Every finding on record at Colonial Nursing and Rehabilitation Center

Based on interview and record review the facility failed to ensure resident's personal funds were available during non-business hours for 1 (Resident #23) of 34 sampled residents. Total facility census was 63.Findings:Review of a facility policy titled Availability of Resident Funds-After Business Office Hours, read in part.Policy: It is the practice of this facility to provide residents reasonable access to their personal funds after business office hours. Policy Explanation and Compliance Guidelines:2. During non-business office hours (e.g .nights, weekends, and holidays), the Business Office Manager, or designee, provides the Charge Nurse on duty at the time the business office closes a residents' fund petty cash box. 5. Staff members receive training on this policy in order to direct residents to the Charge Nurse when requests for personal funds are made during non-business office hours. Interview on 05/26/2026 at 1:20 p.m. with Resident #23 revealed when she asked for her money it usually took two days to receive it. Resident #23 revealed in the evenings and weekends, no staff was available to give her money when she requested it. Interview on 05/27/2026 at 10:21 a.m. with S10 Business Office Manager revealed if a resident requested money during non-business office, they would have to wait until the next day to receive it. S10 Business Office Manager confirmed that residents should be able to have access to their personal funds during non-business hours, and did not. Interview on 05/27/2026 at 10:39 a.m. with S1 Administrator revealed the facility's process for distributing residents' personal funds during non-business hours was S11 Activity Director's responsibility, because she lived near the facility. Interview on 05/27/2026 at 10:43 a.m. with S11 Activity Director confirmed she was not available at all times during non-business hours to disburse residents' personal funds.

Based on record review and interview the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 1 (Resident #65) of 1 resident reviewed for transfer/discharge. The total sample size was 63.Findings:Review of Resident #65's medical record revealed an admission date of 02/16/2026 and a discharge date of 03/02/2026. Resident #65 had diagnosis of Emphysema, Heart Failure, Nutritional Anemia, Cocaine Use, Essential Hypertension, and Unspecified Viral Hepatitis CReview of the facility's March Emergency Transfer Log revealed a list of only hospitalization transfers and Resident #65's discharge was not listed.In an interview on 05/28/2026 at 3:40 p.m., S5 SSD revealed all discharges were reported to the Ombudsman monthly on the 15th for the previous month. She stated she sends the log via email to [NAME], Ombudsman. She confirmed Resident #65 was not on March Emergency Transfer Log, but should have been. In an interview on 05/28/2026 at 3:48 p.m., S1 Adm confirmed Resident #65 was transferred to the hospital in March and was not on March Emergency Transfer Log, but should have been.

Based on record reviews and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the Residents' status for 3 (#6, #17, and #57) of 34 sampled residents by failing:1. to ensure the Significant Change MDS assessments were correct for Resident #6 and Resident #17; and2. to ensure Resident #57's 03/23/2026 Quarterly MDS contained accurate diagnoses.Findings: Review of the facility's undated policy titled, MDS – Conducting and Accurate Resident Assessment revealed the following, in part: Policy: The purpose of this policy is to assure that all residents receive an accurate assessment of relevant care areas. Resident #6 Review of Resident #6's medical record revealed an admission date of 04/24/2024 and diagnoses that included, but are not limited to, Other Psychoactive Substance Abuse With Psychoactive Substance-Induced Psychotic Disorder with Delusions; Type 2 Diabetes Mellitus with Hyperglycemia; Abnormal Weight Loss; Anorexia; and Personal History of Traumatic Brain Injury. Review of Resident #6's orders revealed in part, an order dated 05/04/2026 to admit the resident to hospice services. Review of Resident #6's Significant Change MDS dated [DATE] revealed in part, Hospice was not selected under