 1's SI increasing in frequency, he should have been notified right away. MD 8 stated residents verbalizing SI should always be taken seriously. MD 8 stated he had not been aware that Resident 1 had verbalized SI to staff and that it was something he would have wanted to know. MD 8 stated that he should have been notified. MD 8 stated when Resident 1 made the suicide threat of swallowing glass, the resident should not have been left alone for any length of time. MD 8 stated when the threat was made, other staff should have responded, and the entire room should have been thoroughly searched for glass and other dangers and those hazards should have been removed. MD 8 stated in crisis, staff had to get inside the resident's room even if the resident did not want staff inside the room. MD 8 stated an emergency code response should have occurred when Resident

Based on observation, interview, and record review, the facility failed to protect the dignity of 1 of 1 sampled residents, (Resident A), when two Certified Nursing Assistants videotaped Resident A partially unclothed from her neck to her waist in a shower chair, made fun of the resident's unwillingness to shower, and posted the video on an internet website. In addition, Resident A's family became aware of the incident through a news broadcast. As a result the Resident A who has dementia (dementia describes a group of symptoms which affect memory, thinking and social abilities severe enough to interfere with daily functioning) was unaware she was being mocked, videotaped, and the video was viewed by an undisclosed number of people on a social media website. Findings: On 10/16/15, at 8:15 AM, the Department received a notification from the facility of an incident regarding a resident in the facility who was videotaped nude from the neck to the waist. According to the report the videotape was posted on a social media website where users can post pictures and short videos which will be deleted within 24 hours. On 10/16/15 at 1:07 PM, the Department entered the facility to investigate the incident. On 10/16/15 at 1:10 PM, the Administrator stated she was approached by a television news reporter on 10/15/15 at 5:20 PM. The news reporter produced a picture for the Administrator which showed a Certified Nursing Assistant (CNA) 2, standing next to an elderly lady sitting in a shower chair undressed from the neck down to her waist. The Administrator identified CNA 2 as one of her employees. The Administrator and the Director of Nursing (DON) identified the elderly lady in the picture as one of the residents living in the facility (Resident A). The Administrator stated the television news reporter told her the picture was provided to the television station by an informant who saw the video of the CNAs and the informant took a screen shot (an image taken by a person to record the visible items displayed on a mobile telephone screen) of the video. The Administrator continued to state the screen shot dated 10/9/15, and contained the name of the person who posted the video on the social media website. That individual's name was identified as CNA 1 who was employed at the facility. On 10/16/15 at 1:15 PM, the Administrator acknowledged both CNA 1, CNA 2 and Resident A were identified as the employees and resident of the facility involved in the incident. An observation of the television newscast on 10/16/15 at 11 PM (Channel 10 News San Diego), the news reporter stated an informant notified the television station stating the video posted on the website included the two CNAs mocking and laughing about the patient by stating she was afraid of taking a shower and they were ready to shower the resident. The newscast only presented a blurred picture of an elderly lady in shower chair, with a person standing behind her (later to be identified as CNA 2). According to the news reporters the informant was so shocked by the incident, she reported the incident to the television news station. On 10/16/15 a record review for was conducted. Resident A was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to a According to her latest MDS (Minimum Data Set--(a standardized, primary screening and assessment tool of health status)), dated 8/11/15, Resident A's BIMS (Brief Interview of Mental Status) was scored at 10 out of 15, indicating the resident's cognition (ability to understand and know what is happening) was moderately impaired. A review of the Assignment Sheet -Station 2 dated 10/9/15, both CNA 1 and CNA 2 were listed on duty that day. In addition CNA 2 was assigned shower detail for Station 2. On 10/16/15 at 1:35 PM, CNA 3 stated the staff was not allowed to carry their cell phones on them while on the unit. According to CNA 1, her cell phone was in her car. At 1:40 PM on 10/16/15 CNA 5 stated staff were not allowed to have cell phones on them. CNA 5 stated this was as of today, because when he came to work today, there was a sign by the time clock which stated no staff were to have phones on them while on a nursing unit. On 10/16/15 at 1:55 PM, Resident A was observed and interviewed in her room. Resident A was laying in bed with her covers over her. Resident A could not state the day or month. Resident A was asked if she had been given a shower recently. Resident A adamantly stated, I hate showers. I like a tub bath. On 10/16/15 at 2:03 PM, Licensed Nurse (LN) 3 stated there were no cell phones allowed on the unit as of today. LN 3 stated that prior to today, people had their cell phones with them on the unit. A review of the employee files for both CNA 1 and CNA 2 were conducted on 10/16/15. Both of the employee files contained acknowledgements of Code of Conduct Policy, Resident Rights Policy, Dependent Adults/Elder Abuse Reporting requirements, and dementia training. In addition, both CNAs acknowledged receipt of the facility's Employee Handbook. CNA 1's acknowledgements were signed on 5/12/15, and CNA 2's acknowledgements were signed on 7/31/14 and 8/1/14 respectively. On 10/23/15 at 11:37 AM, Family Member (FM) 1 stated via a telephone