Every finding on record at Camelot Leisure Living

Based on interview and record review the facility failed to inform a family representative of the investigation and the actions that will be taken to correct any identified problems to a resident's complaint/grievance for 1 (#1) of 3 sampled residents. Findings:Review of a facility policy titled Filing Grievances/Complaints, with a revision date of 01/22/2025 revealed in part.Policy Interpretation7. The Resident, or person filing the grievance and /or complaint in behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Such report will be made orally by the administrator, or his or her designee, within 3 workingReview of Resident #1's medical record revealed an admit date of 04/20/2022 with diagnoses that included in part. Adult Failure to Thrive, Gastrostomy Status, Ileostomy Status, and Unspecified Dementia Moderate, without Behavioral Disturbance.Review of Resident #1's Quarterly MDS with an ARD of 07/09/2026 revealed Resident #3 had a BIMS score of 99 (Resident unable to complete the interview). Resident #1's MDS revealed she required supervision or touching assistance with eating, dependent with toileting, partial/moderate assistance with bathing and personal hygiene. During a telephone interview on 08/10/2026 at 2:32 p.m. with Resident #1's Responsible Party (her daughter), revealed she had filed on a grievance via email on 04/29/2026 at 10:23 a.m. Responsible Party stated the grievance was on the following: Resident #1's Ileostomy bag leaking feces and staff not changing the bag timely,Resident #1 having flies on her,Resident #1's toenail/fingernails not trimmed/cleaned,Concerns of staff not being properly trained to provide care for Resident #1.Responsible Party stated the grievance was sent to S4 SSD on 04/29/2026. Responsible Party stated she received a call from S2 DON and was told someone else would contact her concerning the grievance. Responsible Party stated she was not contacted by anyone else. Responsible Party revealed no one discussed what was found in the investigation of the grievance, what actions would be taken to correct the problems or if the grievance was confirmed or resolved. During an interview on 08/11/2026 at 3:04 p.m. S4 SSD revealed she was the grievance official. S4 SSD confirmed she received a grievance from Resident #1's Responsible Party on 04/29/2026 via email. S4 SSD stated she forwarded the email to S1 Administrator, S2 DON, and S3 Corporate Nurse. Review of an email dated 04/29/2026 at 10:23 a.m. from Resident #1's RP revealed in part.I have come to visit my mother often and when I enter the room I can smell there is an issue with her Ileostomy bag. I understand you have high turnovers, but a lack of training is evident especially on the weekend shift. CNA's are repeatedly putting towels under her to soak up leaking feces and she isn't being attended to in a timely manner. Every issue that is ongoing has been addressed with your facility in the past and it gets better for a few weeks, then it reverts back to a lack of proper care. We have to ask for her nails to be clipped and cleaned (they often look like dried feces is under them) and her toes to be clipped. During an interview on 08/11/2026 at 3:25 p.m. with S2 DON and S3 Corporate Nurse confirmed the following: On 04/29/2026 S2 DON and S3 Corporate Nurse received a grievance via email from Resident #1's Responsible Party, with the above listed complaints. The facility failed to inform the Responsible Party of the investigation and the actions that would be taken to correct any identified problems.The facility failed to notify the Responsible Party of a resolution to the grievance.

Based on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the recipe while mixing ingredients to ensure nutritional adequacy for the 7 residents receiving pureed meals prepared by the facility's kitchen.Findings:Observations on 03/16/2026 at 11:00 a.m. of S5 Dietary Manager revealed she chopped 7 slices of bread in the blender, added an unmeasured amount of whole milk, blended the ingredients again to make a slurry, stopped the blender, added 3 more slices of torn bread, blended again, and then scooped the pureed bread into the resident's serving bowls. After washing and sanitizing the blender bowl S5 Dietary Manager placed 10 spoons of unmeasured, cooked vegetables to the blender bowl and blended to a smooth consistency. Next she poured an unmeasured amount of thickener into the blender bowl with the pureed vegetables, blended the mixture for a few seconds, and then scooped the vegetables into the resident's serving bowls.S5 Dietary Manager was observed not following pureed recipe menus, as the closed pureed recipe menu binder was observed on a shelf in the kitchen away from the food prep area.Interview on 03/16/2026 at 11:05 a.m. with S5 Dietary Manger revealed she had recipes to use for preparing pureed foods, but she did not use them. She stated she did not measure the ingredients, she just poured and blended ingredients until the consistency looked right. S5 Dietary Manager revealed that she had already pureed the baked pork loin. She stated she took the pork loin and added an unmeasured amount of broth for the liquid and then she added enough thickener to make the right consistency.Review of the facility's recipe for pureed bread reflected in part, for 10 servings of bread with margarine to use 3 tablespoons + 1 teaspoon margarine, 2 tablespoons + 1 1/2 teaspoons food thickener bulk, and 1 1/4 cup water or juice.Review of the facility's recipe for pureed Capri vegetable blend reflected in part, for 10 servings to use 12.5 cups Capri vegetable blend and 1/4 cup + 1/2 teaspoon food thickener bulk.Review of the facility's recipe for pureed baked pork loin reflected in part, for 10 servings to use 10, 2 ounce portions of pork loin, 1 1/4 cup of water or stock, and 2 tablespoons + 1 1/2 teaspoons food thickener bulk.Interview on 03/16/2026 at 11:10 a.m. with S5 Dietary Manager confirmed she did not use the recipes to prepare the pureed meals for lunch and she should have.

Based on observation and interview the facility failed to ensure nurse staffing data requirements were completed and posted appropriately. This deficient practice had the potential to affect all 65 residents residing in the facility. Observation on 03/16/2026 at 9:10 a.m. revealed a facility form titled, Daily Nursing Census posted on a clipboard (on the wall-near the front desk) with a date of 03/15/2026. No observation of the completed form for the current date, 03/16/2026. Observation on 03/17/2026 at 9:00 a.m. revealed a facility form titled, Daily Nursing Census posted on a clipboard (on the wall-near the front desk) with a date of 03/15/2026. No observation of the current date, 03/17/2026, were noted. Further observation of the previous facility forms titled, Daily Nurse Census revealed several missing dates. Reviewed dates from 02/14/2026 -03/17/2026 revealed the facility form was not completed for the following dates:02/15/2026, 02/16/2026, 02/17/2026, 02/18/2026, 02/19/2026, 02/20/2026. 02/23/2026, 02/24/2026, 02/25/2026, 02/26/2026, 02/27/2026, 03/02/2026, 03/03/2026, 03/04/2026, 03/05/2026, 03/06/2026, 03/08/2026, 03/09/2026, 03/10/2026, 03/11/2026, 03/12/2026, 03/13/2026, 03/16/2026, and 03/17/2026. In an interview on 03/17/2026 at 9:13 a.m., S10 RN revealed that she worked every other weekend and completed the Daily Nurse Census form on the weekends. S10 RN revealed that on opposite weekends the RN on duty completed the Daily Nurse Census forms. S10 RN stated the S1 DON was responsible for completion of the Daily Nurse Census form during the weekdays. In an interview on 03/17/2026 at 9:20 a.m., S2 ADON revealed S1 DON was responsible for completion of the Daily Nurse Census forms during the weekdays and was unaware why the forms were not completed consistently every day. In an interview on 03/17/2026 at 9:30 a.m., S1 DON revealed she thought S2 ADON completed the Daily Nurse Census forms and was unaware she needed to complete these forms during the week. In a record review, with surveyor present, S1 DON confirmed all the above findings and confirmed the Daily Nurse Census forms were not completed daily as required. S1 DON revealed she was unaware the purpose of these forms and had not completed the forms daily- since she was hired in 10/2025.