Section O – Special Treatments, Procedures, and Programs. Interview with S9 MDS on 05/28/2026 at 9:20 a.m. confirmed that the reason for Resident #6's Significant Change MDS was his admission to hospice services and Hospice had not been selected at the time the assessment was entered and submitted as completed. Resident #17 Review of Resident #17's medical record revealed an admission date of 03/06/2026 and diagnoses that included, but are not limited to, Interstitial Pulmonary Disease, Unspecified; Abdominal Aortic Aneurysm, Without Rupture, Unspecified; Chronic Obstructive Pulmonary Disease, Unspecified; and Acute Kidney Failure, Unspecified. Review of Resident #17's orders revealed in part, an order dated 04/22/2026 to admit the resident to hospice services. Review of Resident #17's Significant Change MDS dated [DATE] revealed in part, Hospice was not selected under Section O – Special Treatments, Procedures, and Programs. Interview with S9 MDS on 05/28/2026 at 9:25 a.m. confirmed that the reason for Resident #17's Significant Change MDS was her admission to hospice services and that Hospice had not been selected at the time the assessment was entered and submitted as complete. Interview with S2 DON on 05/28/2026 at 9:32 a.m. acknowledged that Hospice should have been selected for both, Residents #6 and Resident #17's Significant Change MDS when it was submitted and completed, but had not. Review of Resident #57's medical record revealed a readmission date of 04/25/2025 with diagnoses that included Hypertensive heart disease, Unspecified Psychosis not due to a substance or known physiological condition (dated 08/26/2024), Major Depressive Disorder, single episode, Generalized Anxiety Disorder, and Delirium due to known physiological condition. Review of Resident #57's Quarterly MDS with an ARD of 03/23/2026 revealed a BIMS score of 15, indicating intact cognition. Further review of the MDS revealed the resident had a diagnosis of Psychotic Disorder (other than Schizophrenia). Review of Resident #57's current Care Plan and progress notes revealed no evidence of behaviors, psychosis, abnormal behaviors, and no inpatient psych stays. Review of Resident #57's Level 1 PASSAR dated 04/12/2023 revealed no level 2 required. In an interview on 05/27/2026 at 1:31 p.m., S2 DON was unaware that Resident #57 had a diagnosis of Psychosis in the medical record. S2 DON confirmed the resident was not receiving medications or treatment for that diagnosis. S2 DON stated Resident #57 is fully coherent with no behaviors and has only had issues of occasional anxiety and denied any abnormal behaviors. In an interview on 05/28/2026 at 7:35 a.m., S2 DON revealed that after reviewing the Resident #57's chart, she concluded the diagnosis of unspecified psychosis was inputted as a mistake or incorrectly. S2 DON stated in review of the resident's chart she reviewed the nursing and physician notes during the time frame of April 2024 when the diagnosis was initiated and resident was having kidney stone issues that was causing some delirium. In an interview on 05/28/2026 at 2:09 p.m., S2 DON revealed the resident has a high BIMS and does not have any mental or behaviors issues. S2 DON stated the resident does have history of behavioral changes intermittently when dealing with previous kidney stones or infections but nothing permanent. S2 DON confirmed the MDS was not correct, the resident does not have an active diagnosis of psychotic disorder, and the comprehensive assessment does not accurately reflect Resident #57's current status. In an interview on 05/28/2026 at 2:15 p.m., S9 MDS reviewed Resident #57's medical record and Quarterly MDS with an ARD of 03/23/2026. S9 MDS denied the resident having any behavioral or mental health issues. S9 MDS stated she reviewed multiple other MDS submissions that revealed this resident was listed with the active diagnosis of psychotic disorder and this was not an isolated mistake. S9 MDS nurse further revealed that Resident #57's MDS assessment and medical record were not accurate and does not accurately reflect the resident but should. In a telephone interview on 05/28/2026 at 2:09 p.m., S6 NP confirmed Resident #57 does not currently or have a history of any form of psychotic disorder or psychosis.