interview the Director of Nursing (DON) called her on the 15th at 8:30 PM to inform her of the incident related to her mother being videotaped and the videotape being posted on an social media website. FM 1 stated she went to see Resident A at the facility that evening and as she started watching the news she was shocked about her mother being the person whose video had been posted on the website. At 12 noon on 10/23/15, CNA 2 was interviewed via telephone. CNA 2 acknowledged working on 10/9/15 and being assigned to shower Resident A on that specific day. CNA 2 stated, To be honest, I didn't know what was going on. I didn't know anyone was taking my picture. When asked if she remembered CNA 1 helping her shower Resident A on 10/9/15, CNA 2 stated, I think she was in there with me. CNA 2 again stated, I did not know she was taking video. When asked if she remembered seeing a phone in CNA 1's hand, she stated, Most likely she would have been with her phone. CNA 2 stated she did not carry a cell phone, she kept it in her bag. When asked if she saw other staff with cell phones, CNA 2 stated, Everybody's on their phone all the time. Nobody is supposed to have them. CNA 2 also stated she did not remember anyone being reprimanded for carrying their phones on the unit. On 10/23/15 at 12 noon, CNA 2 was asked if she attended the facility abuse training after being hired and CNA 2 stated she did. CNA 2 stated she watched videos about abuse. CNA 2 stated she signed an acknowledgement about receiving orientation regarding abuse, patient privacy policies, and an Employee Handbook. At 12:15 PM on 10/23/15, CNA 1 was contacted by telephone. CNA 1 stated, I have a lawyer, and she told me not to talk to anyone. You can call her for questions. The Administrator was interviewed on 10/23/15 at 3:35 PM. The Administrator stated she could not remember about staff members being reprimanded for carrying their cell phones on the units. The Administrator stated, We've talked about it in staff meetings . When asked if she knew employees were carrying cell phones with them on the units prior to 10/16/15, she stated, I won't say it was uncommon. A lot of employees carried them in their pockets. When asked if she remembered telling staff they could not have phones on them, the Administrator stated, Honestly, I don't think they were ever told. On 10/23/15, at 3:47 PM, the Director of Staff Development (DSD) stated she did not specifically tell staff they could not take pictures of residents in patient care areas. She stated, I never felt it was necessary for me to tell them you shouldn't photograph a resident. Everyone should know that. During the interview, the DSD stated, I am technically the CNA supervisor. The DSD stated she had not reprimanded anyone for having a cell phone on the unit. The DSD stated, I know everyone has a cell phone. I have told people; use your phone to set your alarm, to remember to clock in. We don't want to see it in your hands. On 10/23/15, at 3:47 PM, the (DSD) stated she was responsible for orientation of all the CNAs in the facility. According to the DSD CNAs were oriented either individually or in a group setting upon hire. The DSD acknowledged all employees signed confidentiality agreement and Exhibit A in the Employee Handbook. The DSD stated, By signing (the employee handbook) they acknowledge they will read and abide by its contents. In addition the DSD stated, Everyone goes through abuse training. The DSD added, We just did annual Abuse Training in June. On 11/6/15 at 11:25 AM, during a phone interview, CNA 9 stated he was assigned to care for Resident A on 10/9/15. CNA 9 stated he was responsible for wheeling Resident A into the shower room on 10/9/15, where CNA 2 was waiting to shower the resident. CNA 9 stated he left Resident A with CNA 2 so he could change the resident's bed linen. CNA 9 stated he never went back to the shower room and saw Resident A out of the shower in her wheelchair after CNA 2 completed her shower. Per the Lifehouse Employee Handbook (California) Revised June 1st, 2011, Resident Privacy The Company strongly protects the privacy of the Community Residents both as a moral and legal matter including compliance with the Health Insurance Portabilty and Accountability Act (HIPAA) of 1996 (P.L. 104-191). This protection extends to: (1) employee presence in the resident's rooms; (2) employee presence during therapy and treatments; and (3), access to resident information included protected information. Also included in resident privacy is freedom from having their photograph image taken without approval. Employees shall not permit photography of residents unless: (1) the photography is approved as a part of an activity approved in this Employee Handbook (i.e. resident identification purposes; inclusion in the resident's medical records, support for Community activities programs, etc; (2) the photography is performed as part of an activity approved in writing by the Executive Director; or (3) photography by the resident's family members and the resident's visitors. In the event that the photography is conducted in association of an approved activity, the employee is taking and/or using the photographs are required to ensure that a release to use the photography is present in the resident's file . Social Media Lifehouse respects the right of employees to express themselves through blogging, Twitter, MySpace, Facebook, etc .Employees may not post on a blog or social media website during work time, or at any time with Company equipment or property, unless specifically authorized by your Executive Director, the Resource Center, Humena Capital and Culture Development, or the Resource Center, IT/IS Department. Cameras and Camera Phones Your Community prohibits the use of personal cameras and personal cellular phones with photographic capabilities in any area of the workplace. Employees should not bring cameras or camera phones to the workplace for any reason. Employees are required to understand and comply with the Resident Privacy section in this Employee Handbook.