Based on observation, record review, and interview the facility failed to provide care and services that met professional standards. The facility failed to:Obtain PT/INR for Resident #2; andDocument medications and/or treatments on the EMAR and ETAR for 5 (Resident #1, Resident #6, Resident #8, Resident #37, and Resident #59) of 26 sampled residents. Review of Resident #37's medical record revealed an admission date of 06/20/2022 with diagnoses that included in part.Type 2 Diabetes Mellitus with Diabetic Neuropathy, Methicillin Resistant Staphylococcus, Mild Protein-Calorie Malnutrition, GERD, Dysphagia, COPD, Chronic Hypertension, Diverticulitis of Intestine, Constipation, HTN, and Depressive Episodes, and Atherosclerotic Heart Disease of Native Coronary Artery. Review of Physician Orders 03/2026 revealed an order to clean RLE Dermitits with Dermal wound cleanser, pat dry, and apply Mupirocin ointment, place adaptic non-stick gauze, cover w/foam daily and secure with tubigrip to hold gauze. Review of 03/2026 Treatment Administration Record revealed no documentation of treatment on the following days: 03/04/2026; 03/05/2026; 03/06/2026; 03/07/2026; 03/09/2026; 03/10/2026; and 03/11/2026. Interview on 03/18/2026 at 2:22 p.m. with S2ADON confirmed Resident #37 did not receive treatment on above days. Findings: Resident #2 Review of Resident #2's electronic medical record revealed an admission date of 01/08/2026. Medical diagnoses included Chronic Obstructive Pulmonary Disease, Ataxia, Muscle Weakness, secondary Hypertension, Urinary Tract Infection, Atrial Fibrillation, Generalized Anxiety Disorder, and Depression. Review of the Physician Orders included in part.PT/INR monthly (3/5/26). Review of Lab results revealed no documented evidence of a PT/INR drawn on 03/05/2026. Interview on 03/17/2026 at 4:00 p.m. with the Laboratory Technician revealed the last lab work drawn for Resident #2 was on 03/12/2026 and that a PT/INR was not included in that lab draw. Interview on 03/18/2026 at 10:00 a.m. with S2 ADON confirmed that a PT/INR lab was ordered to be drawn on 03/05/2026. She confirmed that the PT/INR was not obtained, and it should have been. Interview on 03/18/2026 at 10:05 a.m. with S11 MDS confirmed Resident #1's PT/INR ordered for 03/05/2026 was not drawn and it should have been. Resident #1 Review of a facility policy titled, Charting and Documentation dated 01/15/2026, read in part. Documentation of procedures and treatments will include care specific details, including: a. the date and time the procedure/treatment was provided; and b. The signature and title of the individual documenting. Review of Resident #1's electronic medical record revealed an admission date of 02/24/2026, and Medical Diagnoses included in part.Pneumonia, dehisced surgical wounds, chronic burn wounds, Neuralgia and Neuritis. Review of Resident #1's Physician's Orders reflected in part, Physician Orders: Site # 1 superficial dehisced surgical wound to chest wall - clean with wound cleanser, pat dry with 4x4's, apply Triple Antibiotic Ointment, cover with bordered gauze every other day and as needed if soiled/dislodged. Site #4 chronic burn wound to right anterior hip- clean with wound cleanser, pat dry with 4x4's, apply Triple Antibiotic Ointment, cover with bordered gauze every other day and as needed if soiled/dislodged. Site #5 chronic burn wound to right anterior thigh- clean with wound cleanser, pat dry with 4x4's, apply Triple Antibiotic Ointment, cover with bordered gauze every other day and as needed if soiled/dislodged. Site # 6 chronic burn wound right posterior knee- clean with wound cleanser, pat dry with 4x4's, apply Triple Antibiotic Ointment, cover with bordered gauze every other day and as needed if soiled/dislodged. Review of Resident #1's Treatment Administration Record revealed no documentation of treatment on the following days: 03/03/2026; 03/04/2026; 03/05/2026; 03/06/2026; 03/07/2026; 03/09/2026; 03/10/2026; and 03/11/2026. Interview on 03/17/2026 at 1:30 p.m. with S2 ADON revealed that S3 LPN worked on the dates of March 3, 4, 5, 6, 7, 9, 10, and 11. Interview on 03/17/2026 at 1:45 p.m., S2 ADON confirmed that S3 LPN had not documented treatments on 03/03/2026; 03/04/2026; 03/05/2026; 03/06/2026; 03/07/2026; 03/09/2026; 03/10/2026; and 03/11/2026, and she should have. Findings: Resident #6 Review of Resident #6's medical record revealed an admission date of 09/16/2020 with diagnoses which included in part .Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Mild Protein-Calorie Malnutrition, Generalized Anxiety Disorder, Deficiency of other Vitamins, and Unspecified Psychosis not due to a Substance or Known Physiological Condition. Review of Resident #6's 03/2026 EMAR/ETAR (electronic medication administration record/electronic treatment administration record) revealed the following findings in part . On dates 03/03/2026, 03/04/2026, 03/05/2026, 03/06/2026, 03/07/2026, 03/09/2026, 03/10/2026, and 03/11/2026 there was no documented evidence of order administration for the following orders: -Apply geri sleeves one time a day; -Cleanse peg site with normal saline. Pat dry with 4x4's every day. Apply gauze dressing PRN (as needed) if draining one time a day; and -Inflatable carrot or rolled coban to right hand contracture daily. Ensure placement one time a day. On 03/06/2026, there was no documented evidence of order administration for the following orders: -Nurse to ensure nail care is performed every week on Friday and PRN; and -Weekly body audits every Friday. Resident #8 Review of Resident #8's medical record revealed an admission date of 07/16/2025 with diagnoses which included in part .Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Depression, Anxiety Disorder, Type 2 Diabetes Mellitus Without Complications, Acute Respiratory Failure with Hypercapnia, and Severe Persistent Asthma With (Acute) Exacerbation. Review of Resident #8's 03/2026 EMAR/ETAR revealed the following findings in part . On 03/13/2026, there was no documented evidence of order administration for the following orders: -Multi-vitamin mineral oral tablet give one tablet by mouth daily related to vitamin deficiency; -Enhanced barrier precautions to be during resident high contact activities shift twice a day; -Evaluate pain per pain scale (1-10) every shift and PRN. If pain is present document interventions and follow up on effects. Notify MD (Medical Doctor) of persistent pain unrelieved by intervention twice a day; -Monitor for additional signs/symptoms of COVID (corona virus) (loss of appetite, malaise altered mental status, sleeping more than usual, new loss of taste or smell, repeated shaking with chills) every shift, chart (-) No signs/symptoms present or (+) sign/symptoms present and notify MD twice a day; -Monitor for signs/symptoms of bleeding every shift chart (-) non signs/symptoms present or (+) s/s present (nauseas; cold/clammy skin; trouble breathing after an injury; abdominal pain/tenderness; spitting/cough blood; bloody vomit or diarrhea; coffee grained vomit; level of conscience; and notify MD; -Monitor for signs/symptoms of dehydration every shift; chart (-) no sign/symptoms present or (+) signs/symptoms present and chart in nurse's notes twice a day; -Monitor mood and behaviors every shift twice a day; -Oxygen per nasal cannula 2 liters/minute continuously twice a day related to acute respiratory failure with hypercapnia; -Observation antianxiety medication side effects every shift; observe for side effects: drowsiness, slurred speech, dizziness nausea, aggressive/impulsive behavior, and document (-) no signs/symptoms present or (+) signs/symptoms present and chart in nurse notes twice a day related to anxiety disorder; -Observation: antidepressant medications observe for side effects: gastrointestinal upset, insomnia fatigue, dizziness, dry mouth, and headache. Chart (-) no sign/symptoms depression noted or (+) signs/symptoms present and chart in progress notes twice a day related to depression; -Range of motion with ADLs (activities of daily living) twice a day related to hemiplegia ad hemiparesis following cerebral infraction affecting left non-dominant side; -RCS/NAS (Reduced concentrated Sweets/No Added Salt) diet, mechanical soft texture, regular consistency twice a day; -Vitamin C twice a day for skin; -Diltiazem HCL (Hydrochloride) 1 tablet 30 milligrams orally three times a day related to Essential primary hypertension; -Propylthiouracil 50 tablet milligram give 1 tablet orally three times a day related to Thyrotoxicosis, without thyrotoxic crisis or storm; -Humalog Injection Solution 100 UNIT/milliliters (Insulin Lispro) Inject as per sliding scale: if 0 - 150 = 0 UNITS; 151 - 200 = 3 UNITS; 201 - 250 = 6 UNITS; 251 - 300 = 8 UNITS; 301 - 350 = 12 UNITS; 351 - 400 = 16 UNITS; 401 - 999 = 20 UNITS and notify MD, subcutaneously four times a day related to Type 2 diabetes mellitus without complications; and -Ipratropium-Albuterol Nebulizer Solution 0.5-2.5(3) milligram/3milliliter 1 dose inhale orally four times a day related to Severe persistent asthma with (acute) exacerbation. On 03/03/2026, 03/04/2026, 03/05/2026, 03/06/2026, 03/07/2026, 03/09/2026, 03/10/2026, 03/11/2026 there was no documented evidence of order administration for the following order: -Hand towel or carrot in the left hand to address decrease in further contractures ad decreased skin breakdown, wear 8 to 10 hours per day twice a day. On 03/09/2026, there was no documented evidence of order administration for the following order: -Weekly body audit on Monday one time a day every Monday. Resident #59 Review of Resident #59's medical record revealed an admission date of 02/01/2021 with diagnoses which included in part . Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Hemiplegia And Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Other Acute Kidney Failure, and Pseudobulbar Affect. Review of Resident #59's 03/2026 EMAR/ETAR revealed the following findings in part . On 03/13/2026, there was no documented evidence of order administration for the following orders: -Amlodipine Desylate tab 10 milligrams give 1 tablet orally one time a day related to essential primary hypertension; -Aspirin tablet delayed release 81 milligrams give tablet orally one time a day for hemiplegia related to hemiplegia following cerebral infarction affecting the right dominant side; -Atorvastatin Calcium tab 10 milligrams give 1 tablet by mouth at bedtime related to hyperlipidemia; -Docusate Sodium capsule 100 milligram give 1 capsule orally at bedtime for constipation related to constipation; -Hand rolls to left hand for contracture management as tolerated twice a day related to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; -House supplement 8 ounces by mouth twice a day; -Monitor of signs/symptoms of bleeding every shift Chart (-) no signs/symptoms present or (+) signs/symptoms present (nausea, cold/clammy skin, trouble breathing after an injury, abdominal pain/tenderness, splitting/coughing blood, bloody vomit or diarrhea, coffee grind vomit, level of conscience) and notify MD; -Monitor for signs/symptoms of coronavirus every shift such as cough, sore throat, body aches, sob, nasal congestion, seasonal allergies, fever, fatigue, loss of smell and/or taste. (-) no signs/symptoms present (+) signs/symptoms present notify MD if signs/symptoms present two times a day; -Monitor for signs/symptoms of dehydration every shift; chart (-) no signs/symptoms present or (+) signs/symptoms present and chart in nurses notes two times a day; -Monitor mood & behaviors every shift; -Observation: Antidepressant Medication (Prozac) - Observe for behavior (sign/symptoms depression). Observe for side effects: gastrointestinal upset, insomnia, fatigue, dizziness, dry mouth, headache. Document Y if resident is free of side effects. Document N if the resident is not free from side effects. If N document side effects in the progress notes two times a day related to major depressive disorder, single episode; and -On a scale of 0-10 with 10 being worst imaginable, rate your pain (verbal); (a) groans (b) facial grimacing (nonverbal); if pain is present, follow up in 1 hour two times a day. In an interview on 03/17/2026 at 1:35 p.m., S2 ADON stated in reference to nurses charting and documentation in the EMAR/ETAR, If it is not documented then it didn't happened. In an interview on 03/17/2026 at 2:39 p.m., S1 DON revealed she expected all the nurses to always document in the resident medical record in real time for all nursing procedures, such as medication and treatment administrations. In a record review, at this time, S1 DON reviewed Resident #6's, Resident #8's and Resident #59's 03/2026 EMAR/ETAR and confirmed all the above findings. S1 DON confirmed that if the nurses did not chart in the medical record then it didn't happen. S1 DON revealed the nurses who were scheduled on these dates/times were all staff nurses and were aware and in-serviced on proper nurse charting and documentation in the medical record. S1 DON confirmed that for the above findings, the nurses did not document in Resident #6's, Resident #8's and Resident #59's medical record appropriately but should have.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure respiratory equipment/nebulizer was stored properly for 1 (Resident #8) of 1 residents reviewed for respiratory care. The total sample size was 26 residents. Findings:Review of a facility policy on 03/17/2026 at 1:35 p.m. titled, Nebulizer Tubing Policy dated 01/16/2026 revealed in part .Purpose: To ensure safe, effective, and infection-controlled use of nebulizer tubing and equipment for residents receiving aerosolized medications. Policy: Nebulizer tubing and equipment will be maintained, cleaned, and replaced according to infection control standards, manufacturer guidelines, and state/federal regulations. Procedure: 6. Store equipment in a clean, dry area between uses. Review of Resident #8's medical record revealed an admission date of 07/16/2025 with diagnoses which included in part .Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Depression, Anxiety Disorder, Type 2 Diabetes Mellitus Without Complications, Acute Respiratory Failure with Hypercapnia, and Severe Persistent Asthma with (Acute) Exacerbation. Review of Resident #8's Quarterly MDS with an ARD of 01/07/2026 revealed a BIMS score of 15, which indicated intact cognition. Resident #8 received oxygen therapy and was dependent on staff for toileting hygiene, dressing, personal hygiene and showering/bathing.Review of Resident #8's 03/2026 physician orders revealed in part .Order Date: 04/03/2024- Ipratropium-Albuterol Nebulizer Solution 0.5-2.5(3) milligram/3milliliters 1 dose inhale orally four times a day related to Severe persistent asthma with (acute) exacerbation.Observation on 03/16/2026 at 8:45 a.m. revealed Resident #8 lying in bed awake with resident's nebulizer mask placed face down directly on the resident's bedside dresser cabinet. Observation failed to reveal a storage bag for the nebulizer mask and tubing to be stored in, when not in use. In an interview on 03/16/2026 at 8:58 a.m., S10 RN accompanied this surveyor to Resident #8's room and bedside. S10 RN confirmed the above findings and stated Resident #8 used her nebulizer daily multiple times for shortness of breath and anxiety attacks. S10 RN confirmed Resident #8's nebulizer mask should be stored in a plastic bag and labeled when not in use, but was not. In an interview on 03/17/2026 at 2:39 p.m., S1 DON revealed she expected the nurses to properly store and label all nebulizer masks when not in use. S1 DON revealed when a nebulizer mask is not in use, the mask should be properly cleaned and put back into the labelled plastic storage bag, not placed directly on a resident's dresser cabinet.

Based on observations, interviews, and record review the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 2 (#3 and #38) of 26 residents sampled for dignity, by failing to ensure they were free of facial hair. Findings: Review of the facility's policy dated 01/16/2026 and titled Activities of Daily Living (ADLs), Supporting revealed in part.Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. Policy Interpretation and Implementation: 2. (a) hygiene (bathing, dressing, grooming, and oral care). Review of Resident #3's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included in part.Anxiety Disorders, Depression, and Unspecified Psychosis. Review of Residents #3's Quarterly MDS with an ARD date of 02/25/2026 revealed she had a BIMS score of 07 indicating cognition was severely impaired. The MDS revealed Resident #38 required partial/moderate assistance with personal hygiene. Review of Resident #3's care plan revealed she had an ADL self-care performance deficit related to confusion and interventions that included 1 person assist with personal hygiene. Observation and Interview with Resident #3 on 03/17/2026 at 9:30 a.m. revealed Resident #3 was noted to be unshaven with more than 10 facial, chin hairs. Surveyor asked Resident #3 if she would like the hair on her chin shaved, she stated, yes and begin smiling and pulling at the chin hairs. In an interview with S7 CNA on 03/17/2026 at 1:50 p.m., S7 CNA revealed during baths the residents get bathed and men will get shaved if needed. S7 CNA stated, I have never shaved a female. Review of Resident #38's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included in part.Chronic Diastolic (Congestive) Heart Failure, Muscle Wasting and Atrophy, not elsewhere classified right and left upper arms, Other specified Depressive Disorder. Review of Resident #38's Quarterly MDS with an ARD date of 10/05/2023 revealed she had a BIMS score of 99 which means unable to perform due to Resident #38's cognition was severely impaired. The MDS revealed Resident #38 required substantial/maximal assistance with personal hygiene. Review of Resident #38's care plan revealed she had an ADL self-care performance deficit related to confusion, dementia and an intervention that included 1 person assist with personal hygiene. Observation on 03/17/2026 at 12:09 p.m. revealed Resident #38 was noted to be unshaven with a moderate amount of facial, chin hairs. In a telephone interview on 03/18/2026 at 1:57 p.m., Resident #38's responsible party stated she would like Resident #38's chin to be shaved. In an interview on 03/17/2026 at 2:15 p.m., S6 CNA Supervisor acknowledged Resident #3 and #38 had not been shaved but should have. In an interview on 03/17/2026 at 3:14 p.m., S1 DON confirmed Resident #3 and #38 should have been shaved but had not.

Based on record review and interview the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 1 (Resident #68) of 3 residents reviewed for transfer/discharge. The total sample size was 26.Findings:Review of a facility policy on 03/18/2026 at 3:11 a.m. titled, Nursing Home Discharge Policy: Ombudsman Notification dated 01/16/2026 revealed the following in part .This policy outlines when and how the facility will notify the Long-Term Care Ombudsman of resident discharges to ensure compliance with federal regulations and Louisiana requirements. The facility will notify the Long-Term Care Ombudsman Program of discharges in accordance with federal and state regulations to protect resident rights and ensure safe transitions. Review of Resident #68's medical record revealed an admission date of 01/13/2026 and a discharge date of 02/20/2026. Resident #68 had diagnoses of Chronic Obstructive Pulmonary Disease, Chronic Systolic (Congestive) Heart Failure, and Chronic Atrial Fibrillation. Review of Resident #68's Discharge summary dated [DATE] revealed in part .an admission date of 01/13/2026 and discharge date of 02/20/2026. Reason for discharge: Unplanned discharge home. Review of the facility's Emergency Transfer Log form reviewed from 01/2026-03/2026 revealed Resident #68's discharge on [DATE] was not reported to the Louisiana Ombudsman Program. In an interview on 03/18/2026 at 1:44 p.m., S2 ADON revealed Resident #68 was admitted for therapy services and planned to discharge home after completion. S2 ADON stated upon discharge, Resident #68 decided to continue his stay at the facility longer. S2 ADON explained the family of Resident #68 when decided to discharge the resident suddenly, thus Resident #68 had an unplanned discharge home on [DATE]. In an interview on 03/18/2026 at 2:29 p.m., S9 SSD revealed she was responsible for notification to the Louisiana Ombudsman Program for hospitalizations. S9 SSD revealed she was only aware to report the hospitalizations to the Ombudsman Program and had not reported any unplanned or planned discharges from the facility. S9 SSD confirmed she did not report Resident #68's unplanned discharge on [DATE] to the Louisiana Ombudsman Program.