Based on interviews, record reviews, and investigations, the facility failed to ensure the development and implementation of the residents' person-centered plan of care for 3 (#23, #51, and #52) of 34 sampled residents by failing to:1. to develop and implement a care plan for Resident #23's dialysis needs;2. to develop and implement a care plan for Resident #51's ADL needs; and3. to monitor effectiveness of diabetic medications on Resident #52.Findings: Resident #23 Review of Resident #23's medical record revealed an admit date of 07/10/2024 with diagnoses that included in part.Human Immunodeficiency Virus, End Stage Renal Disease, Peripheral Vascular Disease, Hypertensive Heart Disease with Heart Failure, and Generalized Anxiety Disorder. Review of Resident #23's Quarterly MDS with an ARD of 04/06/2026 revealed a BIMS score of 13 which indicated intact cognition. The MDS revealed Resident #23 was dependent with toileting, bathing, dressing and personal hygiene; and required substantial/maximal assistance with eating and oral hygiene. The MDS revealed Resident had End Stage Renal Disease Requiring Hemodialysis. Review of Resident #23's Care Plan read in part.Diagnosis End Stage Renal Disease and requires Dialysis with no nursing interventions listed. During an interview on 05/27/2026 at 2:30 p.m. with S9 MDS confirmed Resident #23's Care Plan did not reflect appropriate nursing interventions for Dialysis and should have. Resident #51 Review of Resident #51's medical record revealed an admit date of 09/30/2025 and readmit date of 02/06/2026 with diagnoses that include in part.Rheumatoid Arthritis, Osteoarthritis, Muscle Weakness, Candidiasis of skin and nail, and Lack of Coordination. Review of Resident #51's Significant Change MDS with an ARD of 03/05/20/26 revealed a BIMS of 15, which indicated intact cognition, and the resident required substantial to maximal assistance with showering/bathing and dressing lower body and partial to moderate assistance with oral hygiene, toileting hygiene, upper body dressing, sitting to standing, and all transfers. Review of Resident #51's current care plan with a next review date of 07/12/2026 revealed it contained no care planning for the resident's bathing needs. During an interview on 05/27/2026 at 7:30 a.m., Resident #51 reported she was about to leave the facility to go to IOP and stated the CNAs did not come to get her for a shower this morning but should have. During an interview on 05/27/2026 at 11:55 a.m., S14 CNA stated she was aware of Resident #51's needs because she just knew them and by looking at EHR tasks. S14 CNA reported Resident #51 requires standby assist with ambulation and takes showers/baths daily with assistance. S14 CNA stated she gave Resident #51 a shower this morning before she left for IOP. Review of Resident #51's PCC EHR task revealed the resident prefers bathing in the morning, showers alternating with bed baths. Further review revealed no documentation to reflect Resident #51 received a shower or bath today. In an interview on 05/28/2026 at 8:45 a.m., S2 DON and S13 Corporate RN stated direct care staff are made aware of each residents' ADL needs by looking in the resident's care plan and task in PCC/EHR. During a review of Resident #51's care plan at this time, S2 DON confirmed Resident #51 did not have a care plan that identified the resident's ADL needs but should have. S13 Corporate RN confirmed all resident ADL needs should be identified in the resident's care plan, but were not for Resident #51. S2 DON reported MDS nurses were responsible for MDS and care planning at this facility. In an interview on 05/28/2026 at 8:50 a.m., S12 MDS revealed she and S9 MDS were responsible for MDS and care plan documentation. After reviewing Resident #51's care plan at that time, S12 MDS confirmed Resident #51's care plan did not identify her ADLS needs, but should have. Resident #52 Review of Resident #52's clinical record revealed an admit date of 09/17/2025 with a re-entry date of 09/26/2024 with diagnoses that included, but not limited to: Type 2 Diabetes Mellitus, Long Term (Current) use of Insulin, Depression, Schizophrenia, and Anxiety Disorder. Review of Resident #52's Care Plan with an initiated date of 09/26/2024 and a next review date of 06/16/2026 revealed in part .Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of Resident #52's Physicians orders revealed in part Insulin Lispro Injection Solution (Insulin Lispro) Inject as per sliding scale: if 401-999 = 6 units notify MD subcutaneously two times a day. Start date 09/26/2024. Interview on 05/26/26 at 11:06 a.m., Resident #52 stated she gets her blood sugar checked twice a day and she gets a whole lot of medicine and insulin, but her sugar is still always high. Resident #52 stated her blood sugar is sometimes so high, it frightens her. Review of May 2026 electronic medication administration record revealed Resident #52 had the following blood sugars documented as: May 11, 2026- blood sugar of 497 May 14, 2026- blood sugar of 416 May 15, 2026- blood sugar of 486 May 17, 2026- blood sugar of 402 May 18, 2026- blood sugar of 500 May 20, 2026- blood sugar of 592 May 23, 2026- blood sugar of 405 May 24, 2026- blood sugar of 429 May 25, 2026- blood sugar of 430 May 26, 2026- blood sugar of 402 Review of May 2026 progress notes for Resident #52 revealed in part.no documentation of the MD being notified of blood sugar readings that resulted in 401 or greater by the nurses. In a telephone interview on 05/27/26 at 11:54 a.m., S6 NP revealed if a resident's plan of care stated 401-999 give 6 units notify MD, the nurses should notify the MD. S6 NP acknowledged if the nurse had contacted her about Resident #52's blood sugar being 401 or greater, she would have ordered extra insulin or given an order to recheck it again after administering the sliding scale insulin that was ordered. Interview on 05/28/2026 at 2:37 p.m. with S2 DON confirmed the nurses did not follow the plan of care to notify the MD for blood sugars resulting 401 or greater, but should have.

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 63 residents who resided in the facility. The facility failed to ensure:1. Expired Food items in the pantry were not available for use;2. Staff are wearing beard restraints to prevent hair from contacting food Findings: Review of an undated facility policy titled, Date Marking for Food Safety revealed in part.Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. 5. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. Review of a facility policy dated January 2025 titled, Infection Control-Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices revealed in part .Food Services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. Observation of the pantry on 05/26/2026 at 8:20 a.m. accompanied by S3 DM revealed the following expired food items:1 large bag of [NAME] frosting with expiration date of 03/19/2026;2 large bags of Jiffy Cookie mix with expiration date of 06/25/2025;2 large cans (6lb 8oz) of spaghetti sauce with expiration date of 05/22/20262 packs of dinner rolls with expiration date of 04/12/2026;One loaf Bunny bread with expiration date of 05/12/2026;Approximately 50 cartons of fat free milk in cooler #1 with expiration date of 05/25/2026.Findings confirmed at the time of observation by S3 DM. In an observation in the kitchen area on 05/26/2026 at 11:30 a.m., revealed S4 [NAME] had a long, curly goatee (facial hair) and no usage of a beard restraint while serving on the line during preparation of lunch. In an interview on 05/26/2026 at 11:45 a.m., S4 [NAME] acknowledged he was not wearing a beard restraint to cover his goatee (facial hair), but should have been. In an interview on 05/26/2026 at 11:45 a.m., S3 DM confirmed S4 [NAME] was not wearing a beard restraint, but should have been.

Based on observation, record review, and interview the facility staff failed to use standard precautions by performing hand hygiene during medication administration for 4(Resident #9, Resident #11, Resident #38, Resident #47) of 4 residents observed.Review of policy Hand Hygiene Table dated January 2025 revealed, hand hygiene should be used between resident contacts- either antimicrobial Soap and Water or Alcohol Based Hand Rub.Observation of medication administration on 05/27/2026 with S7 LPN revealed that she did not perform hand hygiene by not washing or sanitizing her hands between medication administrations of the 4 observed residents.Interview on 05/27/2026 at 08:20 AM with S7 LPN confirmed, Absolutely, I should have used sanitizer between administrations of medication between residents.Interview on 05/27/2026 at 08:30 AM with S2 DON confirmed, that the nurse should have sanitized hands between residents.

