Every finding on record at Sierra Vista

Based on interview and record review, the facility failed to ensure staff treated residents with dignity and respect when a Certified Nursing Assistant 1 (CNA 1) verbally abused one of three sampled residents (Resident 1) by calling Resident 1 a derogatory term and inappropriately discussed details of Resident 1's personal sex life with fellow staff members. This failure resulted in Resident 1 feeling humiliated, dehumanized, embarrassed and to experience emotional distress.Findings: During a review of Resident 1's admission Record (contains medical and demographic information), the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a serious mental disorder characterized by distortions in thinking, perception, emotions, sense of self and behavior), history of traumatic brain injury (past traumatic brain injury) , and congestive heart failure (a condition in which the heart cannot pump blood effectively enough to meet the body's needs). During a review of Resident 1's Minimum Data Set Assessment (MDS assessment - an electronic medical assessment) dated February 19, 2026, the MDS assessment section C (section for cognitive patterns) indicated Resident 1 had a Brief Interview for Mental Status score (BIMS score - a screening tool used to assess a resident's cognitive status, including memory and orientation) of 15 out of 15 (cognitively intact). During a review of Resident 1's Electronic Health Record (EHR - computer based medical record), a progress note dated March 26, 2026 indicated, On 3/26/26 [March 26, 2026] Resident submitted a grievance stating that on 3/25/26 [March 25, 2026] staff reportedly stated He a damn snitch, he went and got the RN. Per resident; Resident reported I went to go get the RN and she called me a damn snitch because I went and got the RN [registered nurse]. During a review of Resident 1's grievance report titled, Concern/Grievance Form, dated March 25, 2026, the Concern/Grievance Form, indicated, At about 9 PM [9:00 PM] I asked [Name of Licensed Psychiatric Technician 1 [LPT 1 ] for a [medication] prn [prn - medication administered as needed]. He [LPT 1] refused I went and got the RN. As I walked back to the nurses station, [Name of CNA 1] said and [I] quote, He a damn snitch, went and got the RN. During a review of a documented witness interview titled, Witness Interview Record, dated March 26, 2026, signed by Primary Counselor 2 [PC 2], the witness interview record indicated, I [PC 2] was in the activities room around 9:15 PM. I [PC 2] was hearing yelling, I got up and I went and stood by the T [a podium in the hallway]. I heard [name of CNA 1] say, I don't give a fuck. I said what I said. [Name of Resident 1] was walking towards the T and sat at the table. During a review of a documented witness interview titled, Witness Interview Record, dated March 26, 2026, signed by Behavioral Specialist 3 [BS 3], the witness interview record indicated, I [BS 3] heard yelling, I came out the activities room and I heard her say, you ain't nothing but a god damn snitch and I said what I said. He [Resident 1].was standing by the phone and talking to another staff about [Name of CNA 1] telling him stuff about sleeping with another resident and how she [name of another resident] is sleeping with other people. During an interview on May 28, 2026, at 3:15 PM, with BS 3, BS 3's signed, Witness Interview Record, dated and signed March 26, 2026, was read. BS 3 stated the record was her recollection of the incident and stated on March 26, 2026, she came out of the activities room and heard CNA 1 say, You ain't nothing but a god damn snitch and I said what I said, BS 3 stated CNA 1 was talking directly to Resident 1 and they were by the T podium at the end of the hallway. BS 3 stated Resident 1 then complained to her about how CNA 1 was taunting him about [name of another resident] sleeping with other residents. During a review of a documented witness interview titled, Witness Interview Record, dated March 26, 2026, signed by PC 4, the witness interview record indicated, I heard commotion. I heard [name of CNA 1]'s voice when I was coming out of the locker room. I heard her [CNA 1] yelling. I walked up to the T and asked them what was going on. They said [Name of CNA 1] was down the hall cussing [Name of Resident 1] out. I hear [sic] [Name of Resident 1] screaming too. I walked towards [Resident 1] at the activity tables writing a grievance. I asked him what was going on. He told me, I'm tired of [Name of CNA 1] and the way she talks to me and any of the residents. She is very disrespectful and rude and I don't have to take her shit.She was taunting me about [name of another resident] and telling me about how [name of another resident] is sleeping with other residents but she doesn't know what she's talking about. We have an open relationship. During an interview on May 28, 2026, at 3:10 PM, with PC 4, PC 4's signed, Witness Interview Record, dated and signed March 26, 2026, was read. PC 4 stated the record was her recollection of the incident and stated on March 26, 2026, she heard CNA 1 yelling and she asked other staff members by the T what was going on, and other staff members told her [name of CNA 1] was down the hall cursing [name of Resident 1] out. PC 4 further stated she also heard Resident 1 screaming and Resident 1 informed her how disrespectful and rude CNA 1 was and how CNA 1 was telling him about [name of another resident] sleeping with other residents. PC 4 stated Resident 1 was visibly upset, his face was red and he was visibly flustered. PC 4 stated in the past, she had also heard CNA 1 tell other residents they were snitches and other discouraging words. During a review of the facility's investigative summary of the incident titled, Event Summary Report, dated April 1, 2026, the report indicated, Date and time of incident: 3/26/26.Resident [Name of Resident 1].Staff: [Name of CNA 1].Alleged Verbal Abuse.Summary of investigation - Regarding grievance submitted by resident, in which he alleges staff stated He a damn snitch, he went and got the RN, investigation is complete and substantiates resident's account. Facility determined staff violated facility policy. During a review of the facility's policy and procedure (P&P) titled, Abuse Prohibition, dated February 23, 2021, the P&P indicated, Sierra vista prohibits abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents.Federal Definitions: .Verbal abuse - is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability.Mental Abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear, shame, agitation, or degradation.5. Actions to prevent abuse, neglect exploitation, or mistreatment.will include: .5.2. Establishing a safe environment that supports to the extent possible, a patient's consensual sexual relationship.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. The sink in the cook area which food service workers use to get tap water for residents, did not have an air gap (a vertical space between the end of a pipe and the top of a nearby sink that prevents the backflow of contaminated water). 2. The storage shelves in the walk-in refrigerator had a fuzzy white material and grime build-up. 3. Dust was found in several areas in the kitchen and equipment. 4. Chipped off/peeling paint found in janitor room and dry storage room. 5. Two frying pans were found with part of their black interior coating scraped off. 6. Two plastic scraping spatulas were found to have damage on their tips. 7. Five discrete brown dots/ spots grime were observed spread out on the ceiling above the holding cabinet. 8. The ice machine was found to have black substance inside the ice storage bin. 9. The microwave in the break room was found to have a brown substance splattered on the ceiling of the microwave. These failures had the potential risk to cause foodborne illness (stomach illness acquired from ingesting contaminated food) for 116 of 116 sampled residents who received food from the kitchen.Findings: 1. According to the Federal Food and Drug Administration (FDA) 2022 Food Code, A backflow prevention device (air gap) must be installed on the hose [NAME] to prevent the back siphonage of contaminated liquid into the drinking water system during occasional periods of negative pressure in the water line. During an observation on February 23, 2026, at 11:45 AM, Dietary Aide 2 (DA 2) was observed filling a pitcher with water from the sink in the kitchen by the prep counter which did not have an air gap, and then carrying the pitcher to an adjacent prep counter and using it to fill resident drinking glasses. During an interview on February 25, 2026, at 7:23 AM, with the Registered Dietician (RD), and the Certified Dietary Manager (CDM), the two acknowledged the need for the air gap in the sink. The CDM explained if the sink was contaminated with sewage water, when dietary staff put the pitchers in the contaminated sink and filled them water, it has potential risk to cross contamination residents drinking water. 2. During an observation on February 23, 2026, at 12:48 PM, in the walk-in refrigerator, four storage shelves inside were found to have a fuzzy white material and black and brown grime build-up underneath them. Foods like: gallons of milk, breads, [NAME] bell peppers and ground beef were observed stored on the shelves. During an interview on February 25, 2026, at 7:23 AM, with the Registered Dietician (RD), and the Certified Dietary Manager (CDM), the CDM admitted unsanitary kitchen storage shelves. The CDM stated dietary staff are just wiping the surface of storage shelves and not performing the deep cleaning. During a review of the facility's policy and procedure (P&P) titled, Equipment, dated September 2017, the P&P indicated, All foodservice equipment will be clean, sanitary. 3. During an observation on February 23, 2026, at 9:29 AM, in the kitchen, brown debris was observed on the rear guard of the fan blowing into the cleaned kitchenware. During an observation on February 23, 2026, at 9:37 AM, in the kitchen, brown debris was observed on a rack in the back of the kitchen where clean kitchenware is stored. During an observation on February 23, 2026 at 9:56 AM, in the kitchen, brown debris was observed on the half cylinder wall behind the ice machine and also behind the rack stored cleaned kitchenware. During an observation on February 23, 2026, at 9:58 AM, in the kitchen, brown debris was observed on the rack in the cooking area where clean kitchenware is stored. During an observation on February 23, 2026, at 10:01 AM, in the dishwashing room, brown debris was observed on the dishwashing room door frame. In a concurrent interview with the Certified Dietary Manager (CDM) regarding above findings, the CDM referred to the brown debris as dust. During an interview on February 25, 2026, at 7:23 AM, with the Registered Dietician (RD), and the CDM, the RD stated the risk of presence of dust in the kitchen is that it can contaminate the food. During a review of the facility's Policy and Procedure (P&P) titled, Environment, dated September 2017, the P&P indicated, All food preparation areas, food service areas. will be maintained in a clean and sanitary condition, and The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. 4. During a concurrent observation and interview on February 23, 2026, at 8:54 AM, with the Certified Dietary Manager (CDM) in the kitchen, the door to the janitor's closet was observed to have two chips in the wood/ paint at the top of the door. CDM stated, it's not good, it's not a smooth surface, .not able to effectively clean the surface. During an observation on February 23, 2026, at 8:57 AM, in the dry storage room, wall paint was chipped off the wall exposing underlying layers in 4 locations. During an interview on February 25, 2026, at 7:23 AM, with the Registered Dietician (RD), and the CDM, the RD stated, You never know what it's getting into. Contamination one way or another. During a review of the facility's Policy and Procedure (P&P) titled, Safety, dated September 2017, the P&P indicated, The Dining Services Director will ensure that the environment will be maintained in good repair . During a review of the facility's P&P titled, Environment, dated September 2017, the P&P indicated, All food preparation areas, food service areas. will be maintained in a clean and sanitary condition, and The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. 5. During an observation on February 23, 2026, at 9:12 AM, two frying pans on the kitchen storage rack were found with part of their black interior coating scraped off. During an observation on at February 23, 2026, 11:15 AM, [NAME] 1 (CK 1) was observed preheating one of the frying pans with scraped interior coating on the kitchen stove. During an interview on February 25, 2026, at 7:23 AM, with the Registered Dietician (RD) and the Certified Dietary Manager (CDM), the CDM stated in response to the frying pans with the scraped interior coating being used for cooking food for residents It can get in the food. It's going somewhere. During a review of the facility's Policy and Procedure (P&P) titled, Equipment, dated September 2017, the P&P indicated, All foodservice equipment will be clean, sanitary, and in proper working order. During a review of the facility's P&P titled, Food: Preparation, dated September 2017, the P&P indicated, Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. 6. During a concurrent observation and interview on February 23, 2026, at 9:53 AM, with the Certified Dietary Manager (CDM) at the cook area, two plastic scraping spatulas were observed to have damage on their tips which did not have smooth surfaces. One was missing a piece, another had small chips along one edge. The CDM discarded the spatulas. During an interview on February 25, 2026, at 7:23 AM, with the Registered Dietician (RD) and the CDM, the CDM stated, the plastic can get in the food, resident can choke on it. Spatulas that do not have smooth surface area are not able to be cleaned properly, bacteria gets in the cracks. During a review of the facility's Policy and Procedure (P&P) titled, Equipment, dated September 2017, the P&P indicated, All foodservice equipment will be clean, sanitary, and in proper working order. During a review of the facility's P&P titled, Food: Preparation, dated September 2017, the P&P indicated, Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. 7. During an observation on February 23, 2026, at 10:16 AM, five (5) discrete brown dots/ spots grime were observed spread out on the ceiling above the cook area. During an interview on February 25, 2026, at 7:23 AM, with the Registered Dietician (RD) and the Certified Dietary Manager (CDM), the CDM stated, Eventually it's (the brown dots/spots grime) going to fall. It can attract flies, pests. It gets moldy, it gets nasty. During a review of the facility's Policy and Procedure (P&P) titled, Environment, dated September 2017, the P&P indicated, All food preparation areas, food service areas. will be maintained in a clean and sanitary condition, and The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. During a review of the facility's P&P titled, Food: Preparation, dated September 2017, the P&P indicated, Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. 8. During an observation on February 23, 2026, at 10:21 AM, in the kitchen, a white napkin was used to wipe inside of the ice storage bin of the ice machine, and the napkin was pulled out with a black substance on it. During an interview on February 25, 2026, at 7:23 AM, with the Registered Dietician (RD) and the Certified Dietary Manager (CDM), the CDM stated potential risks to be cross contamination of the ice stored in the ice storage bin. During a review of the facility's Policy and Procedure (P&P) titled, Equipment, dated September 2017, the P&P indicated, All foodservice equipment will be clean, sanitary. 9.During an interview on February 24, 2026, at 2:13 PM, with Primary Counselor 1 (COUN 1), COUN 1 stated the microwave in the vending machine room is used to heat residents' outside food. During an observation on February 24, 2026, at 2:18 PM, in the vending machine room, the microwave was observed to have a brown substance splattered on the ceiling of the microwave. During an interview on February 25, 2026, at 7:23 AM, with the Registered Dietician (RD) and the Certified Dietary Manager (CDM), the CDM stated potential risks to be cross contamination. During a review of the facility's Policy and Procedure (P&P) titled, Equipment, dated September 2017, the P&P indicated, All foodservice equipment will be clean, sanitary, and in proper working order. During a review of the facility's P&P titled, Food: Preparation, dated September 2017, the P&P indicated, Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when three dumpsters on the side of facility outside of the hallway that leads to the facility's kitchen were filled beyond the brim with trash, and the lids of all three dumpsters were not closed properly. This failure had the potential to attract pests and rodents and comprise the health and safety of 116 residents who reside in the facility.Findings: During an observation on February 23, 2026, at 7:55 AM, on the side of the facility outside of the hallway that leads to the facility kitchen, all three dumpsters were filled above the brim with trash bags and the lids of the dumpsters were unable to fully close. During a concurrent observation and interview on February 23, 2026, at 8:38 AM with Certified Dietary Manager (CDM) outside by the dumpsters, CDM advised the state of the dumpsters is Horrible. CDM advised the lids are supposed to be able to close (and if they don't) they bring rodents and flies. During a review of the facility's policy and procedure (P&P) titled, Dispose of Garbage and Refuse, dated August 2017, the P&P indicated, All garbage and refuse will be collected and disposed of in a safe and efficient manner.