Based on observation, record review and interview the facility failed to maintain a medication error rate of less than 5% for 2 (Resident #12 and Resident #50) of 3 residents observed during medication administration. A total of 27 opportunities were observed which included 2 medication errors for a medication error rate of 7.41% Findings:Review of a facility policy titled Administering Medications with a revision date of 01/15/2026 read in part.Steps in the procedure: (6) Check the label on the medication and confirm the medication name and dose with the MAR. (8) Check the medication dose. Re-check to confirm the proper dose. (9) Prepare the correct dose of medication.Observation on 03/17/2026 at 8:24 a.m. revealed Resident #12 was administered Doxazosin Mesylate (anti-hypertensive) 2 Milligram Tablet by mouth by S4 LPN.Review of Resident #12's current Medication Administration Record (03/2026) revealed an order for Doxazosin Mesylate 4 Milligram Tablet by mouth two times a day.Observation on 03/17/2026 at 8:36 a.m. during medication administration by S4 LPN revealed Resident #50's Metformin Hydrochloride (anti-diabetic) 500 Milligram Tablet by mouth one time a day was omitted. Review of Resident #50's current Medication Administration Record (03/2026) revealed an order for Metformin 500 Milligram tablet by mouth one time a day. Interview on 03/17/2026 at 11:39 a.m. with S4 LPN confirmed she administered Doxazosin Meyselate 2 Milligram tablet by mouth to Resident #12 on 03/17/2026 at 8:24 a.m. and she should not have. S4 LPN confirmed she did not administer Resident #50 Metformin 500 Milligram Tablet on 03/17/2026 during morning medication administration and should have.Telephone interview with Resident #12's Physician revealed Resident #12 should have received Doxazosin Mesylate 4 Milligram Tablet by mouth one time a day. Interview on 03/17/2026 at 1:51 p.m. with S2 ADON revealed the expectation was for all nurses to follow the Medication Administration Record when administering medications.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with current accepted professional principles. The facility failed to: Ensure medications were not left at the bedside for 1 (Resident #8) of 26 sampled residents; and Ensure controlled substances were properly stored in a permanently affixed compartment in the medication refrigerator. Facility census was 65. Findings: Review of a facility policy on 03/17/2026 at 1:35 p.m. titled, Storage of Medications with a date of 01/16/2026 revealed in part .the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 1. Resident #8 Review of Resident #8's medical record revealed an admission date of 07/16/2025 with diagnoses which included in part .Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Depression, Anxiety Disorder, Type 2 Diabetes Mellitus Without Complications, Acute Respiratory Failure With Hypercapnia, and Severe Persistent Asthma With (Acute) Exacerbation. Review of Resident #8's Quarterly MDS with an ARD of 01/07/2026 revealed a BIMS score of 15, which indicated intact cognition. Resident #8 received oxygen therapy and was dependent on staff for toileting hygiene, dressing, personal hygiene, and showering/bathing. Review of Resident #8's 03/2026 physician orders revealed in part .Order Date: 04/03/2024- Ipratropium-Albuterol Nebulizer Solution 0.5-2.5(3) milligram/3milliliters 1 dose inhale orally four times a day related to Severe persistent asthma with (acute) exacerbation. Observation on 03/16/2026 at 8:45 a.m. revealed Resident #8 lying in bed awake. Observed a tube of unopened nebulizer solution (Ipratropium-Albuterol Nebulizer Solution 0.5-2.5(3) milligram/3milliliter) on the resident's dresser cabinet, unattended and unsecure. In an interview on 03/16/2026 at 8:58 a.m., S10 RN accompanied this surveyor to Resident #8's room and bedside. S10 RN confirmed there was an unsecure and unattended medication (Ipratropium-Albuterol Nebulizer Solution 0.5-2.5(3) milligram/3milliliter) placed on the resident's bedside dresser cabinet. S10 RN confirmed Resident #8's nebulizer medication solution should have been stored in the locked medication cart when not in use, but was not. In an interview on 03/17/2026 at 2:39 p.m., S1 DON revealed there were no residents in the facility who self-administered medications. S1 DON confirmed she expected all nurses to store medications in the locked medication cart when not in use and not leave medications at the bedside, unattended. 2. Findings: On 03/16/2026 at 1:45 p.m., an observation of the medication refrigerator in the medication room was conducted accompanied by S10 RN and revealed an unsecure chained, mobile, locked box with the narcotic of an unopened box of liquid Lorazepam. In an interview on 03/16/2025 at 3:24 p.m., S1 DON confirmed the medication room had a locked, mobile narcotic box inside the medication refrigerator, but should have not.

Based on interview and record review the facility failed to ensure that a resident with an identified mental disorder had a completed Preadmission Screening and Resident Review (PASRR) Level II form as required for 1 (#11) of 26 sampled residents.Findings: Review of the facility policy dated 01/16/2026 titled PASRR (Pre-admission Screening & Resident Review) Policy read in part.Purpose: This policy ensures compliance with the Preadmission Screening and Resident Review (PASRR) requirements for all residents admitted to the facility in accordance with Louisiana Department of Health (LDH) and federal regulations. A Review of Resident #11's medical record revealed an admission to the facility on [DATE] with diagnoses that included: Other Depressive Episodes, Major Depressive Disorder, Recurrent, Mild, Chronic Atrial Fibrillation, Other Schizophrenia, and Other Bipolar Disorder. Review of Resident #11's medical record revealed no Level II PASRR screening performed after the new diagnoses of Other Schizophrenia and Other Bipolar Disorder dated 04/19/2023. A Review of Resident #11's Louisiana Department of Health and Hospitals Medicaid Program Notice of Medical Certification form read in part.II. (F.) Level II decision is not required. Refer to Section 1 for decision, signed and dated 01/28/2021. An Interview on 03/18/2026 at 3:19 p.m., S12 LPN revealed Resident #11 had a new diagnosis of Schizophrenia and Bipolar Disorder on 04/19/2023 with no new PASRR completed, but should have.

Based on observation, interview, and record review the facility failed to ensure infection control measures were practiced to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 (#1) of 1 residents observed for wound care.Findings:Review of Resident #1's electronic medical record revealed an admission date of 02/24/2026, and Medical Diagnoses included in part.Pneumonia, dehisced surgical wounds, chronic burn wounds, Neuralgia and Neuritis.Review of Resident #1's Physician's Orders reflected in part:Site # 1 superficial dehisced surgical wound to chest wall - clean with wound cleanser, pat dry with 4x4's, apply Triple Antibiotic Ointment, cover with bordered gauze every other day and as needed if soiled/dislodged,Site #4 chronic burn wound to right anterior hip - clean with wound cleanser, pat dry with 4x4's, apply Triple Antibiotic Ointment, cover with bordered gauze every other day and as needed if soiled/dislodged,Site #5 chronic burn wound to right anterior thigh - clean with wound cleanser, pat dry with 4x4's, apply Triple Antibiotic Ointment, cover with bordered gauze every other day and as needed if soiled/dislodged, andSite # 6 chronic burn wound right posterior knee - clean with wound cleanser, pat dry with 4x4's, apply Triple Antibiotic Ointment, cover with bordered gauze every other day and as needed if soiled/dislodged.Observation of S8 LPN on 03/17/2026 at 10:30 a.m. performing wound care revealed that she did not perform hand hygiene nor did she change gloves between wound care provided to the right posterior knee and the right anterior thigh. After performing wound care to the right posterior knee, she began performing wound care to the right anterior thigh, and she did not remove her soiled gloves, perform hand hygiene, and re-glove between the two sites.Interview on 03/17/2026 at 11:55 a.m. with S8 LPN, confirmed she did not perform hand hygiene, nor did she change gloves between wound care of the right posterior knee and the right anterior thigh, and she should have.

Based on Observation, interview and record review the facility failed to ensure that a resident who required Ileostomy services received such care consistent with professional standards of practice for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents by failing to change Resident #1's ileostomy bag as needed.Findings: Review of the Facility's Policy titled Colostomy/Ileostomy Care with a review date of 01/25/2025 revealed in part.Purpose: The purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter.Documentation: The following information should be recorded in the resident's medical record:1. The date and time the colostomy/ileostomy care was provided.2. The name and title of the individual (s) who provided the colostomy/ileostomy care.6. The signature and title of the person recording the data.Reporting: Report other information in accordance with facility's policy and professional standards of practice.Review of Resident #1's medical record revealed an admit date of 04/20/2022 with diagnoses which included in part.Type 2 Diabetes Mellitus, Moderate Protein-Calorie Malnutrition, Gastrostomy Status, Ileostomy Status, Pain Unspecified, and Unspecified Dementia.Review of Resident #1's Quarterly MDS with ARD of 05/27/2025 revealed Resident #1 had a BIMS score of 99 indicating the resident was unable to complete the interview. Resident #1's MDS revealed she required partial to moderate assistance with toileting, bathing, eating, and personal hygiene.Review of Resident #1's Care Plan with a Target date of 07/22/2025 revealed in part.Alteration in Gastrointestinal Status related to Ileostomy with interventions that included provide treatment as ordered, change Ileostomy appliance (wafer and bag) every Tuesday and Thursday and PRN dislodgement. Review of Resident #1's July 2025 Medication Administration Record revealed in part. Burp/Empty Colostomy-change as needed six times a day related to encounter for attention to Ileostomy.Telephone interview on 07/14/2025 at 7:57 a.m. with Resident #1's daughter revealed she had complained to the DON on three separate occasions (unable to remember dates) of her mother's (Resident#1) Ileostomy bag leaking and her mother having feces on her. Resident #1's Responsible Party stated she visited her mother daily and on several visits her mother would have feces on her and a towel would be stuffed around the Ileostomy bag to catch the feces. Resident #1's Responsible Party revealed her mother had to wait for long periods of time before a nurse could provide Ileostomy care for her.Observation on 07/14/2025 at 11:30 a.m. with S4 CNA in attendance revealed Resident #1 lying in bed. Resident #1 had loose feces on her skin which had leaked from her Ileostomy bag. S4 CNA stated the towel had been placed around the Ileostomy bag to catch the feces. S4 CNA stated that she had informed S5 RN/ADON Treatment Nurse a little after 10:00 a.m. that Resident #1's Ileostomy bag needed to be changed and that S5 RN/ADON Treatment Nurse replied it would be a minute (a while) before she would be able to change Resident #1's Ileostomy bag.Interview on 07/15/2025 at 8:20 a.m. with S1 ADON confirmed the following orders for Resident #1: Burp/Empty Colostomy-change as needed six times a day related to encounter for attention to Ileostomy. S1 ADON revealed it was the treatment nurse's and floor nurse's responsibility to provide Ileostomy care for Resident #1. S1 ADON revealed if the treatment nurse or floor nurse is busy they should notify another nurse to provide ileostomy care for Resident #1. S1 ADON revealed Resident #1's RP had complained of certain staff not changing Resident #1's Ileostomy bag.Interview on 07/15/2025 at 9:48 a.m. with S5 RN/ADON Treatment Nurse revealed she did not provide Ileostomy care to Resident #1 on 07/14/2025. S5 RN/ADON Treatment Nurse stated S6 LPN provided Ileostomy care for Resident #1 on 07/14/2025.Interview on 07/15/2025 at 11:10 a.m. with S9 Bookkeeper revealed S6 LPN clocked in to work at 11:16 a.m.Telephone Interview on 07/16/2025 at 8:09 a.m. with S6 LPN revealed it was after 2:00 p.m. on 07/14/2025 when she provided Ileostomy care for Resident #1. S6 CNA stated she had not been informed that Resident #1 needed Ileostomy care prior to that.Interview on 07/16/2025 at 9:38 a.m. with S5 RN/ADON Treatment Nurse confirmed she had not reported to S6 CNA on 07/14/2025 that Resident #1 needed Ileostomy care.

Based on interview and record review, the facility failed to develop a person-centered care plan for 1 (Resident #2) of 3 (Residents #1, #2, and #3) sampled residents. The facility failed to develop a care plan related to feeding assistance for Resident #2.On 07/16/2025 at 10:39 a.m., review of facility policy titled, Care Plans, Comprehensive Person- Centered, with revision date of 01/15/25, revealed in part. A Comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. A comprehensive, person-centered care plan will. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.On 07/16/2025 at 10:40 a.m., review of facility policy titled, Activities of Daily Living (ADLs), Supporting, with revision date of 01/15/25, revealed in part. Appropriate care and services will be provided to residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with. dining (meals and snacks).A review of Resident # 2's medical record revealed an admission date of 05/28/2025, with diagnoses that included in part. Dysphagia following Unspecified Cerebrovascular Disease, Senile Degeneration of Brain Not elsewhere Specified, Anorexia, Moderate Protein Calorie Malnutrition, and Other Sequelae of Non-traumatic Intracerebral Hemorrhage. Review of Resident #2's admission Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 06/09/2025, revealed Resident #2 was rarely/never understood with an altered level of consciousness that was continuously present. Resident #2 required moderate assistance with eating and was dependent for personal hygiene, mobility, and transfers. On 07/14/2025 at 12:00 p.m., review of grievance filed by Resident #2's family member on 06/23/2025 revealed in part. Date Incident Occurred: 06/20/2025Description: Family member reported that the resident's lunch tray was on the bedside table, left over her mom in bed. Family member reported the tray had tumbled over in her bed next to residents head and no aide was in the room.Findings of Investigation: Findings were that the tray was left in the room over the resident.On 07/14/2025 at 12:30 p.m., review of Resident #2's care plan revealed that the comprehensive care plan did not reflect the level of feeding assistance Resident #2 required. During an interview on 07/15/2025 at 10:00 a.m., S2 MDS Nurse confirmed Resident #2 required staff assistance to be fed. Resident #2's care plan was reviewed with S2 MDS Nurse and S1 ADON at this time. S2 MDS Nurse confirmed Resident #2's level of assistance required for feeding was not care planned and should have been.