Based on interview and record review, the facility failed to ensure a resident's right to be free from staff to resident physical abuse, for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for abuse. Resident #1, a cognitive resident, experienced psychosocial harm as a result of the physical abuse by staff. This deficient practice resulted in psychosocial harm to Resident #1 on 10/11/2025 at 1:15 p.m., when Resident #1 reported to S2 CNA that S3 CNA entered his room without invitation and intentionally poured water on him in an attempt to stop him from masturbating. Resident #1, who had a BIMS score of 15 (cognitively intact), was tearful and fearful following the physical abuse from S3 CNA. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings:Review of the undated facility policy titled Abuse Prevention and Investigation revealed in part. Residents have the right to be free from verbal, sexual, physical, and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of property, exploitation, and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents will not be subjected to abuse by anyone.1. The facility defines resident abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses that included in part. Schizoaffective Disorder, Bipolar Disorder, Diabetes, Hemiplegia and Hemiparesis following Cerebral Vascular Disease affecting Left Non-Dominant Side, Vascular Dementia, Epilepsy, and Unspecified Other Behavioral Disturbance. Review of Resident #1's Quarterly MDS with an ARD of 08/20/2025, revealed Resident #1 had a BIMS score of 15, which indicated cognition was intact. The MDS revealed Resident #1 was dependent on staff for activities of daily living (ADLs). Review of a progress note dated 10/15/2025 revealed that the Nurse Practitioner was consulted regarding the need to restart Resident #1's antipsychotic medication due to increased sexual behaviors. Review of Resident #1's Care Plan, with a review date of 01/08/2025, revealed in part. On 10/13/2025, an incident that occurred between staff and resident on 10/11/2025 was reported. Documentation stated that on 10/11/2025, staff poured cold water on Resident #1's perineal area during care after the resident was observed masturbating. Interventions implemented on 10/13/2025 included: Monitoring for signs and symptoms of psychosocial decline; Monitoring Resident #1's sexual behaviors every shift and providing privacy as appropriate; referring the resident to the Psychiatric Nurse Practitioner for follow-up evaluation; and administering antipsychotic medication as ordered. Resident #1 did not have a care plan addressing self-pleasuring behaviors prior to the incident on 10/11/2025. Interview on 11/20/2025 at 9:30 a.m. with Resident #1 revealed that on 10/11/2025, S3 CNA entered his room without invitation and intentionally poured water on him in an attempt to stop him from masturbating. Resident #1 stated the incident made him feel distressed and that he cried throughout the night. Resident #1 further reported that he continues to feel fearful that a similar incident may occur again. An interview on 11/20/2025 at 1:35 p.m., with S2 CNA revealed that on 10/11/2025 at approximately 1:30 p.m., she was eating lunch in the dining room when S3 CNA verbally informed her that she had poured water on Resident #1 in an attempt to stop him from masturbating. S2 CNA reported that upon hearing this information, she immediately went to Resident #1's room to check on him. S2 CNA stated that Resident #1 was crying when she entered the room. S2 CNA observed that Resident #1's bed sheets and brief were wet. S2 CNA reported Resident #1 said How could anyone be so mean, water, and requested to speak with the administrator. S2 CNA reported Resident #1 masturbates in his room frequently. S2 CNA stated staff are aware of his sexual behaviors and have been instructed to close the door or pull the privacy curtain if Resident #1 engages in self pleasure. A telephone interview on 11/20/2025 at 2:58 p.m., with S3 CNA revealed on 10/11/2025 at approximately 1:00-1:15 p.m. S3 CNA was walking down the hallway when she observed Resident #1 engaging in self pleasuring behavior. S3 CNA stated she attempted to stop Resident #1 from masturbating, at which time the resident attempted to grab her arm. S3 CNA further stated she then picked up a cup of water and poured it onto Resident #1's genital area. S3 CNA confirmed she entered Resident #1's room without invitation or clinical need. Resident #1 had not requested assistance with ADLs and did not have his call light activated prior to her entering the room. S3 CNA acknowledged she has been educated to close the door or pull the privacy curtain when Resident #1 is engaging in self pleasuring behaviors. S3 CNA confirmed she did not do so during this incident. An interview on 11/24/2025 at 8:12 a.m. with S1 Administrator confirmed that physical abuse involving S3 CNA and Resident #1 was substantiated during the facility's investigation. S1 Administrator reported that all staff had received training on appropriate responses when Resident #1 engages in self-pleasuring behaviors. S1 Administrator confirmed Resident #1 was found crying in his room after the incident occurred. S1 Administrator also confirmed S3 CNA was suspended on 10/13/2025 and subsequently terminated on 10/16/2025. The facility has implemented the following corrective actions to correct the deficient practice: 1. Staff Education: All staff were in-serviced on 10/13/2025 on the Abuse & Neglect Policy, resident rights to privacy, requirements for reporting abuse or suspected abuse immediately, and physical restraint free facility. 2. Resident Interviews: All residents who received care from S3 CNA were interviewed by the administrator. No complaints or concerns were identified. Residents who were non-interviewable received a full body audit. 3. Medication Management: Resident #1 was re-started on the antipsychotic medication Saphris 5mg BID on 10/15/2025 for management of increased sexual behaviors. 4. Psychiatric Evaluation: Resident #1 was evaluated by the Psychiatric Nurse Practitioner on 10/17/2025. No new orders or recommendations were made. 5. Psychosocial Monitoring: Monitoring by the LPN/floor nurse every shift was implemented to assess for signs and symptoms of psychosocial trauma, including sadness, crying, mood swings, depressed mood, decreased socialization, withdrawal, and refusal of care. 6. Ongoing Abuse Reporting Oversight: A resident abuse and reporting monitoring tool was established. The Administrator will interview eight residents per week for eight weeks, then monthly thereafter, to ensure compliance with abuse reporting expectations. Facility correction date is 10/17/2025.

Based on record review and interview the facility failed to ensure an allegation of abuse was reported immediately to the administrator of the facility for 1 (Resident #1) of 3 sampled residents reviewed for abuse. The facility failed to ensure staff reported an allegation of staff-to-resident abuse to facility Administrator. Findings:Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses that included in part. Schizoaffective Disorder, Bipolar Disorder, Diabetes, Hemiplegia and Hemiparesis following Cerebral Vascular Disease affecting Left Non-Dominant Side, Vascular Dementia, Epilepsy, and Unspecified Other Behavioral Disturbance. Review of Resident #1's Quarterly MDS with an ARD of 08/20/2025, revealed Resident #1 had a BIMS score of 15, which indicated cognition was intact. The MDS revealed Resident #1 was dependent on staff for activities of daily living (ADLs). Review of Resident #1's Care Plan, with a review date of 01/08/2025, revealed in part.On 10/13/2025, an incident that occurred between staff and resident on 10/11/2025 was reported to administration. Documentation stated that on 10/11/2025, staff poured cold water on Resident #1's perineal area during care after the resident was observed masturbating. An interview on 11/20/2025 at 1:35 p.m., with S2CNA revealed that on 10/11/2025 at approximately 1:30 p.m., she was eating lunch in the dining room when S3CNA verbally informed her that she had poured water on Resident #1 in an attempt to stop him from masturbating. S2CNA revealed she did not report this incident to her immediate supervisor until 10/13/2025. S2CNA confirmed she should have reported this incident immediately to her supervisor, but did not. An interview with S1 Administrator on 11/24/2025 at 8:12 a.m. confirmed S2CNA should have immediately reported the allegation of abuse between Resident #1 and S3CNA on 10/11/2025 to her supervisor, and she did not. S1Administrator stated all staff are responsible for immediately reporting abuse/suspected abuse.