Based on interview, and record review, the facility failed to respond to and act upon the grievances and recommendations of the Resident Council (a group of residents that acts as a formal body to improve quality of life, discuss concerns, and make recommendations to facility's administrator to improve the quality of daily living and care in the facility) regarding dietary services for seven sampled residents (Residents 12, 34, 45, 55, 60, 88, and 113) when the Resident Council requested to increase the frequency of snacks from once daily to three times daily and provide a greater variety of snacks, including more nutritious options, to address resident hunger; however, the facility failed to provide a written response or implement these requested changes. This failure had the potential to cause unmet nutritional needs, increased feelings of hunger and discomfort, decreased quality of life, and diminished the residents' dignity by not addressing resident voiced concerns regarding dietary services.Findings: A combined Resident Council meeting (separate Resident Council meetings were held on Unit 1 and Unit 2) was conducted on February 24, 2026, from 10:00 AM to 10:35 AM with Residents 12, 34, 45, 55, 60, 88, and 113. Resident 60 identified himself as the Resident Council president for Unit 1, and Resident 45 identified herself as the Resident Council president for Unit 2. Resident 113 was the main spokesperson for the group.Resident 113 stated the facility provided only one nighttime snack per day, which was not enough, and that residents were hungry during the day. The group nodded in agreement and stated they needed more than one snack per day. Resident 113 explained that when residents asked for more snacks, they were told to speak with dietary because dietary staff made those decisions; however, they believed the dietary staff member was contracted with the facility, and residents did not know when that individual was present.Resident 113 asked, Can't we have more than one snack a day that we don't have to purchase with our own money? The group nodded again and murmured agreement. Resident 113 further stated the facility provided snacks were always the same items repeated, and when residents requested a greater variety of snack items, they were again told they would need to speak with dietary, though they did not know how to reach that person.Resident 45 stated she also wanted healthier, more nutritious snacks, such as a small chef's salad or something similar. The group again nodded and murmured agreement. The group collectively agreed they would appreciate receiving a snack between breakfast and lunch, another between lunch and dinner, and a bedtime snack.A review of a sign posted to a window outside the Dietary Supervisor's office indicated Snack List!!! Monday: [NAME] Krispie Treats, Fruit Punch, Tuesday: Cheezits, Ice Water, Fresh Fruit, Wednesday: Scooby Snacks, Fruit Punch, Thursday: Fresh Baked Chocolate Chip Cookies, Ice Water, and Fresh Fruit, Friday: Corn Chips, Fruit Punch, Saturday: . Fresh Fruit, Sunday: Lays Chips, Fruit PunchDuring an interview with the Administrator (Admin) and a Social Services Assistant (SSA) on February 26, 2026, at 9:46 AM, the Admin stated she was the grievance official responsible for ensuring a written response to grievances and requests from the Resident Council meetings within 30 days. The SSA stated she was the individual who took the notes at the meetings and assisted with the follow through on grievances and complaints. The SSA stated she had not heard that the Resident Council members wanted more than one snack per day, but she did tell the residents that if they wanted different snacks, they needed to speak with the dietitian. The SSA stated she did not bring the snack issue to the Admin because she thought the council members needed to bring up the issue with the dietitian directly.The Admin provided teaching to the SSA during the interview, indicating the SSA should have filled out a grievance form for the snack issue and submitted it to her so it could be acted upon. The Admin stated that, regarding the increased number of snacks per day, she believed the regulatory requirement was being fulfilled by the one nighttime snack provided to all residents.The Admin reviewed the facility's policy and procedure titled Snacks, dated September 2017, which indicated, snacks will be provided for all residents. Additional snacks and beverages will be available upon request for all residents who want to eat at non traditional times.The Admin stated she had not been made aware of the request from the Resident Council regarding the facility provided snacks; therefore, no written response was given and no action was taken.During an interview with the Registered Dietitian (RD) on February 26, 2026, at 2:00 PM, the RD stated that the snack list posted outside the Dietary Supervisor's office represented the snacks provided to all residents for their nighttime snack. The RD stated the snacks on the list did not change unless a specific request was made for a change. The RD stated she had not been informed of the Resident Council's request for three snacks a day instead of one, nor that they wanted a variety of snacks with healthier options. The RD stated that if she had known, she would have made the recommendations, but she did not have high confidence that the requests would be honored due to budget cuts and operating on a shoestring budget.A review of the facility's policy and procedure (P&P) titled, Resident Council, dated December 2025, indicated, Policy Statement: The facility supports residents' rights to organize and participate in the resident council. Policy Interpretation and Implementation: 1. The purpose of the resident council is to provide a forum for: . b. discussion of concerns and suggestions for improvement; . 6. The resident council may create its own tool for communicating with the facility regarding input, concerns and suggestions for improvement, or the facility can support the council in creating one . 7. All feedback and requests communicated from the resident council to the facility are addressed in writing to the council. While some requests or concerns may take longer, most responses should occur within 30 days of the facility receiving communication from the council. 9. The quality assurance and performance improvement (QAPI) committee reviews information and feedback from the resident council and addresses any quality issues accordingly.A review of the facility's P&P Snacks, dated September 2017, indicated, snacks will be provided for all residents. Additional snacks and beverages will be available upon request for all residents who want to eat at non traditional times.

Based on observation, interview, and record review, the facility failed to protect residents' privacy and confidentiality by failing to secure personal information from public view for 45 sampled residents (Residents 1 to 45) when a whiteboard containing the full names and room numbers of all residents on Unit 1 was posted in a back room of the nursing station but remained clearly visible to unauthorized individuals and other residents walking in the common hallway. This failure had the potential to cause psychosocial harm by compromising the residents' dignity and their right to exercise control over their personal environment, creating an institutionalized atmosphere that devalues resident individuality and can lead to feelings of embarrassment, vulnerability, and a loss of self-worth.Findings: During an observation and interview on Unit 1 at Nursing Station 1, conducted with a Registered Nurse (RN 1) and the Director of Nursing (DON) on February 25, 2026, from 8:19 AM to 9:23 AM, a door with a nameplate indicating Chart Room was propped open. When walking through the Chart Room, one entered through a second door into the medication storage room. On the upper right wall upon entering the Chart Room a whiteboard was hung listing the first and last names and room numbers of all residents on Unit 1. The board was visible to passersby in the common hallway, where the resident names and room numbers could be read. RN 1 stated the Chart Room door was always propped open because it provided access to the medication storage room, where staff were coming and going all day. RN 1 further stated the Chart Room was not used as a chart room, but rather as a place to store items. RN 1 and the DON stood in the common hallway of Unit 1 at Nursing Station 1 and confirmed that the resident names and room numbers could be read from that location. The DON verified that the residents had a right to their personal privacy and privacy regarding their accommodations (room numbers).A review of the facility's policy and procedure (P&P) titled, Confidentiality of Information and Personal Privacy, dated February 2021, it indicated, Our facility will protect and safeguard resident confidentiality and personal privacy. Policy Interpretation and Implementation: 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. 2. The facility will strive to protect the resident's privacy regarding his/her: a. accommodations; . 4. Access to resident personal and medical records will be limited to authorized staff and business associates.