Based on interview and record review the facility failed to ensure prompt resolution of an allegation of not providing proper Ileostomy care for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents by failing to initiate a grievance for Resident #1.Findings: Review of the Facility's Policy titled Filing/Grievances/Complaints with a revision date of 01/22/2025 revealed in part.Policy Statement: Our facility will assist residents or his/her responsible party in filing grievances or complaints when such requests are made.Policy Interpretation and Implementation:3. Grievances and/or complaints may be submitted orally or in writing.5. Upon receipt of written grievance and/or complaint, the social services director will investigate the allegation and submit a written report of such findings to the administrator within 24 hours of receiving the grievance and/or complaint.7. The resident, or person filing the grievance and/or complaint in behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Such report will be made orally by the administrator, or his or her designee, within 3 working days of the filing of the grievance or complaint with the facility.Review of Resident #1's medical record revealed an admit date of 04/20/2022 with diagnoses which included in part.Type 2 Diabetes Mellitus, Moderate Protein-Calorie Malnutrition, Gastrostomy Status, Ileostomy Status, Pain Unspecified, and Unspecified Dementia.Review of Resident #1's Quarterly MDS with ARD of 05/27/2025 revealed Resident #1 had a BIMS score of 99 indicating the resident was unable to complete the interview. Resident #1's MDS revealed she required partial to moderate assistance with toileting, bathing, eating, and personal hygiene.Review of Resident #1's Care Plan with a Target date of 07/22/2025 revealed in part.Alteration in Gastrointestinal Status related to Ileostomy with interventions that included provide treatment as ordered, change Ileostomy appliance (wafer and bag) every Tuesday and Thursday and PRN dislodgement.Telephone interview on 07/14/2025 at 7:57 a.m. with Resident #1's daughter revealed she had complained to the DON on three separate occasions (unable to remember dates) of her mother's (Resident#1) Ileostomy bag leaking and her mother having feces on her. Responsible Party revealed she visited her mother daily and on several visits her mother would have feces on her and a towel would be stuffed around the Ileostomy bag to catch the feces. Responsible Party stated the DON had assured her the matter would be taken care of, but it had not been.Review of the facility's Grievance Log revealed no grievances for Resident #1.Review of the facility's form titled Hand in Hand Program read in part.Date: 04/02/2025Any concerns or issues to be addressed: RP has a concern: says that the Nurse isn't changing Resident #1's Colostomy bag in a timely manner.Action taken to resolve the issue: I will notify the ADON and DON.Person contacted about what was done to resolve: BlankHand in Hand Rep signature: BlankAdministrator signature issue resolved: Signed by AdministratorInterview on 07/15/2025 at 9:16 a.m. with S7 [NAME] Clerk revealed Hands in Hands was a weekly call that she made to all resident's family members to help identify any concerns or complaints. S7 [NAME] Clerk stated Resident #1's RP had voiced many complaints mostly about nursing and those complaints had been given to S1 ADON and S8 DON.Interview on 07/15/2025 at 2:00 p.m. with S3 Administrator and S1 ADON stated department heads decide what is considered a grievance. S3 Administrator and S1 ADON confirmed the Hand in Hand tool did not replace a grievance. S3 Administrator and S1 ADON confirmed the facility had no grievances/investigations or resolutions to any grievances on Resident #1.

Based on observation, record review and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This deficient practice had the potential to effect all 64 residents who resided in the facility. The facility failed to ensure the dietary department was practicing professional standards for food services. This deficient practice resulted in an immediate jeopardy situation on 02/17/2025 at 12:17 p.m. when S3 Dietary [NAME] was observed using a Clorox/Bleach solution for dishwashing of the blender, used during pureed meal preparation. S3 Dietary [NAME] stated this was how she washed dishes normally to save time. S3 Dietary [NAME] was advised by Surveyor to dispose of meats/beef patties on two occasions during meal preparation. Surveyor observed S3 Dietary [NAME] continue to prepare the meats in the same blender and then S3 Dietary [NAME] placed the meat on the serving/steam line for meal plating/serving. S1 Administrator intervened and the meats were disposed of properly on 02/17/2025 at 12:20 p.m. The deficient practice continued at a potential for more than minimal harm for all 64 residents who resided in the facility. S1 Administrator was notified of the Immediate Jeopardy on 02/17/2025 at 5:07 p.m. The Immediate Jeopardy was removed on 02/19/2025 at 1:29 p.m. as confirmed by onsite verification through observation and interview the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Findings: Cross Reference F812 Review of a facility policy on 02/20/2025 at 1:15 p.m. titled, Dietary Staff Competency with a date of 01/15/2025 revealed in part .Purpose: All dietary staff will be trained according to policy. 1. Provide all dietary employees with training upon hire and as needed. 2. Staff should be made aware of all safety precautions, nursing home policies, and necessary in-services regarding dietary equipment and meal services. 3. Dietary Supervisor will provide in-services to dietary staff as needed . Review of an undated facility policy on 02/20/2025 at 1:15 p.m. titled, Dietary Competency revealed in part .the Dining Services Manager will review each skill, observe staff demonstration, and sign each item on this list annually with each evaluation. The completed form will be placed in the employee file competencies included in part .Skill: purpose, emergency preparedness, food storage and handling, procedures, handwashing, food preparation, meal services, safety procedures, sanitary procedures, proper temperatures and recordings, storage, washing dishes, trash containers, operation, cleaning, and safety . In an interview on 02/17/2025 at 8:40 a.m., S4 Maintenance Supervisor revealed the dietary manager had been out for several months so he had been helping S1 Administrator oversee the kitchen and dietary staff. In an observation of and interview in the kitchen area of S11 Dietary [NAME] on 02/17/2025 at 12:03 p.m., revealed S11 Dietary [NAME] had long curly goatee/facial hair and no usage of a beard net. S11 Dietary [NAME] confirmed he does not wear a beard net and he had not been made aware that he needed to wear a beard net since he was hired 4 months ago. S11 Dietary [NAME] stated no one has ever spoke to him about covering his beard/goatee hair. S11 Dietary [NAME] stated that no one has properly trained him. S11 Dietary [NAME] revealed that he was 'self-taught' and stated, To be completely honest, it's a s!@# show every day in this kitchen! S11 Dietary [NAME] stated that S1 Administrator nor S4 Maintenance Supervisor had ever trained him. S11 Dietary [NAME] stated he did not feel comfortable asking them for help because they do not listen and do not help the kitchen staff. S11 Dietary [NAME] stated that S14 Part-Time Dietary Manager comes weekly but had never taught him anything regarding his duties. S11 Dietary [NAME] reported that he worked by himself sometimes and often had little to no help. In an interview and observation on 02/17/2025 at 12:13 p.m., S3 Dietary [NAME] was observed preparing pureed meals in the kitchen blender. S3 Dietary [NAME] was observed free-pouring and unmeasured amount of powdered thickener. S3 Dietary [NAME] revealed this was how she normally prepares her pureed meals and she just eye-balls it. S3 Dietary [NAME] stated no one had taught her differently. In an interview on 02/17/2025 at 1:33 p.m., S3 Dietary [NAME] stated prior to today, she was unaware she was not to use Clorox/Bleach for dishwashing. Review of facility dietary staff personnel files revealed there was no documentation indicating dietary staff had received training upon hire. Findings included in part . S1 Administrator was hired on 09/01/2024 with no documentation of dietary staff competencies or duties check-off. S3 Dietary [NAME] was hired on 12/11/2024 with no documentation of dietary cook competencies or duties check-off. S4 Maintenance Supervisor was hired on 10/29/2001 with no documentation of dietary staff competencies or duties check-off. S11 Dietary [NAME] was hired on 11/22/2024 with no documentation of dietary cook competencies or duties check-off. S12 Dietary Aide was hired on 05/09/2024 with no documentation of dietary aide competencies or duties check-off. In an interview on 02/18/2025 at 2:25 p.m., S13 RD stated there was no current Dietary Manager overseeing the kitchen and that S1 Administrator was overseeing the kitchen daily. S13 RD stated she was made aware today that the kitchen staff had never received training and had never had competency check offs completed. In an interview on 02/17/2025 at 9:26 a.m., S1 Administrator revealed the dietary manager had been out since July 2024 due to an injury. S1 Administrator stated he completed his self-serve certification and was ultimately responsible for managing the kitchen and dietary staff. S1 Administrator stated recently corporate had allowed him to hire S14 Part-Time Dietary Manager who came once a week to assist in the kitchen. S1 Administrator stated S13 RD monitored the kitchen monthly. S1 Administrator confirmed that he was responsible for daily duties, hiring/firing of dietary staff, education, and daily monitoring. Plan of Removal: All 65 residents have the potential for illness or serious harm from the alleged deficiency F835. The dietary staff allegedly was not properly trained on dishwashing practices. After a review of policies and procedures they did not require updating. The training of new dietary staff will be done on hire, and continuing education will be provided at monthly in-services for all dietary staff to improve the knowledge, and basic skills of the dietary staff to ensure regulatory compliance. The training and continuing education of current and new dietary staff will be done by the administrator, the administrator's designee, or the dietary consultant. On 02/17/2025 the administrator immediately verbally in-serviced dietary staff present not to use bleach to sanitize equipment and instructed staff how to use the 3 compartment sink and check for the proper amount of sanitizer. On 02/17/2025 the administrator called the dietary consultant to come 02/18/2025 to in-service and train dietary staff on sanitation in the kitchen and how to set up and check the sanitizer in the 3 compartment sink to ensure regulatory compliance. On 02/18/2025 the administrator called 2 off duty dietary staff to verbally in-service them about not using bleach, and how to setup the 3 compartment sink and check the sanitizer. All dietary staff have been in-serviced as of 02/18/2025. Continuing education will be provided by the administrator, the administrator's designee, or the dietary consultant at monthly in-services for all dietary staff. The training of each new hire in dietary will be monitored using a check list to orient them to the kitchen and dietary policies and procedures, and all dietary staff will receive monthly in-servicing training. The administrator will monitor the training of new dietary staff and the monthly in-services, both will be ongoing. The dietary consultant will monitor the administrator to ensure new hire training and monthly in-servicing is taking place during their monthly visit. This monitoring will be included in the current QAPI being done in the kitchen and reported quarterly in the QA meeting. Correction Date: 02/19/2025 at 1:29 p.m.