Based on observation, interview and record review, the facility failed to ensure staff was adequately trained to use 1 of 3 patient mechanical lift devices, and to ensure the device was safe for use on 25 residents. As result, Resident 1 fell from the device during care, suffering a fracture of the left femoral neck (broken hip). Findings: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A weekly summary, dated 7/31/11, indicated Resident 1 was totally dependent for activities of daily living, except eating. According to facility clinical record, on the morning of 8/4/11 Resident 1 fell from a facility lift device while being transferred by two HCNA's (Hospice Certified Nursing Assistants) from a shower gurney to the residents' bed. On 8/5/11 at 8:15 A.M., during an interview, LN 1 (Licensed Nurse) stated, "(Resident 1) fell from a patient lift yesterday while being transferred to bed by the HCNA's (HCNA 1 and HCNA 2). She was transferred to the acute care hospital emergency department afterwards." At 8:45 A.M., during a joint interview and observation of the sling used on Resident 1, RNA 1 (Rehabilitative Nursing Assistant), Maintenance 1, and the Occupational Therapy Director were unable to identify any damage or deficiency to the sling. The Occupational Therapy Director stated, "The HCNA told me the sling 'snapped' . When the HCNA's called for help, I arrived at Resident 1's room and observed the sling hanging from two of the four straps on the cross bar. I examined the sling immediately with all the parties present (HCNA 1, HCNA 2, LN 1, LN 2) and was unable to find any damage or defect. There were also no indications that the lift failed." RNA 1 stated, "I haven't had any lift training in several years. I don't think I've had any training since we got it (the mechanical lift) several years ago." At 9 A.M., during an interview and record review, LN 1 identified the lift and sling that Resident 1 fell from and stated, "The HCNA's (HCNA 1 and HCNA 2) said the sling 'snapped.' They did not complain of the lift failing." The DON (Director of Nursing) stated, "The HCNA's (HCNA 1 and HCNA 2) come to us trained and certified. The facility does not train them." The facility policy and procedure titled Hoyer Lift Usage indicates the lift was to be inspected for adequacy of function and stability before each use, and was not to be used if unfamiliar with the procedure or if training on use of the lift was not provided. At 10 A.M., RNA 1, RNA 2, and CNA 3 were observed using the lift to transfer a resident. There were no safety latches noted on the cross bar as described in the manufacturers instruction manual. At 10:25 A.M., during an interview, the DON stated, "I'm not sure if the HCNA's received training on the lifts. Hospice is responsible for their training. " At 10:40 A.M., during an interview, HRN 1 (Hospice Registered Nurse) stated, "If we use the facility equipment and are unfamiliar with it we can ask the facility for training or get it from our trainer. I wouldn't use any equipment that I'm not familiar with." At 11:30 A.M., during an observation, interview, and record review at the acute care hospital, Resident 1 was observed in her bed crying out in pain. Resident 1 was alert, but unable to answer any questions. A record review indicated Resident 1 was admitted through the emergency department the morning of 8/4/11. Resident 1 required several doses of intravenous Hydromorphone (a narcotic used to relieve severe pain) and Diazepam (a medication used to relieve muscle spasm). Resident 1's pain was assessed as 10 out of 10 (10 indicating the most severe pain). Records indicated Resident 1 received nineteen doses of intravenous pain medication since admission, the day prior. On 8/16/11 at 11:30 A.M., during a telephone interview, Manufacturer Product Specialist 1 stated, "You wouldn't ever use the lift without the safety latches in place on the sling bar. The sling could become loose from the bar and the resident could fall. Do not remove the safety latches. The product Instruction Guide indicates you should check the function of the safety latches before each use." At 1:45 P.M., during a joint observation of the lift cross bar, where the instruction manual indicated the safety latches belong, the Maintenance Director, Maintenance 1, and DON stated they did not know what belonged in the holes at the end of the cross bar. The Maintenance Director and Maintenance 1 stated they had not made any changes to the device, except to apply a foam pad the entire length of the cross bar. CNA 4 and RNA 1 both stated that the holes at the end of the cross bar were where they usually found safety latches, but they had never seen safety latches on this particular lift cross bar. The Maintenance Director provided a copy of the lift manufacturer Instruction Guide. During a review