Based on observation, interview, and record review, the facility failed to provide comprehensive pharmaceutical services by failing to ensure a medication error-free system and by lacking proper accountability, reconciliation, and witness documentation for the disposal of controlled substances, for 71 residents on Unit 2 (Residents 1 to 71) when:1. Resident 4 was administered two times the dose (400 mg-milligrams, a unit of measurement) of clozapine (an atypical antipsychotic medication used to treat schizoaffective disorder-a chronic mental health condition that is essentially a combination of two different types of illnesses: schizophrenia (which affects how a person perceives reality) and a mood disorder (which affects how a person feels), instead of the physician-ordered 200 mg dose. This failure had the potential to cause serious adverse outcomes, including severe respiratory depression, seizures, or significant hypotension, due to the administration of double the prescribed amount of a high-risk medication. 2. Two controlled medications (medications with a high potential for abuse or addiction) were found in individual, unlabeled plastic bags inside a double-locked, controlled medication drawer of a medication cart. Because neither bag was labeled with a resident's name or the medication's name and dose, the medications could not be identified or reconciled (the process of comparing and verifying medication records to ensure accuracy and ensuring every dose of a controlled medication is accounted for). This failure had the potential to cause medication errors, the administration of unknown substances to residents, and the undetected diversion or loss of controlled medications due to the lack of accountability and identification.Findings: 1. A review of Resident 4's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of February 29, 2016. Resident 4 had diagnoses that included schizoaffective disorder ( a chronic mental health condition which causes hallucinations, delusions, depression, mania, and disorganized speech).During a medication administration observation with a Licensed Vocational Nurse (LVN 2) and Resident 4 on February 25, 2026, at 10:40 AM, LVN 2 withdrew a bubble pack of medication (a type of medication packaging where each individual pill is sealed in its own plastic bubble or compartment) from the medication cart. The pharmacy label on the pack indicated: [Resident 4's name] clozapine [ODT-Orally Disintegrating Tablet] 200 mg [milligrams-a unit of measurement] tab [tablets], take [two] tablets by mouth four times daily. [Fill date: February 10, 2026]. Two tablets were noted in each bubble. LVN 2 popped two tablets from the bubble into a pill cup marked with Resident 4's name and room number.During a continued observation on February 25, 2026, at 11:48 AM with LVN 2 and Resident 4, LVN 2 identified Resident 4 by asking him to state his name and room number; Resident 4 did what was asked. LVN 2 then handed Resident 4 the pill cup containing the two 200 mg tablets of clozapine and a glass of water. Resident 4 took the medication and drank the water independently.A review of Resident 4's physician's order dated February 10, 2025, indicated, clozapine Oral Tablet Disintegrating (Clozapine) Give 200 mg by mouth four times a day for Episodes of Paranoid Delusions that people want to touch him related to [schizoaffective disorder].During an interview with a Registered Nurse (RN 1) and LVN 2 on February 25, 2026, at 2:12 PM, RN 1 reviewed the pharmacy label on Resident 4's clozapine bubble pack and Resident 4's physician's order for clozapine dated February 10, 2026. RN 1 confirmed that Resident 4 had received 400 mg of clozapine instead of the 200 mg ordered by the physician. RN 1 noted that the bubble pack had a sticker with red lettering that indicated, Directions changed refer to chart. RN 1 stated that LVN 2 should have gone to Resident 4's chart and reviewed the physician's order before administering the medication. LVN 2 stated she thought each of the tablets in the bubble was 100 mg, not 200 mg. LVN 2 stated she should have followed the instructions on the sticker and reviewed the physician's order before administering the clozapine, but she had not.During an interview with the Administrator (Admin) and the Director of Nursing (DON) on February 26, 2026, at 2:52 PM, the DON stated she had conducted an investigation into Resident 4's medication error. She found that the pharmacy had sent the wrong clozapine bubble pack with an incorrect label that did not reflect Resident 4's physician's order for clozapine. The DON stated the facility had procedures in place with specific medication checks to identify mistakes such as these and hopefully prevent a medication administration error; however, these checks had not been conducted, which led to Resident 4 receiving twice the dose of clozapine he should have.The DON described the checks that should have occurred: when a new medication was delivered by the pharmacy to the medication room, the LVN scheduled at that time was supposed to check the labeling on the bubble pack against the physician's order before placing the medication in the medication cart. The DON stated this check was not done, noting that if it had been, the wrong clozapine bubble pack would not have been available in the medication cart to give to Resident 4.The DON further stated that when the LVN was going to administer a medication, the medication bubble pack label was supposed to be checked against the order in the Medication Administration Record (MAR) before administering it to the resident. The DON stated this check did not happen, noting that if it had, Resident 4 would not have received a double dose of clozapine. The DON stated LVN 2 was required to follow the five rights of medication administration (a safety standard used by healthcare professionals to prevent medication errors): 1. Right Resident, 2. Right Drug, 3. Right Dose, 4. Right Route (the method by which the medication enters the body), and 5. Right Time. The DON stated LVN 2 had violated right number 3: Right Dose. The Admin stated she agreed with the DON's explanation and statement.A review of the facility's policy and procedure (P&P) titled, Medication Errors, dated June 28, 2022, indicated Purpose: To ensure the prompt reporting of errors in the administration of medications and treatments to residents. Policy: . b. Medication Error means the administration of medication: . At the wrong dose . Procedure: . g. The Director of Nursing Services or his/her designee will investigate the error to determine the cause. 2. During a medication storage observation and interview on Unit 2 in Medication Storage room [ROOM NUMBER], conducted with LVN 2 and the DON on February 25, 2026, from 2:19 PM to 2:44 PM, LVN 2 explained the procedure for wasting controlled medications that residents had refused. LVN 2 stated that when a resident refused a controlled medication, the tablet or capsule was placed in a plastic baggy and kept in the double-locked, controlled medication drawer until the DON arrived to waste the medication.LVN 2 retrieved two unmarked plastic baggies from the controlled medication drawer. One bag held a capsule with writing on it that had smeared, rendering it unreadable except for the date of January 24, 2025-over a year ago. The second bag contained a tablet with no attempt made to write anything on the bag. LVN 2 stated the two medications could not be reconciled or wasted properly because the medication, resident, and dose could not be determined.The DON stated that when the LVN notified her that there were controlled medications to waste and destroy, she would bring a specialized container for the medications and then pour water with a chemical powder into the container, rendering the controlled medications unusable and non-retrievable. The DON stated that before she destroys the medication, she performs a controlled medication reconciliation with the LVN to confirm there are no controlled medications unaccounted for; then, she and the LVN sign the medication disposition log to attest to that fact before she destroys the controlled medications.The DON stated the problem with this situation is that she cannot perform the following medication reconciliation steps:1. Count What You Have: Count the actual number of pills currently in the drawer or bottle.2. Check the Records: Look at the logbook or computer records to see how many pills should be there based on what was delivered and what was given to residents.3. Compare the Numbers: See if the number you counted matches the number in the records.4. Find the Difference: If the numbers do not match, you must investigate to find out why.5. Sign Off: Once the numbers match, the DON and LVN sign their names to confirm that everything is correct.The DON stated these steps were not possible because the capsule and tablet in the baggies were unidentified, the dosages were unknown, and the associated residents could not be determined.During an interview with the Pharmacist Consultant (PC) on February 26, 2026, at 11:49 AM, the PC stated that controlled medications refused by a resident should be wasted immediately by two licensed nurses. The controlled medications should not be placed in a non-labeled bag to wait for the DON to waste them. This practice will lead to medication administration errors and possible drug diversion (when legal medications are taken for illegal use).During an interview with the Administrator (Admin) and the DON on February 26, 2026, at 2:52 PM, the Admin and DON stated they agreed with the statement made by the PC. The DON stated that controlled medications refused by residents should be wasted immediately by two licensed nurses.A review of the facility's policy and procedure (P&P) titled, Controlled Medication Storage, dated August 2014, indicated, Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state and other applicable laws and regulations. Procedures: The director of nursing and the consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. A controlled medication accountability record is prepared by the pharmacy or facility for all Schedule II-V medications. The following information is completed:1) Name of resident2) Prescription number3) Name, strength, and dosage form of medication4) Date received5) Quantity received6) Name of person receiving medication supply7) Dispensing pharmacy informationD. At each shift change, a physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medication accountability record. E. Any discrepancy in controlled substance medication counts is reported to the director of nursing immediately. I. The director of nursing in conjunction with consultant pharmacist or designee routinely monitors controlled medication storage, records, and expiration dates during medication storage inspection.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in an organized and safe manner for 45 sampled residents (Residents 1 to 45) when the Unit 1 medication storage room contained injectables, oral over-the-counter medications, liquid medications, tablets, sublingual medications, rectally applied medications, breathing treatments, eye drops and test kits that were intermingled and disorganized. This failure had the potential to cause significant medication errors, as the intermingling of products with different routes of administration increases the risk of nurses selecting and administering the wrong medication to a resident.Findings: During a medication storage observation and interview on Unit 1 at Nursing Station 1, conducted with a Registered Nurse (RN 1) and the Director of Nursing (DON) on February 25, 2026, from 8:19 AM to 9:23 AM, there were three cabinets in the medication room where medications were stored. On the shelves of each cabinet, medications were stored haphazardly; intermingled together on each shelf were injectables, oral over-the-counter medications, liquid medications, tablets, sublingual medications, rectally applied medications, breathing treatments, eye drops, and test kits. There was no apparent order or organization of the medications. RN 1 stated that the over-the-counter medications were in the cabinets, so staff did not have to go downstairs for more when they ran out. The DON reviewed the disarray of the medications in the three cabinets and confirmed that they were not stored appropriately or per the facility's policy and procedure (P&P).During an interview with the Pharmacist Consultant (PC) on February 26, 2026, at 11:49 AM, the PC stated the facility should store medications separated by route (the specific way or path a medicine takes to get into the body), with each route kept together on one shelf or in a specific container or drawer. The PC further stated that medications of different routes should not be intermingled, as it increases the likelihood of making a medication error.During an interview with the Administrator (Admin) and DON on February 26, 2026, at 2:52 PM, the Admin and DON stated they agreed with the statement made by the PC. They further agreed that the medications in the Unit 1, Nursing Station 1 medication room were not stored in accordance with the facility's policy and procedure.A review of the facility's Policy and Procedure (P&P) titled, Storage of Medications, dated January 2025, it indicated, Policy: Medications and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. Procedures: . c. Orally administered medications are kept separate from externally used medications, such as suppositories [a solid piece of medicine that is inserted into a body opening-most often the rectum or the vagina], liquids, and lotions. D. Intravenously [through a vein] administered medications are kept separate from orally administered medications. E. Eye medications are kept separate from ear medications. F. Except for those requiring refrigeration, medications intended for internal use are stored in a medication cart or other designated area. G. Medications labeled for individual residents are stored separately from floor stock medications when not in the medication cart.

Based on interview, and record review, the facility failed to ensure that snacks provided to residents (Residents 1 through 35) met their specific clinical and therapeutic needs for 35 residents receiving controlled carbohydrate diets (a consistent, set amount of carbohydrates at each meal and snack to stabilize blood sugar levels) when the facility failed to follow physician-ordered controlled carbohydrate diets by providing a uniform bedtime snack to the entire resident population without offering therapeutic alternatives. This failure had the potential to cause significant fluctuations in blood sugar levels, specifically acute hyperglycemia (high blood sugar) from excessive carbohydrate intake or nighttime hypoglycemia (low blood sugar) if the provided snack did not meet the resident's specific stabilization needs.Findings: A review of the facility provided Diet Type Report, dated February 23, 2026, indicated Residents 1 to 35 had a current physician's order for a controlled carbohydrate diet.A review of a sign posted to a window outside the Dietary Supervisor's office indicated, Snack List!!! Monday: [NAME] Krispie Treats, Fruit Punch, Tuesday: Cheezits, Ice Water, Fresh Fruit, Wednesday: Scooby Snacks, Fruit Punch, Thursday: Fresh Baked Chocolate Chip Cookies, Ice Water, and Fresh Fruit, Friday: Corn Chips, Fruit Punch, Saturday: . Fresh Fruit, Sunday: Lays Chips, Fruit Punch.During an interview with the Registered Dietitian (RD) on February 26, 2026, at 2 PM, the RD stated that the snack list posted outside the Dietary Supervisor's office represented the snacks provided to all residents for their nighttime snack. The RD stated that the snacks on the list did not change unless a specific request was made for a change. The RD stated there were no established substitutions for the snack items listed, and there were no established snack options for residents with physician-ordered controlled carbohydrate diets. The RD stated she had not provided a therapeutic alternative for residents receiving controlled carbohydrate diets.During an interview with the Administrator (Admin) and Director of Nursing (DON) on February 26, 2026, at 2:39 PM, the DON stated that residents with physician's orders for a controlled carbohydrate diet should have been offered a snack which aligned with the ordered diet. The Admin and DON stated that the facility's policy and procedure titled Snacks, dated September 2017, was not followed.A review of the facility's P&P titled, Snacks, dated September 2017, indicated, Policy Statement: Snacks and beverages will be provided as identified in the individual plans of care. Bedtime [also known as HS] snacks will be provided for all residents. Additional snacks and beverages will be available upon request for all residents who want to eat at non-traditional times. Procedures: 1. The Dining Services department will collaborate with the residents/patients, and nursing and management team to identify necessary beverage and snack items to be provided to each resident/patient. 2. The Dining Services department assembles on a daily basis snack items (food and beverages) for delivery to each resident/patient care area. 3. Snacks will be assembled, labeled, and dated in accordance with the individual plan of care for each resident and those items will be delivered to patient care areas in a timely manner. 4. The Dining Services department will assemble and deliver to each unit the individually planned snack items and bulk snack items to be offered at bedtime. 5. The Dining Services department provides a listing of the current diet orders and snacks for each resident to each care area. 6. Nursing Services is responsible for delivering the individual snacks to the identified residents and for offering evening snacks to all other residents. 7. All snacks will be properly stored for time and temperature control, as appropriate.