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store, prepare, and serve food in accordance with professional standards for food service safety. This deficient practice had the potential to effect all 64 residents who resided in the facility. The facility failed to ensure: 1. Staff used approved chemicals/sanitizers during dishwashing; 2. Food items in the refrigerators were labeled and dated; 3. Maintenance of a clean freezer, in a safe operating condition, and food stored appropriately; 4. Food items in the pantry were labeled with an open date, stored in a sealed container, and expired foods were not available for use; 5. Food items in hot-warmer were covered and labeled until ready for serving; 6. Maintenance of a clean and sanitary kitchen at all times; 7. Staff are wearing hair restraints including beard restraints to prevent hair from contacting food; 8. Staff are practicing effective hand hygiene and glove usage during food preparation activities; and 9. Staff monitor food and refrigerator temperatures. This deficient practice resulted in an immediate jeopardy situation on [DATE] at 12:17 p.m. when S3 Dietary [NAME] was observed using a bucket that contained a Clorox/Bleach solution for dishwashing of the blender during pureed meal preparation. S3 Dietary [NAME] was alerted by the survey team to dispose of meats/beef patties on two occasions during meal preparation. S3 Dietary [NAME] stated this was how she washed dishes normally to save time. Surveyors observed S3 Dietary [NAME] continue to prepare the meats in the same blender and then S3 Dietary [NAME] placed the meat on the serving/steam line for meal plating/serving. S1 Administrator intervened and the meats were disposed of properly on [DATE] at 12:20 p.m. S1 Administrator was notified of the Immediate Jeopardy on [DATE] at 5:07 p.m. The Immediate Jeopardy was removed on [DATE] at 1:29 p.m. as confirmed by onsite verification through observation and interview the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Findings: Review of an undated facility policy on [DATE] at 2:32 p.m. titled, Dishwashing in Three Compartment Sink revealed in part .utensils and dishes washed by hand will be cleaned and sanitized . Review of a facility policy on [DATE] at 2:32 p.m. titled, Food Storage with a revision date of ,d+[DATE] revealed in part .food storage area shall be maintained in a clean, safe, and sanitary manner. 1. Food storage shall be clean at all times .2. All packaged food or food items stored shall be kept clean .5. All foods stored in walk-in refrigerators and freezers shall be stored above the floor on shelves, racks, or other surfaces that facilitate thorough cleaning .8. The dietary manager, or his/her designee, will check refrigerators and freezers daily for proper temperatures. Records of such information are maintained . Review of an undated facility policy on [DATE] at 2:32 p.m. titled, Food Preparation and Service revealed in part .Food will be maintained at proper temperatures during service and transported in a sanitary manner . Review of an undated facility policy on [DATE] at 2:32 p.m. titled, Sanitation and Food Handling revealed in part .sanitary conditions will be maintained in the storage, preparation and distribution of food .personnel will observe personal cleanliness and exercise satisfactory food handing techniques .8. Employees must wash their hands: d. after touching other parts of the body .F. when going from a soiled job to a clean job .H. when returning to the kitchen for any reason . Usage of Chemicals 1. On [DATE] at 12:17 p.m., S3 Dietary [NAME] was observed preparing pureed meals with the kitchen blender. After blending the white rice, she walked across the kitchen to the 3-compartment sink and cleaned/sanitized the blender to continue with meal preparation. Observed S3 Dietary [NAME] prepare spinach. After blending the spinach, S3 Dietary [NAME] was observed washing the blender with a rag she obtained from a red bucket near her blending station. S3 Dietary [NAME] stated the red bucket contained a Clorox/Bleach solution and she used the rag to wash her blender. She stated that this was her normal routine and she uses the Clorox/Bleach solution for most of her dishwashing to save time from walking across the kitchen to the 3-compartment sink. Surveyor observed S3 Dietary [NAME] put ,d+[DATE] beef patties into the same blender and began to blend the beef patties. S3 Dietary [NAME] was alerted by the survey team on two different occasions to dispose of the beef patties due to the usage of Clorox/Bleach solution during dishwashing. S3 Dietary [NAME] stated, I am going to do it anyways! Surveyor observed S3 Dietary [NAME] continue to blend the beef patties in the same blender and then S3 Dietary [NAME] placed the blended beef patties onto the serving/steam line for meal plating/serving. S1 Administrator was nearby in the Dietary Manager's office and was alerted by the survey team of the above findings. In an interview on [DATE] at 12:18 p.m., S1 Administrator stated the Clorox/Bleach solution in the red buckets (3 total buckets) were for cleaning of the kitchen countertops and shelving (not for dishwashing). In an observation of and interview with S1 Administrator at [DATE] at 12:20 p.m., S1 Administrator counseled S3 Dietary [NAME] that the Clorox/Bleach solution was not for dishwashing and stated it should only be used for surface level disinfecting. S3 Dietary [NAME] confirmed she did use the Clorox/Bleach solution to wash the blender. S1 Administrator instructed S3 Dietary [NAME] to remove the pureed beef patties from the serving/steam line and dispose of them properly. Surveyor observed S3 Dietary [NAME] dispose of pureed beef patties. Surveyor observed S1 Administrator properly clean and sanitize the blender in the 3-compartment sink. S1 Administrator instructed S3 Dietary [NAME] to prepare a new batch of pureed beef patties. In an interview on [DATE] at 8:40 a.m., S4 Maintenance Supervisor revealed he was helping S1 Administrator manage the kitchen and dietary staff due to the Dietary Manager being out on FMLA since ,d+[DATE]. At this time, a tour of the kitchen was conducted with S4 Maintenance Supervisor and revealed the following: Reach-In Refrigerator: 2. Two bowls of unlabeled and undated peaches. Two bowls of unlabeled and undated pureed fruit cocktails. One bowl of unlabeled and undated assorted fruit (oranges/pears/peaches). Three opened gallon jug pitchers of unlabeled and undated red liquid. Walk-In Freezer: 3. Observed freezer door was unable to be closed properly due to the frost build-up. Observed increased production of frost throughout walk-in freezer. Upon entrance of the walk-in freezer, observation of multiple cardboard boxes of food items covered with frost and unable to view item labels due to the excessive amounts of frost. Observed excessive frost accumulated on the freezer ceiling, walls, doorway, and flooring. Observed several boxes of food items stored directly on the walk- in freezer floor. During the tour, S4 Maintenance Supervisor stated that the walk-in freezer door was fixed/replaced recently and the frost accumulation is due to the staff not closing the freezer door properly. No documentation of walk-in freezer door repairs provided from S1 Administrator during the survey, as requested multiple times on [DATE] and [DATE]. Dry Pantry: 4. One undated, open to air, 50-pound bag of white rice. One undated, open to air, box of Quaker oats One undated, open to air, bag of corn flakes One opened and undated squeeze bottle of grape jelly with an expiration date of [DATE]. Hot Foods Warmer: 5. Two large baking pans of uncovered and undated assorted cakes Kitchen Cleanliness: 6. During kitchen tour, Surveyor observed dried brown grease stains on the kitchen floors; sticky floors, food particles on several areas of the kitchen floor, kitchen shelving, equipment, and counter tops; accumulation of dust and crumbs on sealed containers throughout the kitchen, meal prep area, and dry pantry area; dust, debris, and stains on the dishwashing station equipment, brown splatter marks on walls behind stove area; used foil observed in the stove from previous meals. Surveyor observed the inside of the stove contained baked on food accumulation on the walls, racks, and glass door, as well as an accumulation of dust, crumbs, and food stains on the clean dish rack. S4 Maintenance Supervisor confirmed all the above findings during kitchen tour. Hair Restraints: 7. In an observation of and interview in the kitchen area of S11 Dietary [NAME] on [DATE] at 12:03 p.m., revealed S11 Dietary [NAME] had long curly beard/facial hair and no usage of a beard net. S11 Dietary [NAME] confirmed he does not wear a beard net and was unaware to wear a beard net since he was hired 4 months ago. In an observation of and interview in the kitchen area with S12 Dietary Aide on [DATE] at 12:05 p.m., revealed S12 Dietary Aide had a curly beard/facial hair and no usage of a beard net. S12 Dietary Aide confirmed he does not wear a beard net and was unaware to wear a beard net since he was hired 1 year ago. In an observation of S11 Dietary [NAME] on [DATE] at 12:30 p.m., revealed him walking throughout the kitchen and meal prep area with no beard net. Hand Hygiene: 8. On [DATE] at 12:35 p.m., observed S12 Dietary Aide with gloves on assist with lunch meal plating. Surveyor observed S12 Dietary Aide with the same gloves begin to organize the clean plates, sort through the resident meal tickets, adjust clothing/pants, put hands on his hips, touch the lower bottom shelving behind him, and push the serving cart out of the kitchen/prep area into the resident dining area. Surveyor observed S12 Dietary Aide return from dining area with same gloves on. He then touched clean utensils, and grabbed a slice of cornbread with his gloved hand. No hand hygiene or change of gloves observed throughout all of the above tasks. Temperature Logs: 9. On [DATE] at 12:26 p.m., observed S4 Maintenance Supervisor plate the lunch meal. Surveyor observed that S4 Maintenance had not measured the temperature of each food item and logged the temperatures prior to serving lunch. On [DATE] at 12:40 p.m., a review of Food Temperature Logs revealed missing temperature logs for the following dates: [DATE]-lunch [DATE]-lunch [DATE]-breakfast-lunch-dinner [DATE]-breakfast-lunch-dinner [DATE] breakfast-lunch [DATE] breakfast-lunch [DATE]-breakfast-lunch [DATE] breakfast-lunch [DATE] breakfast-lunch-dinner [DATE] breakfast-lunch-dinner On [DATE] at 12:40 p.m., a review of Refrigerator Temperature Record revealed missing temperature logs for the following dates: [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] In an interview on [DATE] at 12:45 p.m., S3 Dietary [NAME] stated the kitchen staff were supposed to monitor and log the food temperatures prior to serving meals and monitor/log the refrigerator/freezer temperature logs on each shift. S3 Dietary [NAME] confirmed the above dates were not logged; therefore, the temperatures were not checked. In an interview on [DATE] at 2:15 p.m., S4 Maintenance Supervisor confirmed he should have checked with S3 Dietary [NAME] to see if she measured food temperatures prior to serving lunch today, but he did not. S4 Maintenance Supervisor confirmed temperatures for food items should be taken prior to food being served to ensure the proper food temperature. In an interview on [DATE] at 2:20 p.m., S1 Administrator confirmed that the dietary staff should perform temperature checks and log all temperatures for each meal (breakfast, lunch, and dinner) prior to serving/plating the foods. S1 Administrator confirmed the above missing temperatures were not monitored or documented but should have been. In an interview on [DATE] at 2:25 p.m., S13 RD revealed she had been the facility RD since [DATE] and had the same concerns as the above survey findings. S13 RD stated when she first toured the kitchen in [DATE], she told the dietary staff not to use Clorox/Bleach and stated it would only be appropriate if they used a capful of Clorox/Bleach. However, the dietary staff were just free-pouring the Clorox/Bleach in the red buckets. S13 RD stated since [DATE], the walk-in freezer has always had excessive frost build-up. S13 RD confirmed the dietary staff should have worn beard nets when they have facial hair and always practice proper hand hygiene/gloving throughout their shift, especially when handling foods and food items. Plan of Removal : All 65 residents have the potential for illness or serious harm from the alleged deficiency F812. On [DATE] a cook used bleach to sanitize a food processor. Immediately the administrator called the dietary consultant to come in [DATE] and in-service and train the dietary staff to ensure regulatory compliance. After review of policy and procedures they did not require updating. The continuing education of current and new dietary staff will be done by the administrator, the administrator's designee, or the dietary consultant at monthly in-services. The administrator removed all bleach from dietary, and the facility on [DATE]. On [DATE] the administrator immediately verbally in-serviced dietary staff present that bleach is not used to sanitize equipment, pots & pans, and cutlery. The 3 compartment sink was explained and how to check the proper level of sanitizer. On [DATE] the administrator called the dietary consultant to come [DATE] to in-service and train dietary staff on sanitary conditions in the kitchen and how to set up and check the sanitizer in the 3 compartment sink to ensure regulatory compliance. On [DATE] the administrator called 2 off duty dietary staff to verbally in-service them about not using bleach, and how to setup the 3 compartment sink and check the sanitizer. All dietary staff have been in-serviced as of [DATE]. Continuing education will be provided by the administrator, the administrator's designee, or the dietary consultant at monthly in-services for all dietary staff. The kitchen will be audited randomly to ensure there is no bleach in the kitchen, the audits will be done bi-weekly for the next 3 weeks and then weekly to monitor the kitchen that no bleach is present. This monitoring will be included in the current QAPI being done in the kitchen and reported quarterly in the QA meeting, the Administrator and Maintenance Supervisor will complete the random audits and weekly audits. Any dietary staff not following policies and procedures given in-services will be given written warnings up to and including termination. Correction Date: [DATE] at 1:29 p.m.

Based on observation, interview, and record review the facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for 11 (#6, #7, #10, #12, #15, #26, #30, #45, #55, #61, and #224) of 11 Residents who were ordered and served pureed diets. Findings: Record Review of the facility's current, undated policy titled Standardized Recipes read in part . Standardized recipes shall be developed and used in preparation of foods. Record Review of the facility's current, undated [NAME] Job Description read in part . Responsibilities: Follows menu and recipes to prepare food. Record Review of the facility's approved 2024 Fall/Winter Lunch Menu revealed the facility was on Week: 3, Day: Monday: Red beans and Sausage, Steamed Rice, Club Spinach, Cornbread, Caramel Sour Cream Cake for Dessert, and Beverage/Water. Alternate Menu item: Beef Patty (hamburger steak). Record Review of the facility's approved recipe for Pureed steamed rice read in part . Ingredients: Serving size 15: 11.25 1/2 cups Seamed Rice, 1 cup and 1 tablespoon of Whole Milk, and 1/2 cup and 1 tablespoon of Soft Margarine. Instructions: Prepare rice according to regular recipe. 2. Place food in processor, process until smooth adding 1.5 tablespoon of milk and 2.5 tablespoons of margarine per portion. Record Review of the facility's approved recipe for Pureed club spinach read in part . Ingredients: Serving size 15: 3 pounds of frozen chopped spinach, 9 1/2 oz. shredded cheddar mild cheese, 4 1/4 oz. bread crumbs, 2 tablespoon, 1 /1/4 teaspoon of soft margarine, 1 3/4 cup of water or stock, 3 tablespoon and 2 1/2 teaspoons of food thickener. Instructions: Steam and drain spinach. Place a layer in greased pan. 2. Cover spinach with cheese. 3. Combine crumbs and margarine, sprinkle equal quantity over cheese in each pan. 4. Bake at 325F for 30 minutes or until internal temperature of 165F or higher for 15 seconds. 5. Prepare slurry (water or stock and food thickener) 6. Process until smooth using 1 oz. of slurry per portion. Record Review of the facility's approved recipe for Pureed hamburger steak read in part . Ingredients: Serving size 15: 15-6 oz. hamburger steak with 3 oz. of onion gravy, 1 3/4 cup and 2 tablespoon Stock beef/soup base, and 3 tablespoon, and 2 1/2 teaspoons of food thickener bulk. Instructions: Prepare hamburger steak according to regular recipe. 2. Prepare slurry (stock beef/soup, and food thickener). 3. Process until smooth adding 1 oz. slurry per portion. Observation on 02/17/2025 at 12:03 p.m. revealed S3 Dietary [NAME] prepared puree meal items: steamed rice, and spinach. S3 Dietary [NAME] was observed placing an unmeasured amount of rice into the blender with no other ingredients, and pureed the rice. S3 Dietary [NAME] then placed the prepared pureed rice onto the steamtable for serving. S3 Dietary cook was then observed preparing pureed spinach. S3 Dietary cook placed an unmeasured amount of spinach and placed in the blender, and added an unmeasured amount of food thickener to the blender as she pureed the spinach. S3 Dietary cook placed the prepared pureed spinach onto the steam table for serving. S3 Dietary [NAME] stated she did not refer to recipes when she prepared pureed food items, and stated she added an unmeasured amount of food thickener due to doing it by sight. Observation on 02/17/2025 at 12:38 p.m. revealed S3 Dietary [NAME] prepared puree meal item: Beef Patty/Hamburger steak. S3 Dietary [NAME] was observed placing 6 hamburger patties into the blender, adding an unmeasured amount of water into the blender, and an unmeasured amount of food thickener to the blender. S3 Dietary [NAME] placed the prepared pureed beef patties onto the steam table for serving. Observation revealed S4 Maintenance Supervisor served the prepared pureed food items to residents who received pureed diets. Interview on 02/17/2025 at 12:38 p.m. with S3 Dietary [NAME] revealed she did not refer to recipes when she prepared the above puree meal items, and did not know if using water when preparing puree food items was appropriate. S3 Dietary [NAME] confirmed she had not been trained on referring to recipes when she prepared meals. Interview on 02/17/2025 at 2:20 p.m. with S4 Maintenance Supervisor, who was the acting dietary manager, confirmed dietary cooks were to refer to recipes when preparing meals.