of the guide with the Maintenance Director, Maintenance 1, and the DON, it was acknowledged the safety latches described in the guide were not present on the lift cross bar. The Maintenance Director, Maintenance 1, and the DON acknowledged that the Instruction Guide called for user inspections of the lift for safety prior to each use, and annual inspections by a manufacturer's representative. The Maintenance Director, Maintenance 1, and the DON stated that the annual inspections had not been done and there were no records to indicate that daily inspections had been done per the manufacturer recommendations. The Maintenance Director, Maintenance 1, and the DON acknowledged that the lift had been operated without the manufacturers recommended safety latches. At 2 P.M., during an interview, CNA 5 and CNA 6 acknowledged that the lift cross bar did not have the safety clips in place and that other lift bars they had used in the past had safety clips to prevent the sling from falling off the cross bar. At 2:15 P.M., during an interview, RNA 1 stated, "We use this lift to weigh all the lift residents in the facility. It's used more often than any other lift. It has been used today, because I was looking for it earlier." The DON indicated that the facility had 25 residents requiring the lift and it was used 1 to 3 times per day on each resident. At 2:20 P.M., during an interview, the Maintenance Director stated, "There are no maintenance records for this lift because there is nothing to maintain." The Maintenance Director acknowledged that the facility had only acquired the manufacturers Instruction Guide "one week ago" and he was "unaware that the lift required annual maintenance." At 3 P.M., during an interview, the DON stated, "Twenty five patients are lifted out of bed with a lift device, 1-3 times per day." On 8/17/11 at 10:45 A.M., during a telephone interview, the Hospice Director of Patient Care 1 stated, " The HCNA's are trained to the general principles of the patient lift and not to each specific model. We did not train HCNA 1 or HCNA 2 to the model lift used to lift Resident 1. The facility did not ask us to train the HCNA's to their model lift. Our training is done on a model that uses two cross bars, not one like the lift at the facility." On 8/19/11 at 9:40 A.M., during an interview, LN 2 stated, "I entered Resident 1's room and saw the resident on the floor and the lift at bedside with two of the four straps hanging from the cross bar. The Occupational Therapy Director came into the room and examined the strap in front of us and found no damage. It was intact. The HCNA, I don't recall which one, said it had just snapped." On 8/19/11 at 2:15 P.M., during an interview, HCNA 1 stated, "The patient had been in the sling for a few minutes, as we moved her close to the bed she stiffened up and I heard the sling snap, and she fell . There was no malfunction in the sling, we looked at it. The lift was fine, also." HCNA 1 acknowledged that she had not received any lift training from the facility and that she had only "saw a training video" from the hospice agency. HCNA 1 stated, "I didn't need any hands on training. I've done it so many times; I've been a CNA for 11 to [AGE] years." HCNA1 further stated, "I think the sling slipped. That lift doesn't' have any safety latches, I don't know if it comes with safety latches." At 3:45 P.M., during an interview, HCNA 2 stated, "We were almost done with the transfer when the resident moved and the sling slipped off the cross bar and she fell . While I was helping to lower her, I think I gave too much support and I think that's when the sling slipped off the bar. We looked at the sling and lift and there was nothing wrong with either of them." HCNA 2 further stated, "I've worked with lifts like that before and they've always had safety latches. The lift we were using that day did not have safety latches." Because of the facility's failure to have systems in place to ensure staff received training prior to operating the mechanical lift, an inspection was conducted to ensure the mechanical lift was safe for use prior to placing a patient in the mechanical lift, and annual safety inspections were conducted by qualified staff, an immediate jeopardy was called on 8/16/11 at 3:40 P.M. with the facility Administrator and the Director of Nursing. The immediate jeopardy was abated on 8/16/11 at 3:55 P.M., after an acceptable plan of correction was presented by the facility Administrator and the Director of Nursing. The plan of correction included: 1. The mechanical lift was removed from the facility. 2. The lift was secured (locked) in the maintenance department. 3. The lift will not be used until the safety latches are properly installed. 4. The maintenance department will contact the manufacturer for yearly safety inspections of the lift.