Based on observation, interview, and record review, the facility failed to ensure food services employees safely and effectively carried out the functions of food and nutrition services when:1. Cooks did not follow standard of practice Cleaning and sanitizing food contact surfaces by using three separate steps (wash, rinse and sanitize) to clean and sanitize work surfaces.2. Multiple food services employees did not follow manufacturer's guideline time length dipping the test strip into sanitizer (sanitizing solution used for sanitizing food contact surfaces) for testing the concentration of the sanitizer.3. Multiple food services employees did not know the concentration range of sanitizer (a solution used to reduce the number of germs on food contact surfaces to acceptable levels).4. Diet Aide 1 did not know the Dish machine sanitizing concentration.5. [NAME] 2 did not know how to calibrate thermometer. 6. [NAME] 2 unable to demonstrate cooling process for Tuna Salad. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated foods) for 116 out of 116 sampled residents who received foods from the kitchen. Findings: 1. During a review of the facility provided in service document titled, CLEANING AND SANITIZING, undated, the document indicated, PURPOSE: To educate all new hires and current employees on the importance of and proper method for cleaning and sanitizing to ensure safety for all staff and residents. PROPER CLEANING AND SANITIZING Resident safety in a healthcare environment is a top priority. Cleaning and sanitizing properly is one of the most important things we continually do in our kitchens to prevent harm.Cleaning: .To clean a surface .clean with a soapy towel; Rinse with clean cloth; Follow with proper sanitizing .During an interview on February 23, 2026, at 9:54 AM, with [NAME] 1 (CK 1), CK 1 was asked to demonstrate how to clean and sanitize soil food-contact work surfaces. CK 1 stated she cleaned soil food-contact work surfaces with soap and water and then sanitized with sanitizer.During an interview on February 23, 2026, at 12:30 PM, with [NAME] 2 (CK 2), CK 2 was asked to demonstrate how to clean and sanitize soil food-contact work surfaces. CK 2 stated he cleaned soil food-contact work surfaces with soap and water and then sanitized with sanitizer.During an interview on February 25, 2026, at 7:22 AM, with the Certified Dietary Manager (CDM). The CDM stated for standard of practice food service employees should wash the soil work surfaces with soap and water; then rinse away the soap; and the final step was sanitized with sanitizer. The CDM stated the soil food-contact work surfaces could not sanitize effectively by skipping rinse. The CDM explained failure to properly clean and sanitize food-contact work surfaces may result in growth of microorganisms which could cross-contaminate foods.2. During a review of the sanitizer manufacturer's guidelines poster, it indicated, Dip paper [test strip] in sanitizer solution for 10 secondsDuring a review of the facility provided in service document titled, CLEANING AND SANITIZING, undated, the document indicated, PURPOSE: To educate all new hires and current employees on the importance of and proper method for cleaning and sanitizing to ensure safety for all staff and residents.Sanitizing .How to test Sanitizer Solution 1. Remove test strip from container and place in the diluted sanitizer solution for 10 seconds.During an interview on February 23, 2026, at 11:34 AM, with Dietary Aide 1 (DA 1), DA 1 was asked to demonstrate how to check the concentration of sanitizer. DA 1 dipped the test strip into sanitizer for 1 second and then checked the concentration of sanitizer.During an interview on February 23, 2026, at 12:30 PM, with [NAME] 2 (CK 2), CK 2 was asked to demonstrate how to check the concentration of sanitizer. CK 2 stated he needed to dip the test strip into sanitizer for 1 minute.During an interview on February 25, 2026, at 7:22 AM, with the Registered Dietitian (RD) and Certified Dietary Manager (CDM), the RD stated the test strip needed to dip into sanitizer for 10 seconds to check the concentration of sanitizer. The CDM stated not following manufacturer's guidelines length of time dipping test strip could resulted false reading of the sanitizer. The CDM stated false reading concentration of sanitizer could lead to ineffective sanitizing food contact surfaces which may result in lack of removal of inadvertent growth on surfaces of microorganisms which may contaminate food and cause food borne illness.3. A review of the Sanitizer manufacturer's guidelines poster indicated, Testing solution (Sanitizer) should be between 150 - 400 parts per million (ppm - a unit of measurement).During an interview on February 23, 2026, at 11:34 AM, with Dietary Aide 1 (DA 1) in the dishwashing room, DA 1 was asked to demonstrate how to check the concentration of sanitizer. DA 1 stated the sanitizer concentration should be between 200 -500 ppm.During an interview on February 23, 2026, at 12:30 PM, with [NAME] 2 (CK 2), CK 2 was asked to demonstrate how to check the concentration of sanitizer. CK 2 stated the sanitizer concentration should be between 400 -500 ppm.During an interview on February 25, 2026, at 7:22 AM, with the Certified Dietary Manager (CDM), the CDM stated 150 - 400 ppm was the concentration of sanitizer per manufacturer's guidelines. The CDM stated food service workers should follow manufacturer guidelines. The CDM stated sanitizer with 500 ppm was too concentrate.During a review of the facility provided in service document titled, CLEANING AND SANITIZING, undated, the document indicated, PURPOSE: To educate all new hires and current employees on the importance of and proper method for cleaning and sanitizing to ensure safety for all staff and residents.Sanitizing .Sanitizer solution should be tested for correct PPM .Consult manufacturer's directions for proper dilution rate for the chemical in sue at your facility. How to test Sanitizer Solution. Follow manufacturer guidelines for correct dilution/PPM for the chemical in use at your facility .4. During an interview on February 25, 2026, at 11:34 AM, with Dietary Aide 1 (DA 1) in the dish washing room, DA 1 was asked to demonstrate how to check the Dish machine sanitizing concentration. DA 1 dipped the test strip into Dish machine sanitizing solution. The test strip indicated at 100 ppm. DA 1 stated the sanitizer concentration should be between 100 -200 ppm.During an interview on February 25, 2026, at 7:22 AM, with the Registered Dietitian (RD) and Certified Dietary Manager (CDM), the RD stated according to manufacturer guidelines dish machine sanitizing concentration should be 50 -100 ppm. The CDM stated sanitizing concentration between 100 -200 ppm was too strong. The CDM stated using too strong concentration sanitizing solution could result the cleaned kitchenware had strong chlorine odor.During a review of the facility provided document titled, Dish Machine log, undated, the log indicated, Manufacturer Recommended PPM: 50 -100.5. During an interview on February 23, 2026, at 12:30 PM, with [NAME] 2 (CK 2) in cook area, CK 2 was asked to demonstrate how to calibrate thermometer. CK 2 inserted thermometer into a cup of ice water. When the thermometer reached 32 degrees Fahrenheit ( F - a unit of measurement). CK 2 stated he needed to calibrate thermometer at 40 F.During an interview on February 25, 2026, at 7:22 AM, with the Registered Dietician (RD). The RD stated the cooks should calibrate the thermometer at 32 F. The RD stated failure to calibrate thermometers may result in inaccurate reading thermometers.During a review of the facility provided in service education document titled, TIME AND TEMPERATURE CONTROL AND RECORDING, undated, the document indicated, PURPOSE: To educate all new hires and current employees on the importance of and guidelines for time and temperature control and recording procedures.Thermometers The first step in avoiding temperature abuse is to maintain a properly calibrated thermometer.Calibrate and testing Using Ice-Point Method: .if the temperature is at 32 F, .It is now ready for use.6. Potentially Hazardous Foods (PHFs) are those capable of supporting bacterial growth associated with foodborne illness PHFs. PHFs shall be cooled within four hours to 41 F or less if prepared from ingredients at ambient temperature, such as reconstituted FOODs and canned tuna. (Food Code, 2025).During an interview on February 23, 2026, at 12:30 PM, with [NAME] 2 (CK 2) in cook area, CK 2 was asked to demonstrate cooling process for making Tuna Salad. CK 2 unable demonstrated despite the Certified Dietary Manager (CDM) providing him with a copy of the cooling log.During an interview on February 25, 2026, at 7:22 AM, with the Registered Dietician (RD). The RD stated CK 2 should know the cooling process for making Tuna Salad. The RD stated the potential risk for CK 2 did not know the cooling process making Tuna Salad was foodborne illness outbreak.

Based on observation, interview, and record review, the facility failed to ensure the Controlled Carbohydrate Diet (a meal plan for diabetic residents) lunch dessert was provided for 34 of 34 sampled residents who are on a Controlled Carbohydrate Diet (CC) when the 34 sampled residents received a regular dessert for lunch on February 23, 2026. This failure had the potential to negatively impact the residents' nutritional status and further compromising residents' medical status.Findings: During an observation on February 23, 2026, at 11:04 AM in the kitchen, Dietary Aide 3 (DA 3) was observed preparing dessert for the lunch service for the residents. DA 3 used a spatula to slice two of two sheet pans of cake into even portions. DA 3 then applied frosting to all slices of cake on both sheet pans and used a spatula to separate each cake slice portion and distribute them onto dessert plates. No additional or differing size chocolate cakes were prepared for lunch. During an observation on February 23, 2026, at 12:01 PM in the dining room, all residents, including residents who were on CC Diet were observed being served the same size chocolate cake with frosting as regular diet residents. During a concurrent interview and record review on February 23, 2026, at 12:30 PM with the Certified Dietary Manager (CDM), the therapeutic spreadsheet (the document used to guide dietary staff on food items, portions, and therapeutic diet) on February 23, 2026 was reviewed. The therapeutic spreadsheet indicated, Residents on CC diet were to receive a 1/2 portion of chocolate cake, plain (without frosting) for lunch. The CDM admitted DA 3 did not prepare CC dessert and CC diet Residents being served regular dessert. During an interview on February 25, 2026, at 7:23 AM with the RD, and the CDM, both of them stated food service employees should follow the spreadsheet when preparing and serving food. The RD stated in response to risks of giving CC residents regular dessert portion, Blood sugar can spike, because they get more carbohydrates. During a review of facility's Policy and Procedure (P&P) titled, Menus, dated September 2017, the P&P indicated, Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. During a review of facility provided diet definition titled, Controlled-Carbohydrate Diet, dated February 2025, the definition indicated, The controlled-carbohydrate diet incorporates the (menu company) regular menu with consistent amounts of carbohydrate meals and snacks. In this diet, priority is given to the total amount of carbohydrate consumed at each meal and snack rather than to the specific source of carbohydrate. Portion sizes on this menu must be followed.

Based on observations, interviews, and record reviews, the facility failed to maintain a sanitary and orderly medication storage room for 45 residents (Residents 1 through 45) when:1. A tub containing various used personal care products-some labeled with resident names and others unlabeled-was stored in a cabinet alongside resident medications.2. A bag of discontinued prescription topical medications awaiting disposal was stored on the bottom shelf of a medication cabinet next to discarded items, disinfectant spray, and trash. This failure had the potential to cause cross-contamination and the transmission of infectious agents for 45 residents who reside in Unit 1 of the facility.Findings: 1. During a medication storage observation and interview on Unit 1 at Nursing Station 1, conducted with a Registered Nurse 1 (RN 1) and the Director of Nursing (DON) on February 25, 2026, from 8:19 AM to 9:23 AM, there were three cabinets in the medication room where medications were stored. In the third cabinet on the third shelf, a tub of personal care products was stored (10 different colognes, one electric razor, and one disposable razor).RN 1 stated that residents at the facility were not allowed to keep breakable objects, such as glass, or sharp objects, such as razors, in their rooms. Therefore, when residents wanted these items, they would come to the nursing station to request them, and a staff person would assist and monitor them to keep the residents safe. RN 1 acknowledged that not all items were labeled with a resident's name, causing a risk of giving an item to the wrong resident and increasing the risk of transmitting an infection. RN 1 further acknowledged that the personal care products were stored with the medications, increasing the risk for cross-contamination. Upon reviewing the storage of these items, the DON noted that the majority of the personal care products were unlabeled. The DON stated that all personal care products should have been labeled with the resident's name and should not have been stored with medications in the medication room.During an interview with the Pharmacist Consultant (PC) on February 26, 2026, at 11:49 AM, the PC stated that non-medication-related items were not to be stored in a medication room with resident medications. The PC stated that a medication room was strictly for medication storage.During an interview with the Administrator (Admin) and the DON on February 26, 2026, at 2:52 PM, the Admin and DON stated they agreed with the PC's statement. The DON agreed that not all personal care items had been labeled with a resident's name, creating a risk of giving an item to the wrong resident and increasing the risk of transmitting an infection. The DON further agreed that personal care products should not be stored with medications, as it increased the risk for cross-contamination.2. During a medication storage observation and interview on Unit 1 at Nursing Station 1, conducted with RN 1 and the DON on February 25, 2026, from 8:19 AM to 9:23 AM, there were three cabinets in the medication room where medications were stored. In the third cabinet on the fourth shelf, a bag of discontinued prescription topical medications awaiting disposal was stored on top of and next to discarded items, disinfectant spray, and trash. RN 1 acknowledged that this storage practice did not provide a sanitary environment for storing medications. The DON stated that discontinued medications should not be stored alongside discarded items, trash, or disinfectant spray.During an interview with the PC on February 26, 2026, at 11:49 AM, the PC stated that the facility should store medications awaiting disposal in an area dedicated solely to that purpose. The PC stated it was not appropriate to store prescription medications (whether discontinued or not) on top of discarded items, trash and next to a disinfectant chemical spray. The PC stated this creates an unnecessary risk for cross-contamination and was not an appropriate way to handle and separate waste from clinical items.During an interview with the Admin and DON on February 26, 2026, at 2:52 PM, the Admin and DON stated they agreed with the statement made by the PC. They further agreed that storing discontinued medications on top of discarded items, trash and next to a disinfectant chemical spray in the Unit 1 medication room was not acceptable.A review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated January 2025, indicated, Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations of those of the supplier. Procedures: . F. Except for those requiring refrigeration, medications intended for internal use are stored in a medication cart or other designated area. H. Potentially harmful substances such as . household poisons, cleaning supplies; disinfectants are clearly identified and stored in a locked area separately from medications. M. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, . N. Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures. O. Medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified.A review of the facility's P&P titled, Infection Prevention and Control Program, dated September 18, 2024, indicated, Purpose: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on observation, interview, and record review, the facility failed to ensure the proper maintenance of essential equipment when: 1. The handwashing sink did not consistently maintained water temperatures in accordance with the standard of practice. This failure had the potential for inadequate water temperature which may result in ineffective handwashing putting residents at risk for food borne illness. 2. The Veggie reach-in freezer had ice condensation buildup. This failure had the potential to cause poor quality of food served to a population of 116 out of 116 sample residents who received food from the kitchen. Findings: 1. During a review of FDA (Food and Drug Administration) Food Code 2025, Section 5-202.12., the FDA Food Code indicated, A handwashing sink shall be equipped to provide water at a temperature of at least 85 degrees Fahrenheit ( F - a unit of measurement) through a mixing valve or combination faucet. An inadequate flow or temperature of water may lead to poor handwashing practices by food employees. A mixing valve or combination faucet is needed to provide properly tempered water for handwashing. The International Plumbing Code (IPC) states that tempered water is having a temperature range between 85 F and 110 F. During an observation on February 23, 2026, at 8:50 AM, in the kitchen at the handwashing sink near dietary office, the surveyor turned on hot water to wash her hands. The water in the handwashing sink was cold. Surveyor let the water ran for approximate1 minute and checked the water with thermometer which indicated 63 F. An additional follow up observation on February 23, 2026 at 8:55 AM, revealed the water was too hot. Surveyor checked the water with thermometer which indicated 114 F. In a concurrent interview with the Certified Dietary Manager (CDM), the CDM stated handwashing water temperature supposed to be at least 85 degrees F. to 110 degrees F. During an interview on February 25, 2026, at 7:22 AM, with the Registered Dietitian (RD) and CDM. The CDM stated according to standard of practice and Food Code, handwashing temperature should be at least 85 F to 110 F. The RD explained if handwashing temperature too hot, it would be scalding food service employees. And if too cold, lower than 85 F, it may result in ineffective handwashing. 2. During a concurrent observation and interview on February 23, 2026, at 9:20 AM, with the Certified Dietary Manager (CDM), in the kitchen. inside the Veggie reach-in freezer had ice condensation buildup on the ceiling. The CDM stated the reach-in freezer not supposed to have ice condensation buildup on the ceiling. During an interview on February 25, 2026, at 7:22 AM, with the Registered Dietician (RD) and CDM. The RD stated it was an early sign of malfunction freezer with the ice condensation buildup. The RD stated malfunction freezer could affect the quality of foods stored in the freezer. During a review of the facility's policy and procedure (P&P) titled, Equipment, revised dated 9/2017, the P&P indicated, All foodservice equipment will be .in proper working order. Procedures: 1. All equipment will be routinely . maintained .