Based on observations, interviews, and record review, the facility failed to provide sufficient support personnel to effectively carry out the functions of the food and nutrition services. The facility failed to ensure meals were served timely according to the meal times posted. This deficient practice had the potential to affect the 62 residents that received meals from the facility kitchen. Findings: Review of the facility's Meal Times revealed the following in part: Dining Room: Breakfast 07:30 a.m., Lunch 11:30 a.m., and Supper 4:30p.m. Hall Trays (Cart): Breakfast 7:45 a.m., Lunch 12:00 p.m , and Supper 5:00p.m. Review of the facility's policy titled Frequency of Meals dated 06/2003 read in part . 1. At least three meals or their equivalent are served daily, at regular times. Observation on 02/17/2025 at 12:35 p.m. revealed kitchen staff began to serve lunch to residents in the dining room. Observation revealed the lunch meal service began 1 hour and 5 minutes past the posted lunch meal service time. Resident #32 Interview on 02/17/2025 at 1:45 p.m. with Resident #32 revealed the facility served lunch late, almost daily, around 1:00 p.m., or 1:30 p.m. Review of Resident #32's medical record revealed he was admitted to the facility on [DATE]. Resident #32 had diagnoses that included in part . Type 2 Diabetes Mellitus, Heart Failure, Hypertensive Heart Disease, Generalized Edema, Chronic Obstructive Pulmonary Disease, and Primary Generalized Osteoarthritis. Review of Resident #32's Annual MDS with ARD of 01/21/2025 revealed Resident had BIMS of 15, which indicated his cognition was intact. Interview on 02/18/2025 at 11:58 a.m. with S15 CNA, S16, CNA, S17 CNA, and S18 CNA who were present in the dining room during lunch meal service revealed CNA's stated lunch meal service was almost always served late. S15 CNA stated residents often waited a long time for lunch, and were almost always served between 1:00p.m. - 1:30p.m. 46773 Resident #26 Review of Resident #26's medical records revealed an admitted [DATE] with a readmitted [DATE]. Resident #26 had diagnoses that included: Protein Calorie Malnutrition, Cognitive Communication Deficit, and Depressive Episodes. Review of Resident #26's Quarterly MDS with ARD 02/11/2025 revealed BIMS was not conducted because resident is rarely or never understood, and a mechanically altered diet was used for nutritional approach. Interview on 02/17/2025 on 2:35 p.m. with Resident #26's RP (responsible party) revealed that lunch had been consistently late for the past 6 weeks. RP stated lunch was served between 12:30 p.m. to 2:00 p.m. Observation on 02/19/2025 at 12:40 p.m. revealed Resident #26 was observed sitting in room in wheelchair. Lunch tray had not been delivered yet. Interview on 02/19/2025 at 12:42 a.m. with S23 RN revealed that lunch was being served a little later recently, and the halls was served lunch around 1:00 p.m. daily. Observation on 02/19/2025 at 1:04 p.m. revealed Resident #26's lunch tray was served to her in her room.

Based on observation, interview, and record review the facility failed to ensure drugs were stored in accordance with currently accepted professional principles by: 1. Failing to ensure an insulin vial was labeled with the date it was opened; 2. Failing to maintain accurate and complete documentation for medications in the emergency kit; 3. Having a loose pill in 1 (Cart A) of 1 medication cart checked for safe and secure storage; 4. Failing to ensure expired medications were not available for use; 5. Failing to document administration of controlled substances; 6. Failing to ensure a narcotic record included the strength of the medication; and 7. Failing to discard a controlled substance when it was discontinued. Findings: Review of the facility's policy entitled Insulin Administration dated 01/15/2025 revealed, in part .if opening a new vial, record the expiration date and time on the vial, and follow the manufacturer's recommendations for expiration after opening. Lantus insulin vials expire 28 days after opening. Review of the facility's undated policy entitled Emergency Medication Kit revealed, in part .when an emergency or stat medication is needed, the nurse breaks the container's seal and removes the prescribed medication. The nurse records the name of the medication, strength, quantity taken, date, the name of the resident, name of the physician, and the nurse's signature. A new seal is placed on the kit after the replacement medication has been added. Review of the facility's policy entitled Administering Oral Medications revised on 01/15/2025 revealed, in part .select the drug from the unit dose drawer or stock supply. Check the label on the medication and confirm the medication name and dose with the medication administration record. Check the expiration date on the medication. Expired medication should be turned in to your supervisor for medication destruction. Review of the facility's policy provided on 02/19/2025 at 1:44 p.m. and entitled Controlled Substances dated 01/15/2025 revealed, in part .a resident's controlled substance record must include the name and strength of the medication, the number on hand, the time of administration, and the signature of the nurse administering the medication. Review of the facility's policy provided on 02/19/2025 at 3:06 p.m. and entitled Controlled Substances dated 01/15/2025 revealed, in part .the DON shall investigate any discrepancies in narcotics reconciliation. When a controlled substance is discontinued, the nurse will bring the medication to the DON. The controlled medication will be placed into a locked closet until the medication is destroyed. #1 Observation of the medication storage room on 02/19/2025 at 11:50 a.m. with oversight from S5 ADON revealed an opened undated vial of Lantus in the medication refrigerator. An interview was conducted with S5 ADON at this time. She confirmed vials of insulin should be labeled with the date they are opened and discarded 28 days after opening. S5 ADON confirmed the Lantus was not labeled with the date it was opened, but should have been. #2 Observation of the facility's emergency kit (E-Kit) revealed the box was locked with seal/tag #0138033. Review of the facility's E-Kit Log dated February 2025 revealed, in part, the current tag # was #0138086/1143910 applied on 02/18/2025 by S2 DON. Further review of the E-Kit Log revealed documentation of the strength of the medication, quantity taken or added, and the name of the physician were not included on the log. An entry dated 02/12/2025 did not include the name of the medication removed. An interview was conducted with S5 ADON at this time who confirmed the tag # on the E-Kit should match the most recent tag # on the E-Kit Log. S5 ADON confirmed the tag on the E-Kit does not match the tag # documented on the E-Kit Log, but should. In interview was conducted with S2 DON at this time who confirmed she did document tag #0138086/1143910 on 02/18/2025 on the E-Kit log. S2 DON confirmed the tag on the E-Kit was not the same tag # documented on the E-Kit Log, but should be. #3 Observation of Cart A on 02/19/2025 at 12:20 p.m. with oversight from S7 LPN and S5 ADON revealed half of an unidentified loose yellow tablet in the bottom of the 2nd drawer of the cart. An interview was conducted with S7 LPN at this time who confirmed there was half of an unidentified loose tablet in bottom of the 2nd drawer of the medication cart, but should not have been. #4 Further observation of Cart A revealed one bottle of Latanoprost Ophthalmic Solution 0.005% with an open date of 10/29/2024, one bottle of Dorzolamide Ophthalmic Solution 2% with an open date of 11/30/2024, and one opened bottle of Brimonidine tartrate Ophthalmic Solution 0.2% without an open date. An interview was conducted with S5 ADON at this time who confirmed eye drops should be labeled with the date they are opened and discarded 28 days after opening. S5 ADON confirmed the Latanoprost Ophthalmic Solution 0.005% and Dorzolamide Ophthalmic Solution 2% were not discarded 28 days after opening, but should have been. S5 ADON confirmed the Brimonidine tartrate Ophthalmic Solution 0.2% was not labeled with the open date, but should have been. #5 Observation of the Cart A narcotic storage drawer with oversight from S7 LPN and S5 ADON revealed one blister pack for Resident #55 containing 13 tablets of Lorazepam 0.5mg. Review of the narcotic record revealed one record for Resident #55 dated 02/21/2024 indicating 13 Lorazepam 0.5mg tablets remaining, and one record for Resident #55 dated 08/01/2024 indicating 13 Lorazepam 0.5mg tablets remaining. An interview was conducted with S5 ADON at this time who confirmed there were two narcotic records for Resident #55, indicating a total of 26 tablets of Lorazepam 0.5mg. S5 ADON confirmed there were 13 tablets of Lorazepam 0.5mg for Resident #55 and the narcotic record was incorrect for Resident #55. Further observation revealed one blister pack for Resident #41 containing 19 Norco 5/325mg tablets. The narcotic record for Resident #41 revealed 20 Norco 5/325mg tablets remaining. One blister pack was observed for Resident #67 containing 39 Norco 5/325mg tablets. The narcotic record for Resident #67 revealed there were 40 Norco 5/325mg tablets remaining. An interview was conducted with S7 LPN at this time who revealed she had provided one Norco 5/325mg tablet to Resident #41 and one Norco 5/325mg tablet to Resident #67 this am. S7 LPN confirmed she did not document the narcotic medications on the narcotic record when they were administered, but should have. #6 The narcotic record for Resident #67 stated the name of the medication, Zolpidem, but did not include the strength. S5 ADON confirmed the strength of the medication should be documented on the narcotic record. #7 An interview with S5 ADON on 02/19/2025 at 2:09 p.m. revealed the Lorazepam had been previously discontinued for Resident #55. She did not know the date the Lorazepam had been discontinued. S5 ADON confirmed when controlled substances were discontinued, they should be removed from the cart and the DON was responsible for returning them to the pharmacy. S5 ADON confirmed the Lorazepam for Resident #55 should not have been in Cart A. An interview was conducted on 02/19/2025 at 4:48 p.m. with S2 DON who confirmed the discontinued Lorazepam for Resident #55 should have been removed from Cart A, but was not. Review of Resident #55's current Order Summary Report revealed no current order for Lorazepam.

Based on observation, interview and record review the Facility failed to provide respiratory care consistent with professional standards for 3 (Resident #10, Resident #17 and Resident #273) of 35 residents reviewed for respiratory care. The Facility failed to ensure respiratory equipment was properly changed, labeled and stored. Findings: Review of a Facility Policy titled Oxygen Administration with a revision date of 12/02/2024, revealed in part . All safety precautions and care of equipment shall be performed according to recommended State and Federal guidelines and facility procedures. Prefilled humidifier bottles and nasal cannulas/masks will be changed every week and PRN. All tubing and bottles are to be labeled each week when changed. When the tubing I not being used, it should be stored properly in a zip lock bag. Humidifiers are not required but are permitted with oxygen flow of 1-2 LPM. Resident #273 Review of Resident #273's medical record revealed an admitted [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease, Pulmonary Fibrosis, Type 2 Diabetes Mellitus, and Human Immunodeficiency Virus. Review of Resident #273's Medication Administration Record dated 02/2025 revealed in part .Budesonide inhalation Suspension 0.5 MG/2ML (breathing treatment) 1 inhalation two times a day related to Chronic Obstructive Pulmonary Disease. Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (breathing treatment) 1 inhalation three times a day related to Chronic Obstructive Pulmonary Disease. Review of Resident #273's care plan with a target date of 05/08/2025 revealed in part .Impaired Gas Exchange related to Chronic Obstructive Pulmonary Disease with approaches that included: Administer medications as ordered, Administer oxygen therapy as ordered. Observation and interview on 02/17/2025 at 9:57 a.m. revealed Resident #273 sitting in a recliner in her room. A nebulizer mask was lying uncovered on top of Resident #273's refrigerator. Resident #273 revealed she received breathing treatments via the nebulizer mask. Observation and interview on 02/17/2025 at 10:00 a.m. with S24 LPN revealed Resident #273 received breathing treatments via the nebulizer mask. S24 LPN confirmed Resident #273's nebulizer mask was lying on top of her refrigerator uncovered, and it shouldn't have been. 51503 Resident #10 Review of Resident #10's medical record revealed an admitted [DATE] with diagnoses that included in part . Dementia, Unspecified Severity, without Behavioral Disturbance, (Congestive) Heart Failure, Acute Respiratory Failure with Hypoxia, Dyspnea, and Shortness of Breath . Review of Resident #10's Modification of Quarterly and State Optional MDS with ARD of 11/12/2024 revealed a BIMS score of 14, which indicated cognition was intact, and resident received oxygen therapy. Resident #10 required total dependence with one person physical assist for bed mobility and required total dependence with two persons physical assist for transfers. Review of Resident #10's current physician orders revealed in part . -Change oxygen and nebulizer tubing weekly on Thursday every night shift with a start date of 01/30/2025 . -Oxygen per nasal cannula at 3LPM continuously every twelve hours related to acute respiratory failure with hypoxia with a start date of 09/01/2024 . Review of Resident #10's care plan with an initial date of 08/20/2024 revealed in part .a focus of altered respiratory status/difficulty breathing with interventions included change oxygen and nebulizer tubing weekly on Thursday, provide oxygen as ordered-oxygen per nasal cannula at 3LPM continuously with an initiated date of 08/20/2024. Observation and interview on 02/17/2025 at 10:50 a.m., revealed Resident #10 with oxygen in progress at 3 LPM, no humidified bottle attached to the oxygen and no date on the oxygen tubing. Resident stated she wears her oxygen at all times. Observation and interview on 02/18/2025 at 12:10 p.m., revealed Resident #10's oxygen in progress with no humidifier bottle attached and undated oxygen tubing. Observed an unopened, bagged humidifier bottle on the bedside table, not in use. Observation and interview on 02/18/2025 at 12:39 p.m. with S24 LPN stated Resident #10 had orders for continuous oxygen and sometimes she had a humidifier bottle and sometimes she does not. S24 LPN stated that the facility staff change out the oxygen tubing, label, and date the tubing and humidifier bottles when ordered. S24 LPN was not sure if Resident #10 required humidified oxygen. S24 LPN confirmed Resident #10 did not have a humidifier bottle for her continues oxygen and the oxygen tubing was not dated. In an interview on 02/19/2025 at 9:35 a.m., S2 DON revealed that oxygen/nebulizer tubing should be labeled and stored in a bag when not in use. The nursing staff change the nebulizer/oxygen tubing and label bags weekly on Thursdays. S2 DON stated that residents with oxygen orders of less than 2 liters per minute do not require a humidifier bottle for oxygen usage. S2 DON confirmed residents with orders oxygen therapy of 2 liters per minute or above required a humidifier bottle during oxygen therapy. In an interview on 02/19/2025 at 1:45 p.m., S2 DON confirmed Resident #10 should've had a humidifier bottle attached to her oxygen. Resident #17 Review of Resident #17's medical record revealed an admitted [DATE] with diagnoses that included in part .Persistent Asthma with (Acute) Exacerbation, Anxiety Disorder, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, and Acute Respiratory Failure with Hypercapnia . Review of Resident #17's Quarterly and State Optional MDS with ARD of 01/07/2025 revealed a BIMS score of 15, which indicated cognition was intact, and resident received oxygen therapy. Resident #17 required total dependence with one person physical assist for bed mobility and required total dependence with two persons physical assist for transfers. Review of Resident #17's current physician orders revealed in part . -Change oxygen and nebulizer tubing weekly on Thursday every night shift with a start date of 01/30/2025 . -Oxygen per nasal cannula at 2LPM continuously every twelve hours related to severe persistent asthma with acute exacerbation with a start date of 09/03/2024 . -Ipratropium-Albuterol Nebulization Solution 0.5-2.5(3)mg/3ml dose inhale orally four times a day related to severe persistent asthma with acute exacerbation with a start date of 09/03/2024 . Review of Resident #17's care plan with an initial date of 01/18/2025 and a next review date of 04/18/2025 revealed in part .a focus of impaired gas exchange related to ineffective air clearance with interventions included administer oxygen therapy as ordered and provide breathing treatment as ordered with an initiated date of 01/18/2025 . On 02/17/2025 at 10:15 a.m., observed Resident #17's oxygen tubing on the resident's bedroom floor, un-bagged, and unlabeled. Observed Resident #17's nebulizer mask placed directly on the bedside dresser drawer, un-bagged, and undated. In an interview and observation on 02/17/2025 at 10:20 a.m., S10 LPN confirmed Resident #17's oxygen tubing and nebulizer mask should be in a bag and that both the nebulizer and oxygen items should be stored/labeled correctly and was not. In an interview on 02/19/2025 at 9:35 a.m., S2 DON revealed that nursing staff are ordered to change the nebulizer/oxygen tubing and bags weekly on Thursdays. S2 DON confirmed that all oxygen and nebulizer tubing should be labeled and stored in a bag when not in use.