Based on observation, interview, and record review, the facility failed to ensure two of two resident's communal shower rooms (blue and green shower rooms) located on unit 1 were maintained in good repair and in a safe and sanitary condition, when the blue and green shower rooms were both observed to have cracked and stained tile surfaces. This failure had the potential to expose all 45 residents on unit 1 who utilize these shared showers to potential harm, contamination and transmission of healthcare-associated infections.Findings:During a concurrent observation and interview on February 25, 2026, at 9:01 AM with Infection Preventionist (IP), in the green and blue shower rooms, it was observed multiple cracked and stained tiles. The IP stated, I see there are multiple cracked and stained tiles within both shower rooms. The IP further stated, shower surfaces should be intact and cleanable to prevent infection control issues.During a concurrent observation and interview on February 25, 2026, at 9:42 AM with Maintenance Supervisor (MS), in the green and blue shower rooms, it was observed multiple cracked and stained tiles. MS, confirmed, the two showers have multiple cracked and stained tiles. He stated, I wasn't aware of the cracked and stained tiles but has been trying to get a remold for both shower rooms. He further stated, cracked tile surfaces doesn't meet the standards for a safe and sanitary environment.During a concurrent observation and interview on February 25, 2026, at 9:50 AM with Administrator, in the green and Blue shower rooms, Administrator verified both shower rooms have multiple cracked and stained tiles. The Administrator further stated, These two showers are old and need a remodel without a tile surface. During a concurrent interview and record review on February 25, at 11:20 AM, with Administrator, the facility's Policy and Procedure (P&P) titled, Maintenance Service undated, was reviewed. The P&P indicated, 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.2b. maintaining the building in good repair and free from hazard. The Administrator stated the facility did not follow the P&P.

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans (an individualized plan based on assessment that identifies needs, sets goals, and outlines interventions for the medical care of a resident) for two of 35 sampled residents (Resident 14 and 34) when:1. For Resident 14, who had a documented history of falls, the facility did not create a fall risk care plan to address fall risk factors, individualized interventions, and preventive strategies.2. For Resident 34, who was identified as a smoker, the facility did not create a care plan that addressed smoking supervision, safety precautions, and risk mitigation. These failures had the potential to place Residents 14 and 34 at risk for injury, burns, fire hazards, and recurrent falls with injury.Findings: 1. During a review of Resident 14's admission Record (contains medical and demographic information), the admission Record, indicated, Resident 14 was admitted to the facility on [DATE], and had diagnoses which included schizophrenia (a mental disorder marked by disturbances in thinking, perception, and behavior, often including hallucinations, delusions, and impaired functioning), unspecified convulsions (episodes of involuntary muscle contractions or seizure-like activity that are not further defined or classified as a specific seizure disorder), and hypo-osmolality and hyponatremia (a condition where the sodium level in the blood is too low, causing the blood to become too diluted. This can lead to neurological symptoms like confusion, headaches, seizures, or changes in alertness.) During a concurrent observation and interview on February 23, 2026, at 12:22 PM, with Resident 14, Resident 14 was sitting on the edge of his bed and stated he had fallen in the facility but he could not remember when it occurred. During a review of Resident 14's Electronic Health Record (EHR), a progress note dated November 11, 2025, indicated, .resident had what appeared to be seizure activity while watching television with other residents in the rec [recreation] room. The seizing lasted about 2 min [minutes].staff worked quickly to assist him to the floor to prevent falls. During a review of Resident 14's EHR, a progress note dated November 13, 2025, indicated, At approx. [approximately] 0700 [7:00 AM] Resident tripped on his foot, fell on right knee when walking in hallway. During a review of Resident 14's EHR, a progress note dated November 14, 2025, indicated, .while on a community smoke break, resident had moved to an area that was not well lit while walking with peers. According to reports from peers, resident collapsed convulsing in what appeared to be a seizure. Peers alerted staff to the resident falling and staff called emergency services.resident was found on the ground convulsing and unresponsive to staff. During a review of Resident 14's EHR, a progress note dated November 18, 2025, indicated, .staff had heard the resident make a grunting noise and went to investigate. Resident was found by staff laying on the floor in front of roommate's bed, face down.it is unknown how the resident got onto the floor.staff was unable to wake resident. Resident soon sat up and was visibly disoriented.resident began to regain consciousness but then began having a seizure lasting approx. [approximately] 3 minutes. During a review of Resident 14's EHR, a progress note dated November 20, 2025, indicated, IDT [interdisciplinary team] discussed resident on 11/20/25 d/t [due to] seizures resulting in falls.no complications d/t fall resident currently on Q15 monitoring [monitoring every 15 minutes]. Resident had medication adjustment for low sodium and seizures. During a review of Resident 14's HER, a progress note dated January 15, 2026, indicated, .resident had a witnessed fall without injury. During a review of Resident 14's EHR, there was no active care plan for falls or risk for falls. During a concurrent interview and record review on February 25, 2026, at 7:36 AM, with the Director of Nursing (DON), the DON stated Resident 14 had a history of seizures with falls and the resident should have a care plan for fall risk or fall history. The DON reviewed Resident 14's care plans and stated she was unable to find an active care plan for falls or fall risk and that she needed to create one for him. During a review of the facility's policy and procedure (P&P) titled, Fall Management, dated May 26, 2021, the P&P indicated, Purpose – To reduce risk for falls and minimize the actual occurrence of falls.Policy – Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury.Procedure – 1. Identify patient's fall risk by reviewing the Nursing Documentation. 2. Communicate patients fall risk status to caregivers. 3. Develop individualized plan of care. During a review of the facility's P&P titled, Care Plan Comprehensive, dated August 25, 2021, the P&P indicated, Purpose – an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident. Policy – the facility's interdisciplinary team, in coordination with the resident and/or his/her family or representative, must develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a residents medical, physical, and mental and psychosocial needs. 2. A review of Resident 34's admission Record, (contains demographic and medical information), indicated Resident 34 was admitted to the facility on July18, 2025, with diagnoses which included, Schizoaffective disorder bipolar type ( a chronic mental health condition that combines symptoms of schizophrenia (hallucinations, delusions) with severe mood swings of bipolar disorder (high mania, depression), and Vitamin D deficiency (not enough vitamin D in the body). During a review of Resident's 34 Minimum Data Set ([MDS] a standardized, core set of essential information collected to evaluate a person's health, needs, and capabilities) Section J dated July 24, 2025, indicated Resident 34 currently uses tobacco. During a record review of Resident 34's Smoking Evaluation (health assessment that looks at a person's smoking habits, their physical addiction to nicotine, and their health risks) dated January 20, 2026, indicated Resident 34 doesn't require special equipment during smoking and resident is independent for smoking. The facility's policy and procedure (P&P) require supervision during smoking. During a record review of Residents 34's comprehensive care plan dated January 12, 2026, indicated, there was no care plan to address Resident 34 smoking assessment, measurable goals, or individualized interventions to safely manage the residents smoking. During an interview on February 25, 2025, at 8:31 AM, with the Director of Nursing (DON), the DON stated Resident 34 didn't not have a care plan for smoking but should to address his smoking needs and safety. During a concurrent interview and record review on February 25, 2026, at 8:50 AM with DON, the facility's Policy and Procedure (P&P) titled, Smoking, dated August 9, 2022, was reviewed. The P&P indicated, .I. Purpose: To provide a safe environment for resident, staff and visitors.III.Procedures: IDT will develop an individual plan for safe storage, use of smoking materials, assistance and required supervision, if necessary, for residents who smoke. This is documented on the resident's smoking evaluation, the residents plan of care and discussed with the resident and responsible party at the resident care conference meeting. DON stated the facility did not follow the policy.

Based on observation, interview, and record review, the facility failed to ensure nursing staff followed physician's orders for one of five sampled residents (Resident 19) investigated for nutrition, when the facility did not have documented weights of Resident 19 in the frequency as ordered by the physician. This failure resulted in Resident 19 not being monitored as ordered by the physician for changes in weight and placed the resident at risk for undetected significant weight loss or gain.Findings: During a review of Resident 19's admission Record (contains medical and demographic information), the admission Record, indicated Resident 19 was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia (a mental disorder characterized by intense paranoia, delusions, and auditory hallucinations), and vitamin D deficiency.During an interview on February 24, 2026, at 8:45 AM, with Resident 19, Resident 19 stated he had lost 60 pounds since he was admitted to the facility.During a review of Resident 19's care plan titled, Resident is at nutritional risk: overwt [overweight].wt loss planned; is desired w/o [without] sig [significant] changes.goal.gradual wt loss toward long term 166# [166 pounds] wt loss goal. interventions in the care plan included, Weekly weights for monitoring progress to assess for no more than loss of 2% per week or loss of 5% per month.weigh as ordered.During a review of Resident 19's physician's orders, an order dated February 24, 2025, indicated, Weigh weekly x 4 [for four weeks] post admission, then monthly.During a review of Resident 19's Electronic Health Record (EHR), Resident 19 did not have documentation of weights recorded by staff weekly as ordered by the physician. Weights were recorded as follows: 240 pounds (lbs) February 25, 2025, 238 lbs. March 4, 2025, but then there was no other weights recorded until March 28, 2025, at 236 lbs. There was no weights for the week of March 9, 2025, and March 16, 2025.During a concurrent observation, interview, and record review on February 25, 2026, at 2:20 PM, with the Director of Nursing (DON), the DON reviewed Resident 19's EHR and stated staff was supposed to weight the resident weekly for four weeks starting February 24, 2025, and then monthly as ordered by the physician but it was not done. The DON stated the resident did not have weights recorded in his medical record for the weeks of March 9, 2025, or March 16, 2025. The DON further stated the individual who was responsible for weighing and documenting resident weights was no longer at the facility and used to document weights on a paper chart sometimes. The DON then found the paper chart she was referring to and upon review it was blank for the weeks of March 9, 2025, and March 16, 2025, where Resident 19's name was indicated. The DON stated Resident 19 was not weighed weekly for four weeks as ordered by the physician.During a review of Resident 19's Minimum Data Set Assessment (MDS assessment - a federally mandated, standardized evaluation of a residents functional skills, medical conditions, cognitive and psychosocial status, which is used to guide care planning and quality monitoring) the MDS assessment indicated Resident 19 had significant weight loss and was not on a prescribed weight loss program.During a review of the facility's policy and procedure (P&P) titled, Weight Management, dated August 25, 2021, the P&P indicated, Purpose - To obtain baseline weight and identify significant weight change.Policy - Each individual's weight will be obtained and documented upon admission to the facility.Procedure.2. In nursing facilities, weights will be obtained weekly for 4 weeks after admission. Subsequent weights will be obtained monthly unless physician's orders or an individual's condition warrants more frequent weight measurements.4. Staff will follow acceptable procedure to obtain accurate weights.

Based on observation, interview, and record review, the facility failed to ensure resident's rights to be free from physical restraint (a manual method, physical or mechanical device or material that restricts the resident's freedom of movement or normal access to his/her body), for one of one resident (Resident 1), were followed when a Certified Nursing Assistant (CNA 1) placed his arm over Resident 1's shoulders, restricting his movement, on June 8, 2025. This failure had the potential for Resident 1to be at risk for physical and psychological harm (the unpleasant emotional or psychological symptoms that individuals experience when they feel overwhelmed, impacting their quality of life). Findings: During a review of Resident 1's admission Record (clinical record with demographic information), the admission Record indicated, Resident 1 was admitted to the facility on [NAME] 3, 2025, with diagnoses which included schizophrenia unspecified (a chronic mental illness characterized by significant disturbances in thought, perception, emotion, and behavior), and functional dyspepsia (a condition characterized by persistent or recurring pain or discomfort in the upper abdomen). During a concurrent observation and interview, on June 26, 2025, at 3:20PM, with Resident 1, in his room sitting on bed. Resident 1 stated, on June 8, 2024, at approximately 6:10 PM, he was in the room (an area in which residents are typically not permitted without supervision that had a vending machine). During a concurrent observation and interview, on June 26, 2025, at 3:35 PM, with the Administrator (Admin), in the hallway, there was a small room with open door next to a bathroom, inside the room, there was a vending machine and microwave. The admin stated that it was the room where the incident took place. The admin further stated Resident 1 was inside the room, unsupervised. CNA 1 then entered the room and asked him to leave but Resident 1 repeatedly calling him Fagette and refuse to leave the room. Resident 1 became agitated, and CNA 1 puts his hands over Resident 1's shoulder, to escort him out the room. During a review of Resident 1's Nurses Progress Notes, dated June 8, 2025, at 6:41 PM, the Nurses Progress Notes indicated, Documenting staff was on lunch break and saw [name of Resident 1] using the vending machine unsupervised. Document staff was asking [name of Resident 1] what he was doing. While trying to answer, another staff member [CNA 1] came and began to say that he's seen [name of Resident 1] do this before. [name of Resident 1] and the other staff member [CNA 1] started engaging in a verbal altercation. During the verbal altercation, 2 additional staff members came to help de-escalate the situation. The staff member [CNA 1] that [name of Resident 1] was arguing with pushed him [Resident 1] against the wall and held his arm there. They were separated and [name of Resident 1] returned to his visit and was given a grievance form to fill out. During a review of the facility's document titled, Event Summary Report, dated June 13, 2025, the Event Summary Report, indicated, . The identified Staff initiated capture of Resident by taking hold of Resident and holding him to the wall against which Resident was already standing . investigators determined Resident's [Resident 1] behavior did not pose an imminent danger and, therefore, capture was not indicated. The identified staff's actions were not consistent with facility policy regarding criteria for restrictive behavioral intervention . During a concurrent interview and record review on June 26, 2025, at 3:50 PM with the Admin, the facility's policy and procedure (P&P) titled, STP305-CA Restrictive Behavioral Interventions (RBI): Philosophy of Care, dated November 01, 2017, was reviewed. The P&P indicated, . Prior to the use of physical and /or psychopharmacological restraints: .Will only be used as emergency measures to protect the resident from injury to self or to others . Containment means a brief physical restraint of a person for the purpose of effectively gaining quick control of a person who is aggressive or agitated, or is a danger to self or others . The Admin stated CNA1 did not follow the procedure. The Admin further stated, Resident 1 was not a danger to himself, or others and CNA 1 should not have used its arm to restrain Resident 1, even though it was with good intention. Admin stated, it did not need to be escalated to that.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food safety when: 1. A toaster was stored in the dry storage, and it had an accumulation of food residue. 2. On the floor under the industrial mixer, there was black grime, food crumbs, and paint splashes. 3. The shelf under the cook's preparation area that was storing clean pans had crusted food and debris. 4. In the Unit 2 kitchen area where food is served to the residents, the refrigerator door handle had crusted food and smudges. Under the steam table, there was a storage compartment that had black grime and food debris. These failures had the potential to result in accumulating pathogenic microorganisms (germs or infectious agents that can cause disease) and to attract insects or rodents. Findings: 1. During a concurrent observation and interview on December 9, 2024, at 8:10 AM, in the kitchen's dry storage room, an unused toaster with crusted debris and crumbs was observed on a shelf rack. The Dietary Supervisor (DS) stated that the toaster works but is not currently in function. The DS further stated the unused toaster should not have been stored in the dry storage room and will be removed and cleaned. During an interview on December 11, 2024, at 8:15 AM, with the Registered Dietician (RD), the RD stated the expectation for the kitchen is to be cleaned, with no presence of grime or crusted food. During a review of the FDA Federal Food Code, dated 2022, section 6-601.11, titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, indicated, Equipment food-contact surfaces and utensils shall be clean to sight and touch .The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations .Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The FDA Food Code, Section 4-601.11, further indicated, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 2. During a concurrent observation and interview on December 9, 2024, at 8:18 AM, in the kitchen, paint splashes, crumbs, and black grime were observed on the floor behind underneath the industrial mixer. The DS stated that the kitchen was recently painted, but there should not be any paint on the floor. The DS further stated that the kitchen is deep-cleaned every Thursday, but it was not done the week prior. During an interview on December 11, 2024, at 8:15 AM, with the Registered Dietician, the RD stated that the expectation is for the kitchen to be cleaned weekly, with no presence of paint splashes, crumbs, and black grime. During a concurrent and record review on December 11, 2024, at 10:20 AM with the Facility Administrator, the facility's policy and procedure (P&P) titled, Environment, revised September 2017 was reviewed. The P&P indicated, All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition .Ensure the kitchen is maintained in a clean, sanitary manner, including floors, walls. ceiling, lighting, and ventilation. The facility administrator stated the facility staff should have followed the P&P. 3. During an observation on December 9, 2024, at 8:25 AM, in the kitchen, crusted food and stains were observed on the metal pans and trays underneath the cook's prep table. The DS stated the pans and trays were cleaned by the cooks every day. The DS further stated it should have been cleaned. During a concurrent and record review on December 11, 2024, at 10:20 AM with the Facility Administrator, the facility's policy and procedure (P&P) titled, Environment, revised September 2017 was reviewed. The P&P indicated, All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition .Ensure the kitchen is maintained in a clean, sanitary manner, including floors, walls. ceiling, lighting, and ventilation. The facility administrator stated the facility staff should have followed the P&P. 4. During an observation on December 9, 2024, at 9:03 AM, in unit 2's kitchenette, the refrigerator handle had sticky residue. The compartment underneath the steam table had black residue and debris. The DS stated that it was not acceptable, and both had to be cleaned. During a concurrent and record review on December 11, 2024, at 10:20 AM with the Facility Administrator, the facility's policy and procedure (P&P) titled, Environment, revised September 2017 was reviewed. The P&P indicated, All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition .Ensure the kitchen is maintained in a clean, sanitary manner, including floors, walls. ceiling, lighting, and ventilation. The facility administrator stated the facility staff should have followed the P&P. During a review of the FDA Federal Food Code, dated 2022, section 6-601.11, titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, indicated, Equipment food-contact surfaces and utensils shall be clean to sight and touch .The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations .Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The FDA Food Code, Section 4-601.11, further indicated, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted.

Based on observation, interview, and record review, the facility failed to ensure medications were administered according to the facility's policies and procedures (P&P) for two of 71 residents (Resident 22 and 85) when: 1. For Resident 22, 11 tablets of Clozapine (medication used to treat severely ill patients with serious mental illness that have difficulty distinguishing what is real and what is not) 50 mg (milligrams- unit of measurement) were found with an expiration date of August 9, 2024 (expired 124 days) and were available for resident use when stored in Unit 2's medication cart (Cart 2). 2. For Resident 85, five tablets of Vitamin B6 (a vitamin used to treat movement disorder) 100 mg were found with an expiration date of December 3, 2024 (expired 8 days) and were available for resident use when stored in Unit 2's medication cart (Cart 1). These failures had the potential for the medications to lose their potency over time, making them less effective and to adversely affect the health and safety of Residents 22 and 85. Findings: 1. During a review of Resident 22's clinical records, the Admission Record (contains demographic and medical information) indicated, Resident 22 was admitted to the facility on [DATE], with diagnoses of paranoid schizophrenia (mental illness characterized by significant disruptions in thought processes, perceptions, emotions, and social interactions with false beliefs or sensory experiences that are not real), insomnia (difficulty falling or staying asleep), and hyperlipidemia (high concentration of fats in the blood). During a review of Resident 22's physician order, dated May 25, 2023, the physician order indicated, Resident 22 had an order for Clozapine 50 mg by mouth three times a day for Disrobing in Public related to PARANOID SCHIZOPHRENIA). During a concurrent observation and interview on December 11, 2024, at 7:55 AM, with the Registered Nurse (RN 1). The RN 1 opened the contents of medication cart 2 and found a bubble pack (a card that packages doses of medication within small plastic bubbles) containing Resident 22's tablets of Clozapine 50mg. The RN 1 stated the label on the bubble pack indicated an expiration date of August 9, 2024 (expired 124 days). The RN 1 counted the contents of the bubble pack and stated there were 11 remaining tablets. During a concurrent interview and record review on December 11, 2024, at 9:11 AM with the Director of Nursing (DON), the facility's P&P titled, Medication storage in the facility, dated April 2008 was reviewed. The P&P indicated, .Outdated .medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed or according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. The DON stated the policy was not followed and further stated there should be no expired medication stored in the medication cart. 2. During a review of Resident 85's clinical record, the Admission Record, indicated, Resident 85 was admitted to the facility on [DATE], with diagnoses of schizophrenia, neutropenia (a abnormally low number of white blood cells that fights infection), and astigmatism (eye condition where the lens on the eye has an irregular curvature) During a review of Resident 85's physician's order dated February 27, 2023, the physician order indicated, Resident 85 had an order for Vitamin B6 100 MG tablets. During concurrent observation and interview on December 11, 2024, at 8:10 AM, with a Licensed Vocational Nurse (LVN 1), LVN 1 opened the contents of medication cart 1 and found a bubble pack containing Resident 85's tablets of Vitamin B6 100 mg. LVN 1 stated the label on the bubble pack indicated an expiration date of December 3, 2024 (expired 8 days). LVN 1 counted the contents of the bubble pack and stated there were five remaining tablets. During an concurrent interview and record review on December 11, 2024, at 9:14 AM with the DON, the facility's P&P titled, Disposal of medications and medication-related supplies, effective date December 2018, which indicated If a medication expires .[medication] shall be marked or otherwise identified and shall be stored in a separate location designated solely for this purpose .and destroyed in accordance with the Medication Destruction policy. The DON stated the policy was not followed and further stated there should be no expired medications stored in the medication cart. During a telephone interview on December 11, 2024, at 11:03 AM, with the facility's Pharmacy Consultant (PC), the PC stated non-controlled expired medications should not be left in medication carts and be removed to disposal area, so it does not get mixed up with non-expired medications and be given to residents.

Based on observation, interview, and record review, the facility failed to ensure secure storage of medications when one of two medication rooms (Unit 2's medication room) and two of three medication carts (Medication Cart 1 and 2 in Unit 2's medication room - carts used by licensed nurses and Psych technicians [PT] to hold medications for all residents) were found unlocked and unattended by a licensed nurse and PT. This failure had the potential for medications to be accessed and dispersed by an unauthorized person, in a vulnerable population of 71 residents. Findings: During an observation on December 10, 2024, at 4:40 PM, PT 1 was inside Unit 2's medication room, using medication cart 1 and 2. Psych Tech left the nurses station and went across the hall to a locked closet to assist a resident. PT 1 left Unit 2's medication room, medication cart 1, and medication cart 2 unlocked and unattended. During a concurrent observation and interview on December 10, 2024, at 4:45 PM, with PT 1, PT 1 walked towards the opened Unit 2's medication room door and went inside. When PT 1 was asked about the opened medication room and unattended unlocked carts, he stated, If the medication room door is locked, cart 1 and cart 2 does not have to be locked. Oh but I see now that the medication room door was not closed all the way and the carts are not locked. PT1 then went to medication cart 1 and medication cart 2 and proceeded to lock them. PT 1 further stated it should have been locked when unattended to prevent unauthorized people from opening the cart. During a concurrent interview and record review, on December 10,2024, at 4:49 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier., dated, April 2008. was reviewed. The P&P indicated, .Medication cart is locked at all times unless in use and under the direct observations of the medication nurse . The DON stated the policy was not followed and further stated the medication carts were expected to be kept locked when unattended because someone who was not authorized can take the medications away from the cart.