Based on interview and record review, the facility failed to protect Resident #5's right to be free from resident to resident physical abuse by Resident #1, in a sample of 5 residents reviewed for abuse (#1, #2, #3, #4 and #5). This deficient practice resulted in an actual harm situation for Resident #5 on 02/28/2023 at 8:20 p.m., when Resident #5 who had a diagnoses of Dementia and had wandering behaviors, was observed on the floor with Resident #1 standing over Resident #5 kicking, hitting and yelling at her. Resident #1 was pulled off of Resident #5 by staff. Abrasions were observed to Resident #5's bilateral knees, and her left upper arm was red with non-pitting edema. Resident #5 complained of pain to her left hip with a rating of 6 out of 10. Resident #5 was sent to the emergency roiagnom on [DATE] at 8:42 p.m. for complaints of left hip pain, abrasions to bilateral knees and left arm edema, and was diagnosed with Strain of back muscle and Contusion of lower back. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Non Compliance citation. Findings: Review of the Facility's policy titled Abuse, Neglect-Exploitation or Misappropriation-Reporting and Investigating revealed the following in part .upon receiving any allegations of abuse, the Administrator is responsible for determining what actions (if any) are needed for the protection of residents. Resident #5 Review of Resident #5's medical record revealed an admitted [DATE], and diagnoses which included: Unspecified Dementia, Other specified Depressive Episodes, Primary Generalized Osteoarthritis and Pain Unspecified. Resident #5's medical record revealed she resided on Hall A. Review of Resident #5's Quarterly MDS assessment, with an ARD of 05/16/2023, revealed a BIMS score of 2, which indicated severely impaired cognition. The MDS revealed Resident #5 was independent with bed mobility, transfer, eating, locomotion on and off room/unit, and required limited one person physical assistance with bathing and personal hygiene. Review of Resident #5's Comprehensive Plan of Care with a target date of 08/16/2023 revealed in part . a problem of wandering, with approaches to place resident in an area where constant observation is possible, and to assign staff to account for resident whereabouts at all times. Review of Resident #5's CNA Care Guide revealed Resident #5 was to be monitored by staff every 1 hour, although Resident #5's Comprehensive Plan of Care revealed approaches to place resident in an area where constant observation is possible, and to assign staff to account for resident whereabouts at all times. Review of an Incident/Accident Reporting Form dated 02/28/2023 at 8:20 p.m. and prepared by S10 LPN read as follows in part .Description: Resident #1 was observed standing over Resident #5, kicking, hitting and yelling at her in the corner of the doorway beside Hall A. Resident #5 was observed lying on her back in the corner of the doorway beside Room A kicking Resident #1 to defend herself. Resident #1 was pulled off of Resident #5 by staff, and Resident #1 walked away to his room while continuing to yell. Resident #1 stated that Resident #5 had been coming in his room all day. Resident #5 was assisted to the medication room and a head to toe assessment was given. Abrasions were noted to Resident #5's bilateral knees, and her left upper arm was red with non-pitting edema. Resident #5 complained of pain to left hip with a rating of 6 out of 10. Tylenol 650 MG administered. Review of Resident #5's hospital records dated 02/28/2023 revealed diagnoses of Strain of back muscle, and Contusion of lower back. Medications prescribed were: Ultram 50 MG (used to treat moderate to severe pain), and Flexeril 10 MG (used to treat pain and stiffness). Review of Resident #5's physician's order dated May 2023 revealed an order to monitor Resident #5 every hour, with a start date of 04/2022. Observation and interview on 05/30/2023 at 11:00 a.m. revealed Resident #5 in bed in her room. Resident #5 stated she remembered going to the hospital recently, but did not remember why. Resident #5 was unable to recall any details about the incident that occurred on 02/28/2023. Interview on 05/30/2023 at 2:19 p.m. with S4 LPN revealed she provided care for Resident #5 on the 7:00 a.m. to 7:00 p.m. shift. S4 LPN stated Resident #5 had Dementia, was very confused, and was ambulatory with no behaviors other than wandering. S4 LPN stated she was not on duty the evening of 02/28/20223 when Resident #5 was physically abused, but it was reported to her the next morning that Resident #5 wandered into Resident #1's room and said something to him. S4 LPN stated Resident #1 physically attacked Resident #5, and she was sent to the hospital for evaluation and treatment. Interview on 05/31/2023 at 1:05 p.m. with S6 CNA revealed she provided care for Resident #5 on the 6:00 a.m. to 2:00 p.m. shift, and had to redirect her often because she wandered. S6 CNA stated resident wandered into other resident's rooms at times. S6 CNA revealed Resident #5 was on every one hour monitoring but she was not aware that Resident #5 had to be in constant sight. Interview on 05/31/2023 at 1:18 p.m. with S4 LPN revealed Resident #5 was on every one hour checks by the nurses. Review of Resident #5's medical record with S4 LPN on the above date and time revealed the following: a physician's order dated 05/2023 to monitor Resident #5 every one hour, and Resident #5's E-MAR for 05/2023 revealed there was no documentation of monitoring of Resident #5's whereabouts by the nurses. Interview on 05/31/2023 at 1:30 p.m. with S7 CNA revealed she worked the 6:00 a.m. to 2:00 p.m. shift, and provided care for Resident #5. S7 CNA stated Resident #5 was ambulatory throughout the facility, and had to be redirected often. S7 CNA stated Resident #5 would try and assist other residents to their rooms, and sometimes opens other residents' doors. S7 CNA stated she was aware that Resident #5 was to be checked on every hour, but she worked Hall A by herself and it was impossible that she could have Resident #5 in her eyesight at all times. Interview on 05/31/2023 at 2:21 p.m. with S5 [NAME] Clerk /CNA revealed she was working as the [NAME] Clerk on the night of 02/28/2023 when Resident #1 physically abused Resident #5. S5 [NAME] Clerk/CNA stated she was seated at the nurse's station when she heard a loud outburst. S5 [NAME] Clerk/CNA stated she was unable to see down Hall A, so she had to push her chair back from the desk so she could see down Hall A, and witnessed Resident #1 kicking and hitting Resident #5. Resident #5 in her stomach/side like she was a dead dog, and yelling at Resident #5 because she had opened the door to his room. S5 [NAME] Clerk/CNA stated she hollered for help and ran down Hall A to assist Resident #5. S5 [NAME] Clerk /CNA stated Resident #1 hit her (S5 [NAME] Clerk/CNA) upside the head when she attempted to intervene. S5 [NAME] Clerk/CNA stated S10 LPN made it to the incident and put herself between Resident #1 and Resident #5, enabling them to slide Resident #5 away from Resident #1. S5 [NAME] Clerk/CNA stated Resident #5 had bruising on the left side of her arm and she said she was hurting. S5 [NAME] Clerk/CNA confirmed Resident #5 was not in her eyesight when the incident occurred, and she only knew the incident was occurring because she heard Resident #1 yelling. S5 [NAME] /Clerk CNA stated she was not aware that Resident #5 had to be in constant sight. Surveyor was unsuccessful in contacting the two nurses who worked the night of 02/28/2023. Administrator of the facility at the time of the incident, is no longer employed at the facility. Interview on 05/31/2023 at 3:30 p.m. with S8 CNA revealed she provided care for Resident #5 on the 2:00 p.m. to 10:00 p.m. shift. S8 CNA stated Resident #5 wandered about the facility, and had to be redirected because she went into other residents' rooms. S8 CNA stated she checked on Resident #5 every 2 hours. S8 CNA did not know Resident #5 was to be checked on every hour or within constant sight. Interview on 06/01/2023 at 9:13 a.m. with S9 CNA revealed she provided care for Resident #5 on the 6:00 a.m. to 2:00 p.m. shift. S9 CNA stated Resident #5 had to be redirected often because she wandered into other residents' rooms to assist them, because she thought she was an employee at the facility. S9 CNA stated she knew Resident #5 was on every hour monitoring but was not aware that Resident #5 should have been within eyesight at all times. Interview on 05/31/2023 at 4:10 p.m. with S2 DON and S3 ADON MDS Coordinator confirmed Resident #5's current care plan with a target date of 08/16/2023 revealed Resident #5 wanders, with a goal for Resident #5 to only wander within specified boundaries (inside the facility). S2 DON and S3 ADON/MDS Coordinator confirmed care plan approaches instructions included to place Resident #5 in an area where constant observation was possible, and to assign staff to account for resident's whereabouts at all times. S3 ADON stated the staff on Resident #5's hall were to provide supervision of Resident #5, and although the care plan stated that staff were to be assigned to account for Resident #5's whereabouts at all times, staff were not assigned because the nurse was responsible for checking on Resident #5 every hour. S2 DON and S3 ADON/MDS Coordinator confirmed Resident #5's whereabouts had not been constantly observed when Resident #5 was physically abused by Resident #1 on 02/28/2023. Observation of Resident #5 during the survey revealed she was being observed by staff every hour, and monitoring was documented on the MAR. Resident #1 Review of Resident #1's medical record revealed an admitted [DATE] and diagnoses which included: Cerebrovascular disease, Hypertension, Hyperlipidemia and Lack of Coordination. Review of Resident #1's Quarterly MDS assessment with an ARD of 01/03/2023, revealed a BIMS score of 1, which indicated severely impaired cognition. The MDS revealed Resident #1 was independent with bed mobility, transfer, locomotion on/off unit, dressing, eating, personal hygiene and toilet use. Review of Resident #1's Care Plan with a target date of 04/03/2023 revealed in part .potential for social isolation because Resident stays in his room most of the time. Approaches included to remind resident with verbal reminders of upcoming activities and document resident response to intervention. The Care Plan did not reveal Resident #1 had a history of abuse or aggressive behaviors. Interview on 05/30/2023 at 2:19 p.m. with S4 LPN revealed Resident #1 did not attend activities and ate meals in his room. S4 LPN revealed Resident #1 kept to himself and to her knowledge had no prior history of aggressive behavior. S4 LPN stated she was not on duty the evening of 02/28/20223 when Resident #1 physically abused Resident #5, but it was reported to her the next morning that Resident #5 wandered into Resident #1's room and said something to him. Interview on 05/30/2023 at 3:11 p.m. with S2 DON revealed after the incident on 02/028/28 the MD was notified and gave orders to PEC (Physician's Emergency Certificate) Resident #1 to the hospital. S2 DON stated Resident #1 did not agree to leave the facility and law enforcement had to intervene. S2 DON stated from the hospital Resident #1 was sent to a behavioral hospital and discharged from the facility. S2 DON stated Resident #5 did not attend activities and ate meals in his room. S2 DON revealed Resident #5 kept to himself and to her knowledge had no prior history of aggressive behavior. The facility has implemented the following actions to correct the deficient practice: There have been no resident to resident abuse incidences prior to 02/28/2023 or afterwards. There is one other resident identified as a wanderer. 1. In review of the incident with Resident #1 (accused) and Resident #5 (victim), the following was done: Investigation: On 2/28/23 at approximately 8:20 pm. , Resident #5 opened the door of Resident #2 and closed it after realizing it was not her room and proceeded to walk away from the door, down the hall towards the nursing station. Resident #1 came out of his room and came up behind Resident #5 and pushed her to the floor, standing over her pointing and shouting, and began to punch and kick her. Resident #5 was noted to kick back towards Resident #1 while lying on the floor. Staff members intervened to separate both residents. 2. Resident #1 was returned to his room with one-on-one supervision. MD was notified and order received to send to ER for evaluation and treatment. The paramedics arrived with one sheriff deputy to assist. Ambulance staff and sheriff spoke with Resident #1 for several minutes and a second deputy arrived to assist in taking resident to ER. Resident #1 agreed to be transported to ER for evaluation and was then transferred to Behavioral Health Unit for treatment from local ER. The accused resident has no previous behaviors of this type in the past 6 months. This facility is in the process of administering an involuntary/emergency discharge of the accused. 3. Resident #5 was removed to another area. Upon assessment MD was notified and Resident #1 was sent to local ER for evaluation and treatment. RP was notified of the incident. Resident #5 returned to facility the same night with no injury, With prescriptions for pain med and muscle relaxer PRN and was placed on a separate hall until it was determined that Resident #1 was not returning. She was then returned to her room on 100-hall. She remains ambulatory throughout the facility, no change in gait. Remains unchanged in cognition. Administrator has spoken with victim's family on several occasions, victim has no recollection of incident and does not appear to have been negatively affected by incident and no further complaint of pain. 4. An in-service was immediately provided with the staff on duty at the time of the incident. The entire staff was provided with an in service the day following the incident (03/01/2023). Training included Dementia Training, to include handling residents with difficult behaviors, residents who wander, and resident to resident abuse. Dementia training, to include handling residents with difficult behaviors was conducted on 2 February 2023 and 11 November 2022, and following the 02/28/2023 incident. 5. Abuse Policy reviewed with no revisions. 6. Resident #5's care plan was reviewed and updated. Resident #5 was to be monitored every one hour and document monitoring on the MAR every shift. 7. Training is scheduled for March 13, 2023 for the entire staff on crisis prevention with a certified instructor with a focus on handling resident to resident crisis. 8. Incident discussed in the morning department head QA meeting the day after the incident and interventions discussed. Abuse will be included in monthly QA meetings with evaluations and interventions as needed. Monitoring: 1. Resident #5's nurse on duty will monitor Resident #5 every 1 hour and document on MAR. This is to be continued as long as ordered by the physician. 2. The other resident identified as a wanderer has an intervention to monitor every one hour, and will be monitored every 1 hour by her nurse on duty and document on MAR. 3. ADON will review MARs weekly to ensure monitoring is taken place as instructed. ADON will randomly observe Resident #5 and other resident for wandering and interventions being taken by staff. 4. QA - Monitor weekly for 2 months by ADON. Evaluate and revise interventions as needed. Correction date: 03/13/2023