Based on observation, interview, record review, the facility failed to prepare food in a form designed to meet the need of one resident (Resident 28) when Resident 28's lunch on Monday, December 9, 2024, had visible chunks of food. This failure had the potential to result in Resident 28 choking during the meal. Findings: During an observation on December 9, 2024, at 12:24 AM, in Unit 2's dining room, Resident 28's tray consisted of chicken potpie and carrots with notable lumps present. Resident 28's diet ticket stated dysphagia puree. (food texture that is smooth). During an interview on December 10, 2024, at 11:40 AM with the Dietary Supervisor (DS), in the kitchen, the DS stated that Resident 28's diet order is dysphagia puree. The DS further stated the meal should have had a smooth texture with no lumps. During an interview on December 11, 2024, at 8:15 AM with the Registered Dietician, the RD stated that Resident 28's diet order is dysphagia puree and that the order should have been followed. The RD further stated the expectation for a dysphagia puree diet is to have no lumps and to be smooth like pudding. During a review of the Physician Orders for Resident 28, the ordered diet stated Resident 28 is to have a consistent carbohydrate (CCD) diet; dysphagia puree texture, pureed meats with gravy/sauce. During a review of the Nutritional Assessment, dated November 11, 2024, the nutritional assessment indicated the dysphagia puree diet for Resident 28 was appropriate for chewing ease and swallowing safety due to Resident 28's seven missing teeth. During a concurrent interview and record review on December 11, 2024, at 10:20 AM with the Facility Administrator, the facility's policy and procedure (P&P) titled, Menu, revised September 2017 was reviewed. The P&P indicated, Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. The facility administrator stated the facility staff should have followed the P&P.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was supervised appropriately to prevent elopement from the facility. This failure resulted in placing the resident at risk for harm and endangerment in the community and not meeting the needs of the resident. Findings: A report was received from the facility of Resident 1's elopement on (MONTH) 17, (YEAR). The alleged event indicated that while conducting at 1000 hour (10:00 AM) rounds on (MONTH) 17, (YEAR), Certified Nurse Assistant (CNA) was not able to account for Resident 1's whereabouts. Resident 1 presumed to have eloped after a search was done from the interior, exterior, grounds of the facility, and community. A review of Resident's 1 admission record indicated, his original admitted was (MONTH) 20, (YEAR) and was readmitted at the facility on (MONTH) 18, (YEAR). Resident 1 returned to the facility accompanied by the resident's mother from elopement status. A visit was conducted at the facility on (MONTH) 19, (YEAR) at 9:15 AM. A meeting was held on (MONTH) 19, (YEAR) at 9:15 AM with the Quality Assurance (QA) Nurse and informed her of the reason for the visit as an abbreviated survey. During a concurrent interview with the QA nurse, she stated Resident 1 was brought back to facility by the resident's mother on the eve of (MONTH) 18, (YEAR). She further stated that Resident 1 was readmitted to the facility on (MONTH) 18, (YEAR). During an interview and a concurrent observation with Resident 1 on (MONTH) 19, (YEAR) at 9:20 AM, he stated that he left facility without permission from the staff on (MONTH) 17, (YEAR). He stated that he jumped over the fence from the basketball yard. He then showed the area where he went over the fence to leave the facility. He further stated that he was able to go over the fence at the corner of the courtyard and the staff did not know about it. He stated he was the last resident to go out to the courtyard that morning during the exercise activity and did not go back inside. He stated, I did not tell anybody I was leaving. I did not eat breakfast that day and no medication either. I have a lot of energy. I was walking around the patio during morning workout. No staff saw me leaving. I do not want to be here (facility). During a concurrent interview with Resident 1, he was observed to have a superficial laceration in his left palm and right forefinger. Resident 1 stated that he obtained the laceration from the wire by the fence when he went over the fence of the facility. During a concurrent interview with Resident 1, he stated that he took the bus on (MONTH) 17, (YEAR) and dropped off at (name of county) then walked around overnight. Resident 1 further stated he took another bus in the morning of (MONTH) 18, (YEAR) and went to his mother's house. He stated that his mother took him back to the facility in the afternoon on (MONTH) 18, (YEAR). During an interview with a Primary Counselor (PC 1) on (MONTH) 19, (YEAR) at 10:00 AM, she stated she was assigned at the courtyard on (MONTH) 17, (YEAR) with another PC to supervise the group exercise beginning 8:30 AM to about 8:50 AM. She stated that she and the other PC were in the courtyard including two CNAs. She said, I was giving out the card to the resident who attended the exercise to give the number of points for attending from the start to the end of exercise time. If any resident came late and did not participate actively then the resident will not get credit for attendance. She stated she did not see Resident 1 go over the fence. She stated there were two CNAs assigned at the courtyard, one CNA by the door to open and let resident go out to the yard and one CNA at the left corner of the courtyard from the entrance door. During an interview with CNA 1, on (MONTH) 19, (YEAR) at 10:15 AM, he stated that he was assigned to the courtyard at the corner away from the fence. He stated that he saw the two PC's sitting on the bench across the yard supervising the activity but was not on any two corners by the fence areas. He stated that his responsibility was to ensure residents don't get close to the entrance door, prevent resident altercation, and arguments. CNA 1 stated, The count for resident attendees were left up to the program counselors, because the program staff gave points to the residents. The residents were allowed to go into the courtyard even if it was in the middle of activity. CNA 1 further stated, The elopement could have been prevented if program staff were not sitting on the bench and rather standing at the gate area of the fence. During an interview with the Administrator (ADMIN), on (MONTH) 19, (YEAR) at 11:10 AM, she stated the resident had a history of [REDACTED]. She further stated that resident's mother stated that Resident 1 had previous elopement from other places. During a record review with the QA nurse of Resident Supervision Rounds and Area Safety/Security Rounds log, it indicated that Resident 1 section was coded as RA (means in Room Awake) on (MONTH) 17, (YEAR) at 8:00 AM and 9:00 AM rounds and at 10:00 AM round coded as E (means off grounds without approval). A review of Resident 1's Nursing Assessment record under section f 9 was checked off and indicated, verbalizing/history of a desire to leave/exit seeking. The nursing assessment record was signed and completed on (MONTH) 21, (YEAR) by a registered nurse. A review of Resident 1's care plan initiated on (MONTH) 21, (YEAR) and revised on (MONTH) 10, (YEAR), indicated under focus area section, At risk for elopement related to: has made one or more attempts to leave the facility during this stay or previous stays in this or other facilities. The interventions indicated, encourage resident/patient participation in activity preferences and encourage resident to participate in community reintegration focus groups. During an interview with the ADMIN on (MONTH) 19, (YEAR) at 11:30 AM, she stated that the care plan has no other interventions except to encourage resident to participate in the program activities. She further stated that there was no monitoring of whereabouts of resident except during CNA hourly check assignment indicated in the log titled, Resident Supervision Rounds and Area Safety/Security rounds. The ADMIN further stated, There was no specific intervention unless resident had demonstrated signs of wanting to leave or elope. Just engaged in activity is part of intervention. During an interview with the Director of Nursing, on (MONTH) 19, (YEAR) at 11:50 AM, she stated that there was no specific assignment for staff at each corner of the courtyard. The staff in the courtyard were to supervise the residents during community break (smoking time) and activity time. During an interview via phone with PC 2 on (MONTH) 19, (YEAR) at 12:10 PM, she stated that she was scheduled at the courtyard and assigned to observed the residents during the exercise activity between 8:30 AM to 8:45 AM. She stated that she was sitting on the bench with another PC during that time. She mentioned that Resident 1 was at the courtyard during the exercise activity period. She further stated that there was no attendance list of all residents at the courtyard. The PC 2 stated that she did not know of Resident 1's history of elopement from other facilities. A review of the facility policy and procedure titled, Elopement of Patient, revised 5/15/14 indicated, Policy: Patient will be evaluated for elopement risk upon admission, re-admission, quarterly and with a change in condition as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions and reduce risk and minimize injury. A review of the facility policy Guidelines for Levels of Supervision, revised 3/21/18 indicated, General Supervision. 3. CNA staff on every shift are responsible for visual checks and documentation of resident location every hour to ensure that all residents are in the facility, or accounted for if offsite. 4. Staff assigned to hallway or courtyard supervision are responsible for redirecting any resident who attempts to elope or leave without permission. The staff members alerts other staff so they can intervene to keep the resident safe. An IJ (Immediate Jeopardy - a crisis situation in which the health and safety of individuals are at risk) was identified and called on (MONTH) 19, (YEAR) at 3:15 PM in the presence of the Administrator (ADMIN) and Director of Nursing (DON) due to the lack of supervision and monitoring for Resident 1 resulting in elopement. During an interview with Resident 2, on (MONTH) 20, (YEAR) at 9:55 AM, he stated that he was at the courtyard on (MONTH) 17, (YEAR) during the exercise time. He further stated he was close to the fence and walking while other residents were exercising. He stated he observed a resident (Resident 1) going over the fence and already on top of the big fence at corner of the courtyard. He stated that he reported to the staff (PC 1) that a resident jumped over the fence, staff got up to check but the resident was not there anymore. The facility submitted an acceptable corrective action plan on (MONTH) 20, (YEAR). Observation, resident interviews, staff interviews, and record review were conducted to ensure the corrective action plan was implemented. The facility's corrective action plan included resident elopement risk assessment, development of care plan, monitoring guidelines for resident identified with elopement risk, in-serviced staff on elopement monitoring guidelines to prevent resident from elopement during community break and activity outside at the courtyard with staff supervision, utilizing the electronic of 24 hour communication report, following Elopement of Patient Policy standards and installation of additional mesh wire at the fence corner from which resident eloped, blocking access from the top of the gate to the wire cage. The IJ was lifted on (MONTH) 21, (YEAR) at 12:45 PM in the presence of ADMIN and DON.

Based on observation, interview, and record review, the facility failed to provide a safe environment which was free from abuse for four out of four sampled residents (Residents 1, 2, 3, and 4) when: 1. For Resident 1, she reported she had sex with the Maintenance Staff 1 (MS 1) on (MONTH) 7, (YEAR) in exchange for an [MEDICATION NAME] (stimulant). 2. For Resident 2, she reported to staff that she had a sexual encounter with MS1. 3. For Resident 3, she reported she was sexually harassed by MS 1. 4. For Resident 4, she reported she had multiple sexual encounters with MS 1. This failure resulted in Residents 1, 2, 3 and 4, being subjected to sexual abuse. Findings: 1. A review of Resident 1's clinical record indicated that she was admitted on (MONTH) 7, (YEAR), with a [DIAGNOSES REDACTED]. During an interview with Resident 1 on (MONTH) 11, (YEAR) at 2:35 PM, she stated that she had sex with a male employee (stating the name of MS 1) on (MONTH) 7, (YEAR). She identified the male perpetrator as the maintenance man. She further stated that MS 1 gave her speed pills. She stated that the incident happened on (MONTH) 7, (YEAR) at 10:30 AM and 2:00 PM, and MS 1 used his cell phone and took a picture of part of her body. She stated the incident happened in the storage area room by the end of the hallway near to where her room is located. She described the storage room as having boxes with names. Resident 1 further stated that the police came to the facility and took the report and asked her if she wanted MS 1 to be arrested, and she said Yes. During the interview, Resident 1 was observed calm, with good eye contact, fidgety at times while sitting down in a chair. When Resident 1 was asked how she was feeling, she stated that she was feeling safe not seeing MS 1, but if he comes back, she will be scared. During an interview with Licensed Vocational Nurse 1 (LVN 1) on (MONTH) 11, (YEAR) at 2:45 PM, she stated that the storage room Resident 1 was describing is the medical record storage area, in the same hallway where Resident 1's room is located. She stated the room is locked but the staff who have a key to the room included the Maintenance Staff, Administrator, Medical Record Staff, and the Director of Nursing. During an interview with the Program Director (PD) on (MONTH) 11, (YEAR) at 3:00 PM, he stated during his interview with Resident 1 to follow up an incident, Resident 1 disclosed that she had sex with MS 1 in exchange for speed pills on (MONTH) 7, (YEAR). The PD stated that Resident 1 described what the staff was wearing that day, mentioned MS 1's name, and described older one who does painting. Resident 1 stated the sexual encounter happened twice, and Resident 1 was offered pills to perform sexual activity. During the process of interviewing Resident 1, she mentioned that another female peer (Resident 2) had the same sexual encounter with the same male staff member. During an interview with the Administrator (ADM) on (MONTH) 11, (YEAR) at 4:30 PM, she stated that the male employee reported by the resident was working on (MONTH) 7, (YEAR). The ADM stated MS 1 was suspended on (MONTH) 10, (YEAR) at 5:48 PM. 2. A review of Resident 2's clinical record indicated she was admitted on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. During an interview with Resident 2 on (MONTH) 11, (YEAR) at 2:20 PM, she stated that the male staff (MS 1) had been making sexual advances and she had sexual activity with him in her room. She stated it happened a week ago from (MONTH) 11, (YEAR) after lunch. Resident 2 described the male staff as the one who paints wall, repairs hole in the wall. Resident 2 stated, I feel safe if he (stated MS 1's name) will be physically harmless and will not bother me again. She further stated if she did not do the sexual activity, MS 1 will not forgive her for not being with him. 3. A review of Resident 3's clinical record indicated she was admitted on (MONTH) 5, (YEAR) with a [DIAGNOSES REDACTED]. During an interview with Resident 3 on (MONTH) 16, (YEAR) at 4:30 PM, she stated that male staff (MS 1) was sexually harassing her. She described the male staff as dark skinned, tall, working with MS 2 and working in construction. She stated that a month ago, during the day time, MS 1 came to her room and got on the bed with her. She stated the male staff grabbed part of her body, made fun of her because she is short. She stated that if nobody was around, MS 1 bothered her. She stated she felt comfortable without the male staff (stated name of MS 1) around the facility. 4. A review of Resident 4's clinical record indicated that she was admitted on (MONTH) 10, (YEAR) with a [DIAGNOSES REDACTED]. During an interview with Resident 4 on (MONTH) 16, 2019 at 4:55 PM, she stated that she was bothered by MS 1 and said he worked as janitor. Resident 4 stated that she had sex with (used MS 1's name). She stated MS 1 was bothering her by chasing her. A review of the ADM's notes dated (MONTH) 13, (YEAR) indicated, Resident 4 was interviewed by the QA (quality assurance) Nurse related to investigation of sexual abuse involving a staff and peer. The QA nurse reported to ADM that Resident 4 admitted to having sex with the staff (MS 1) who offered her things in exchange for sex. Resident 4 then provided details of multiple alleged sexual encounters. A review of the facility policy and procedure titled, Abuse Prohibitions, revised (MONTH) 1, (YEAR) indicated, Policy: Will prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. Definition of Sexual Abuse: is a non- consensual sexual contact of any type with a resident. It includes but is not limited to sexual harassment.