Based on observation, record review and interview, the facility failed to ensure written policies and procedures that prohibited mistreatment and abuse of residents by staff for 1 (#2) of 5 (#1, #2, #3, #4, and #5) sampled residents (#2) was implemented. The facility failed to: A.) Ensure that S1 CNA immediately reported to the Administrator, DON or charge nurse that S2 CNA (the alleged perpetrator) told her that she (the alleged perpetrator) had hit resident #2 while providing her ADL's. B.) Protect all 68 residents residing in the facility from the alleged perpetrator (S2 CNA) by allowing S2 CNA to work an 8 hour shift with residents after the Administrator had been informed of the alleged physical abuse report. This resulted in an Immediate Jeopardy situation which begin on 3/26/16 at 4:00 a.m. when S2 CNA (alleged perpetrator) reported to S1 CNA that she had hit a resident while working the night shift on 03/25/16 (10:00 p.m. to 6:00 a.m.). S1 CNA did not immediately report the incident to a supervisor. S1 CNA did not report the incident until 3/27/16 at 10:00 p.m. The Administrator was called and notified of the incident but staff failed to follow instructions given to them and allowed S2 CNA to work the night shift on 3/27/16 (10:00 p.m. to 6:00 a.m.). Review of facility's current abuse investigation revealed there was no in-service on the Policy and Procedure until 4/1/2016 after S4 Administrator was informed of the IJ. The total facility census was 68. The IJ was lifted on 4/1/16 at 5:00 p.m. when the facility provided an acceptable plan of removal which included the following: 1. Inservicing all facility staff on regulations regarding resident abuse, notification of allegations or admission of resident abuse, facility requirement of following directions of the supervisor. 2. All employees will receive copies of the facility's policy and protocol and will be reminded of the location of the policy's posting throughout the facility. 3. The facility will monitor staff to ensure the policy was followed weekly. The deficient practice continues at a scope and severity level greater than minimal harm. Findings: Upon entrance to the facility on [DATE] at 11:15 a.m., abuse investigations were requested. S4 Administrator stated that she had 2 completed investigations and was currently working on a third investigation. A request was made to provide the completed investigations and any information she had up to that point regarding the ongoing investigation. Review of the ongoing investigation revealed it involved physical abuse of resident #2. Review of the DHH Incident Tracking Form revealed the incident occurred on 3/26/16 at 4:00 a.m., was reported in the facility on 3/27/16 at 10:02 p.m. and was entered into the computer system on 3/28/16 at 8:55 p.m. S4 Administrator provided copies of hand written statements she had obtained from staff. Review of statements: Review of the hand written statement by S1 CNA dated 3/27/2016 revealed S2 CNA (alleged perpetrator) told her that she (S2 CNA) had hit resident #2. In a second hand written statement by S1 CNA, she revealed she did not report the abuse incident until 3/27/16 at 10:00 p.m. She noted that she reported the incident to her nurse, S3 LPN and then began to make her rounds on her assigned hall. Review of a hand written statement dated 3/27/16 by S2 CNA revealed she did not know what was going on. She stated she arrived to work and was accused of hitting resident #2. She indicated that she did not know where the allegation had come from. She wrote she was not aware of what was happening and thought it was hear say. She added that resident #2 had not had any bodily harm done to her. Review of a statement by S3 LPN dated 3/27/16 revealed she documented that at approximately 9:55 p.m. on 3/27/16, S1 CNA reported to her that she (S2 CNA) hit resident #2. This incident allegedly occurred on the 10:00 p.m. to 6:00 a.m. shift on 3/25/16. S3 LPN then documented that she immediately notified the Administrator and obtained statements from staff. Review of a statement dated 3/27/16 by S5 LPN revealed a CNA informed her that S1 CNA stated S2 CNA told her she had hit resident #2. S5 LPN revealed she attempted to call S6 DON and did not get an answer. She then called S4 Administrator. She also documented that she performed a full body audit on resident #2 on 3/27/16 and did not see any redness or bruising noted to the resident's body. She documented the resident did not flinch or appear to be afraid of staff during the body audit. Review revealed the resident did her usual hollering. Interviews with staff: Interview with S1 CNA on 4/1/16 at 11:25 a.m. revealed she worked with S2 CNA on the 10:00 p.m. to 6:00 a.m. shift on 3/25/16. She stated that around 4:00 a.m. on 3/26/16, S2 CNA told her that resident #2 had hit her during ADL care and that she hit the resident back. S1 CNA stated she did not report the incident to anyone at that time. She stated she returned to work on the night of 3/26/16 and did not report the incident to anyone that night. She stated that S2 CNA did not work on the night of 3/26/16. Further interview with S1 CNA revealed she returned to work on the night of 3/27/16 and went into the break room to clock in for the 10:00 p.m. to 6:00 a.m. shift. She stated S7 CNA was in the break room at that time. She told S7 CNA what S2 CNA had told her about hitting resident #2. S7 CNA told her that she needed to report that to the nurse, S3 LPN. She confirmed she did report the incident to S3 LPN at that time. S1 CNA also provided a hand written statement. She stated S2 CNA was allowed to work the 10:00 p.m. to 6:00 a.m. shift the night of 3/27/16 after S3 LPN had been informed of the incident between S2 CNA and resident #2. S1 CNA revealed S2 CNA was assigned to another hall that night and did not work with resident #2 the night of 3/27/16. Telephone interview with S2 CNA on 4/1/16 at 12:00 p.m. confirmed she did work the entire shift on 3/27/16 from 10:00 p.m. until 6:00 a.m. Interview with S3 LPN on 4/1/16 at 12:16 p.m. confirmed S2 CNA worked a different hall the night of 3/27/16 from 10:00 p.m. until 6:00 a.m. She stated S2 CNA was reassigned halls that night after S1 CNA had reported an allegation of physical abuse from S2 CNA to resident #2. Further interview with S3 LPN on 4/1/16 at 1:00 p.m. revealed she and S5 LPN had made the decision together to move S2 CNA to another hall after receiving the abuse allegation. She stated she did not speak directly to S4 Administrator the night of 3/27/16 because S5 LPN spoke with her regarding the reported incident. She stated that S5 LPN did not say that S4 Administrator instructed them to send S2 CNA home after the allegation. Interview with S5 LPN on 4/1/16 at 1:15 p.m. revealed she called and spoke with S4 Administrator the night of 3/27/16 after she heard of the abuse allegation regarding S2 CNA and resident #2. She stated that S4 Administrator instructed her to get statements from all staff and perform a body assessment of the resident. She stated she then handed the phone to S3 LPN who spoke with S4 Administrator. Initial interview with S4 Administrator on 3/31/16 at 1:38 p.m. revealed she received a phone call from S5 LPN on the night of 3/27/16. S5 LPN informed her that S1 CNA reported to her that S2 CNA had hit resident #2. S4 Administrator revealed she told S5 LPN to get statements from the staff and perform a full body assessment on resident #2. She stated S5 LPN did not find any bruises on resident according to S4 Administrator. Further interview with S4 Administrator on 3/31/16 at 1:38 p.m. revealed she stated S2 CNA did not work the night of 3/27/16. S4 Administrator also stated that she counseled S1 CNA on not reporting the incident immediately when S2 CNA told her. She stated she had finished her investigation and made her decision, but had not yet written it up. The surveyors asked if she had in-serviced facility staff. S4 Administrator confirmed she had only counseled S1 CNA concerning her not reporting the alleged abuse. An additional interview with S4 Administrator on 4/1/16 at 2:21 p.m. revealed she instructed the nurses, S3 and S5 LPN on the night of 3/27/16 at approximately 10:05 p.m., to get statements from the staff, do a full body assessment of resident #2, send S2 CNA home and call her (S4 Administrator) back with the findings of the assessment. She confirmed that the staff did not call her back that night to inform her of their findings. She stated that she did not call the staff back either to determine their findings, because she fell asleep. Interview with S4 Administrator on 4/1/16 at 3:10 p.m. revealed she was not aware that S2 CNA had worked the entire 10:00 p.m. until 6:00 a.m. shift the night of 3/27/16. She stated she had directed the nurses, S3 and S5 LPN, to send the CNA home. She stated she just assumed they did what she had instructed. She stated she found out about 2 hours prior to the 4/1/2016 interview that S2 CNA was not sent home per her instructions, and did work the entire shift on 3/27/16 from 10:00 p.m. until 6:00 a.m. Observation on 3/31/2016 at 12:55 p.m. revealed resident #2 was lying in bed on her back. Further observation revealed resident #2 moaned when S8 CNA removed the top covering. Resident #2's right hand revealed it was slightly swollen with darkened areas on her knuckles. Record Review: Review of resident #2's Face Sheet revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Time Card Report for S2 CNA dated 3/27/2016 revealed she clocked in for duty at 10:00 p.m. and remained on duty until she clocked out at 10:30 p.m. Review of the March 2016 CNA schedule revealed S2 CNA was scheduled to work on 3/27/2016 from 10:00 p.m. until 6:00 a.m. Review of the CNA Assignment Sheet dated 3/27/2016 revealed S2 CNA worked the 200 Hall on 3/27/2016 during the 10:00 p.m. to 6:00 a.m. shift. Interview with S6 DON on 4/1/16 at 2:05 p.m. confirmed that S2 CNA worked the night shift (10:00 p.m. to 6:00 a.m.) on a different hall than the one usually assigned to her on 3/27/2016. The assignment sheet she provided was not dated. S6 DON was asked to confirm the date of the assignment sheet, and she stated the assignment sheet was for the date of 3/27/16. Review of the facility's Abuse policy and Procedure revealed the following procedures: 1. Any (personnel, residents, visitors,ect.) who has knowledge or reason to believe that a resident has been a victim of mistreatment, abuse neglect, or any criminal offence shall report or cause a report to be made of the mistreatment or offense. The policy revealed that alleged violations must be immediately reported to the Administrator and Director of Nurses, alleged violations may be reported to the charge nurse. 2. Employees of this facility who have been accused of the resident abuse will be immediately suspended without pay pending the results of the investigation. Interview with S4 Administrator on 4/1/16 at 3:10 p.m. confirmed staff failed to report physical abuse immediately to the Administrator, DON or charge nurse according to policy. In addition, the facility failed to protect residents from the alleged perpetrator (S2 CNA) by allowing S2 CNA to work an 8 hour shift with residents after the Administrator had been informed of the alleged physical abuse report.