Based on interview and record review, the facility failed to ensure one of 23 sampled residents (Resident 20), received the necessary medications as prescribed by the resident's attending physician/psychiatrist in a timely manner. As a result of this failure, Resident 20 experienced an increase in psychotic behaviors as evidenced by restlessness, irritability, and talking to himself out loud. Findings: A review of Resident 20's face sheet indicated Resident 20 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 20's physician's orders [REDACTED]. in AM and 2 mg at bedtime" was prescribed by the attending physician/psychiatrist. A review of Resident 20's interdisciplinary progress notes indicated as follows: 1. On December 17, 2014 at 9:00 PM, Resident 20 was admitted to the facility without any distress. 2. On December 18, 2014 at 5:30 AM, Resident 20 was observed "...walking in the hallway, talking with peers and staffs..." and Resident 20 "denied c/o (complaint of) pain or discomfort..., no signs of acute distress." 3. On December 18, 2014 at 1:03 PM, Resident 20 "(showed) no behavior issues, no s/s (signs and symptoms) of distress, getting along well with peers and staff." 4. On December 18, 2014 at 9:25 PM, Resident 20 was "calm (and) cooperative with staffs and other residents." 5. On December 19, 2014 at 2:35 AM, Resident 20's attending physician/psychiatrist was contacted because the resident "did not have his psychotic medications during AM and PM shift on 12/18/14" and Resident 20 started to display "psychotic bx (behaviors) aeb (as evidenced by) being restlessness, irritability, talking to himself and loud." The record indicated the attending physician responded to the call and ordered [MEDICATION NAME] (medication used to treat depression) and [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]) to be administered right away. 6. On December 19, 2014 at 5:45 AM, Resident 20 was resting in bed and no longer having "signs of acute distress observed at this time." A review of Resident 20's Medication Administration Record [REDACTED]. It was over 24 hours after the medications were initially prescribed by the attending physician. During an interview with LVN 1, on January 8, 2015, at 11:05 AM, she was asked when are new medications expected to be delivered to the facility, she stated for new medications or newly admitted residents, the facility would receive the medications on the same date or the next morning if ordered after midnight. During a phone interview with a representative for the facility's pharmacy, on January 8, 2015, at 3:05 PM, the representative stated [MEDICATION NAME] and [MEDICATION NAME] medications for Resident 20 were delivered to the facility on [DATE] at 1:00 AM. During an interview with Resident 20, on January 8, 2015, at 3:20 PM, he stated he did not receive the medications on December 17, 2014 (the day of his admission) and the following day. During an interview and record review with the Director of Nursing (DON) and the Administrator, on January 8, 2015, at 3:45 PM, the DON confirmed the first time [MEDICATION NAME] and Rispderal were administered to Resident 20 was on December 19, 2014 at 2:35 AM. The DON and the Administrator were unable to provide documentation of physician notification on the availability of [MEDICATION NAME] and [MEDICATION NAME] and the missed dosage administration. The administrator stated she did not know how the scheduled administration of [MEDICATION NAME] and [MEDICATION NAME] was missed and why the physician was not informed when the doses were missed. A review of Resident 20's clinical record titled "Change of condition documentation" dated December 18, 2014 at 10:30 PM, indicated: "PM shift charge nurse did not call or follow up with the pharmacy. Medications ([MEDICATION NAME] and [MEDICATION NAME]) (were) scheduled to be given twice a day (AM and PM). Orders were faxed on (December 17, 2014)." A review of Resident 20's interdisciplinary nursing plan dated December 18, 2014, indicated under plans/interventions, "nursing staff lic (licensed) to give routine and PRN (as needed) medications ([MEDICATION NAME] and [MEDICATION NAME]) as ordered by physician." A review of the facility's policy and procedures titled "1.0 Providing pharmacy products and services" revised January 7, 2013, indicated: ...3. The pharmacy will provide new routine and PRN (as needed) medication orders the same day, unless the medication would not be started until the next day. A review of the facility's policy and procedures titled "7.0 Medication shortages/Unavailable medications" revised January 1, 2013, indicated: ...8. When a missed dose is unavoidable, Facility nurse should document the missed dose and the explanation for such missed dose on the MART or TAR and in the nurse's notes per Facility policy. Such documentation should include the following information: 8.1 A description of the circumstances of the medication shortage; 8.2 A description of Pharmacy's response upon notification; and 8.3 Action(s) taken.

Based on observation, interview and record review, the facility failed to protect 3 of 4 sampled residents (Residents 2, 3, 4) from verbal and physical abuse from Resident 1. This failure resulted in multiple residents being verbally and physically abused by Resident 1 and had the potential to put Resident 1 at risk for ongoing verbal and physical abuse towards other residents for a universe of 45 residents of the facility. Because of the facility's failure to have a system in place to ensure residents of the facility were protected, an Immediate Jeopardy (IJ) was called on November 19, 2014 at 11:40 AM in the presence of the facility's Administrator and Compliance Representative. The IJ was abated on November 20, 2014 at 2:00 PM in the presence of the facility Administrator after a plan of correction was accepted by the surveyor. The facility plan of correction accepted included 1:1 staff supervision of Resident 1 with monitoring protocol until he was transferred to the acute psychiactric facility on November 19, 2014. Prior to being discharged staff was inserviced on 1:1 monitoring. The facility staff was also inserviced in the need to obtain a physician order [REDACTED]. Findings: During a review of the clinical record for Resident 1, on November 18, 2014, at 10:00 AM, it was documented Resident 1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview with Resident 1, on November 18, 2014 at approximately 10:30 AM, Resident 1 was observed standing outside of his room. Resident 1 refused to be interviewed and began to yell at staff. An interview was conducted with Resident 2, on November 18, 2014 at 10:35 AM. Resident 2 was asked about the incident which occurred on October 31, 2014. He stated he was "ok" and did not want to talk about the matter anymore. A review of the "psychiatrist progress note", dated October 8, 2014, documented Resident 1 was diagnosed with [REDACTED]. Resident 1 refused to be seen by the psychiatrist. Resident 1's medications were [MEDICATION NAME] Deconate (anti psychotic medication), [MEDICATION NAME] (antipsychotic), [MEDICATION NAME](anti-anxiety) and [MEDICATION NAME] (antipsychotic). The note indicated Resident 1 refused his medications, lab works, assessments and would not participate in the treatment program. The psychiatrist had suggested to transfer Resident 1 to an acute psychiatric facility with the facility's Assistant Director of Nurses (ADON). However, there was no documented evidence in the clinical record that the psychiatrist wrote an order for [REDACTED]. A review of the interdisciplinary treatment plan summary sheet documented Resident 1 had been experiencing physical aggression behavior since August 29, 2014. During a review of the discharge plan with the Assistant Director of Nursing (ADON), on November 18, 2014, the ADON confirmed there was no documented plan in the resident's clinical record for Resident 1 to transfer to a higher level of care which was suggested by the psychiatrist on October 8, 2014. A review of the physician's orders [REDACTED]. of all medications. During an interview with the ADON, on November 18, 2014 at 3 PM, he stated Resident 1 had been refusing his medications. The ADON stated he was there on October 8, 2014 when the psychiatrist recommended for Resident 1 to transfer to a higher level of care. The ADON stated he did not communicate the psychiatrist's plan with the social service or the administrative staff. During a review of the "change of condition documentation" notes, the resident incidents occurred as follows; On October 31, 2014, documentation reflects Resident 1 punched Resident 2 in the face four times for non-specified related aggression. Resident 1 suffered minor abrasions to his left hand knucle and right side of the neck, and Resident 2 had no apparent injuries. There was no documented evidence in the clinical record that Resident 1's IDT treatment plan was updated or formulated addressing this specific incident. This was verified by the Assistant Director of Nurses (ADON). On November 15, 2014, documentation reflects Resident 1 punched a wall by the outside patio, which caused a hole on the wall. There was no documented evidence in the clinical record that Resident 1's IDT treatment plan was unpdated and formulated addressing this specific incident. The ADON verified that Resident 1's IDT treatment plan was updated nor formulated addressing this incident. On November 16, 2014 at approximately 9:25 PM, documentation reflects Resident 1 exhibited verbal aggression towards Resident 3. There was no documented evidence in the clinical record that Resident 1's IDT treatment plan was updated or formulated to adress this specific incident. The ADON verified that Resident 1's IDT treatment plan was not updated or formulated to reflect this incident. During an interview with certified nursing assistant (CNA) 1, on November 20, 2014 at 2:20 PM, she stated Resident 1 would pace the unit using profanity toward peers and staff daily. He would posture to fight towards certain residents and staff. He would stand by his room talking to himself, and put himself in a bad situation so his peers thought that he was yelling and cursing at them. Resident 1 refused his medications and care. During an interview with primary counselor (PC) 1, on November 20, 2014, at 2:30 PM, he stated Resident 1 will scream, yell and was very delusional (having false or unrealistic beliefs). He would argue and talk to himself. He would confront other residents directly. PC 1 stated he had noticed significant changes in Resident 1's behavior in the past months, especially after his anti psychotic medications were discontinued. Resident 1 became very difficult to deal with and he would not listen anymore. When asked about Resident 2, PC 1 stated Resident 2 was quiet and does not like to talk. Resident 2 does not have any issues on the unit. During an interview with the Administrator, on November 19, 2014 at approximately 11:40 AM, she stated she reviewed Resident 1's clinical record and determined the suggestion from the physician for Resident 1 to be placed in a higher level of care was over looked by staff and not carried out. During a review of the facility's policy and procedure, titled OPS302-CA "Abuse Prohibition " dated 7/01/13, defines physical abuse "includes hitting, slapping, pinching, kicking, etc. It further defines verbal abuse, any use oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients regardless of their age, ability to comprehend, or disability " The policy further states the facility prohibits abuse for all patients.

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) who displayed mental and psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problems. On October 8, 2014, the psychiatrist recommended for Resident 1 to transfer to a higher level of care. The facility failed to: 1). Develop and implement a Discharge Plan. 2). Develop a care plan on how to manage Resident 1's aggressive behaviors. This failure caused Resident 1 to verbally and physically abuse Resident 2, 3 and 4 and had the potential for verbal and physical abuse to be directed to other residents in a universe of 45 residents. Because of the facility's failure to have a system in place to ensure Resident 1 received appropriate treatment and services to correct the assessed problem, an Immediate Jeopardy (IJ) was called on November 19,2014 at 11:40 AM in the presence of the facility's Administrator and Compliance Representative. The IJ was abated on November 20, 2014 at 2:00 PM after a plan of correction was accepted by the surveyor. The facility plan of correction was validated by the surveyor and supervisor prior to abatement of the IJ. Findings: A review of the clinical record for Resident 1, on November 18, 2014, at 10:00 AM, revealed Resident 1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an attempted interview with Resident 1, on November 18, 2014, at approximately 10:30 AM, Resident 1 was observed standing outside of his room. Resident 1 refused to be interviewed and began to yell at staff. During an interview with certified nursing assistant (CNA 1) 1 on November 20, 2014 at 2:20 PM, she stated Resident 1 would pace the unit using profanity toward peers and staff daily. He would posture to fight towards certain residents and staff. He would stand by his room talking to himself, and put himself in a bad situation so his peers thought he was yelling and cursing at them. Resident 1 refused his medications and care. An interview was conducted with Resident 2, on November 18, 2014 at 10:35 AM. Resident 2 was asked about the incident which occurred on October 31, 2014 when he was hit by Resident 1 multiple times. He stated he was "ok" and did not want to talk about the matter anymore. No injuries were noted for Resident 2. During an interview with primary counselor (PC) 1, on November 20, 2014 at 2:30 PM, he stated Resident 1 will scream, yell and was very delusional (having false or unrealistic beliefs). He would argue and talk to himself. He would confront other residents directly. PC 1 further stated he had noticed significant changes in Resident 1's behavior in the past months, especially after his anti-psychotic (used to treat [MEDICAL CONDITION]) medications were discontinued. Resident 1 became very difficult to deal with and he did not listen anymore. When asked about Resident 2, PC 1 stated Resident 2 was quiet and does not like to talk. Resident 2 does not have any issues on the unit. A review of the "psychiatrist progress note", dated October 8, 2014, documented Resident 1 was diagnosed with [REDACTED]. Resident 1 refused to be seen by the psychiatrist. Resident 1's medications were [MEDICATION NAME] Deconate (anti-psychotic medication), [MEDICATION NAME] (antipsychotic), [MEDICATION NAME](anti-anxiety) and [MEDICATION NAME] (antipsychotic). The note indicated Resident 1 refused his medications, lab works, assessments and did not participate in the treatment program. The psychiatrist had suggested to transfer Resident 1 to an acute psychiatric facility. There was no documentation in the clinical record that a physician order was written to transfer Resident 1 to an acute psychiatric facility. During a review of the discharge plan with the assistant director of nursing (ADON), on November 18,2014, the ADON confirmed there was no documented plan in the resident's clinical record for Resident 1 to transfer to a higher level of care which was suggested by the psychiatrist on October 8, 2014. During a review of the physician's orders and physician's notes with the ADON on November 18, 2014, documentation reflected on October 20,2014 the physician discontinued Resident 1's [MEDICATION NAME] deconate and [MEDICATION NAME] due to Resident 1's refusal of all medications. During an interview with the ADON, on November 18, 2014 at 3 PM, he stated Resident 1 had been refusing his medications. The ADON stated he was there on October 8, 2014 when the psychiatrist recommended for Resident 1 to transfer to a higher level of care. The ADON stated he should communicate the psychiatrist's plan to the social service or the administrative staff to provide appropriate care and services to Resident 1. The ADON's failure to communicate Resident 1's psychiatrist's plan to administratiave staff had the potential to affect the safety of other residents due to his aggressive behavior being untreated. During a review of the "change of condition documentation" notes, the incidents occurred as follows; On October 31,2014, documentation reflects Resident 1 punched Resident 2 in the face four times for non-specified related aggression. On November 15, 2014, documentation reflects Resident 1 punched a wall by the outside patio, which caused a hole in the wall. On November 16, 2014 at approximately 9:25 PM, documentation reflects Resident 1 exhibited verbal aggression towards Resident 3. On November 18, 2014 at approximately 4:12 AM Resident 1 was found shouting at Resident 4. Resident 1 turned around and pushed staff out of room by using the door. A review of the facility policy and procedure, titled "Behaviors: Management Challenging", dated May 15, 2014, indicated "Patients exhibiting behaviors will be individually evaluated..." A review of the Interdisciplinary (IDT) Treatment Plan, showed no documented evidence to show the IDT had developed a comprehensive care plan interventions on how to manage Resident 1's verbal and physical aggressive behaviors. In addition, the IDT had not developed a comprehensive care plan with interventions on how to prevent Resident 1 from harming other residents, after the psychiatrist recommended for Resident 1 to transfer to a higher level of care on October 8, 2014. The finding was verified with the ADON on November 18, 2014 during the record review. A review of the facility policy, titled "Care Plans", dated January 2, 2014, indicated "A comprehensive, individualized care plan will be developed by the interdisciplinary team for each patient...Purpose to provide necessary care and services to attain or maintain the patients' highest...mental, and psychosocial well being...Communicated to appropriate staff..." During an interview with the Administrator, on November 19, 2014 at approximately 11:40 AM, she stated she reviewed Resident 1's clinical record and determined the suggestion from the psychiatrist for Resident 1 to be placed in higher level of care was over looked by staff.