Based on interview, and record review the facility failed to ensure a resident's person centered plan of care was reviewed and revised to include approaches/ interventions to address the resident's self pleasuring behavior for 1 (Resident #1) of 3 sampled resident's care plans reviewed. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses that included in part. Schizoaffective Disorder, Bipolar Disorder, Diabetes, Hemiplegia and Hemiparesis following Cerebral Vascular Disease affecting Left Non-Dominant Side, Vascular Dementia, Epilepsy, and Unspecified Other Behavioral Disturbance.An interview on 11/20/2025 at 1:35 p.m., with S2CNA revealed Resident #1 masturbates in his room frequently. S2CNA stated staff were aware of his sexual behaviors and have been instructed to close the door or pull the privacy curtain if Resident #1 engages in self-pleasure.A telephone interview on 11/20/2025 at 2:58 p.m., with S3CNA revealed on 10/11/2025 at approximately 1:00-1:15 p.m. S3CNA was walking down the hallway when she observed Resident #1 engaging in self-pleasuring behavior. S3CNA stated she attempted to stop Resident #1 from masturbating, at which time the resident attempted to grab her arm.Review of Resident #1's Care Plan, with a review date of 01/08/2025, revealed in part. On 10/13/2025, an incident that occurred between staff and resident on 10/11/2025 was reported. Documentation stated that on 10/11/2025, staff poured cold water on Resident #1's perineal area during care after the resident was observed masturbating. Resident #1 did not have a care plan addressing self-pleasuring behaviors prior to the incident on 10/11/2025.

Based on observation, interview and record review, the facility failed to ensure adequate supervision was in place for a cognitively impaired resident who was identified as being at high risk for elopement, exhibited exit seeking behaviors, and voiced a desire to leave the facility did not exit the building for 1 (#156) of 11 (#2, #3, #23,#24, #25, #38, #44, #47, #48, #156 and #157) residents at risk for elopement. Findings: This deficient practice resulted in an immediate jeopardy situation for Resident #156 on 05/16/2025 at 8:15 a.m., when Resident #156, who had a BIMS of 4, was cognitively impaired, and exhibited exit seeking behaviors went out of a bathroom window. Resident #156 then walked to a nearby neighborhood approximately 0.5 miles away. At approximately 10:30 a.m., the local police department notified the facility that Resident #156 was in custody after being arrested for theft of a motor vehicle. On 05/16/2025 at 1:00 p.m., Resident #156 returned to the facility. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility policy on 05/27/2025 with a review date of 05/16/2025, and titled Elopements and Wandering Residents, read in part .This facility ensures that residents who exhibit exit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Elopement occurs when a resident leaves the premises or a safe area without authorization (an order for discharge or leave of absence) and/or any necessary supervision to do so. 1. The facility is equipped with door locks/alarms to help avoid elopements. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation, and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. d. Adequate supervision will be provided to help prevent accidents or elopements. Review of Resident #156's medical record revealed an admit date of 04/30/2025, with diagnoses that included, in part .Cerebral Infarction due to Thrombosis of Right Posterior Cerebral Artery, Cocaine Abuse with Cocaine-Induced Mood Disorder/Sleep Disorder, and Anxiety Disorder. Review of Resident #156's admission MDS with an ARD of 05/02/2025, revealed a BIMS score of 04, which indicated severe cognitive impairment. Resident #156 was independent for transfers and used a walker for mobility. Review of Resident #156's 05/2025 Physician's Orders revealed in part . 05/01/2025 -Elopement precautions: Census checks every 1 hour each shift related to history of Delirium and wandering. 05/16/2025- Elopement precautions: 1 on 1 staff supervision each shift. Review of Resident #156's Care plan with a target completion date of 08/11/2025, read in part .Elopement risk related to reported history of Altered Mental Status, Status post history of CVA (Cerebral Vascular Accident), Cocaine use with wandering attempts to leave hospital noted. 05/15/2025-Elopement attempt noted: Willfully attempted to leave facility without notifying staff, wanted to be discharged back home. Interventions included in part .Elopement precautions: Census checks every 1 hour each shift related to history of delirium and wandering. (initiated on 05/02/2025). Supervision increased to 1:1 for safety. (initiated on 05/15/2025). Review of Resident #156's Risk of Elopement Evaluation dated 05/01/2025, revealed Resident #156 had verbally expressed the desire to go home, packed belongings to go home, or stayed near an exit door. Resident #156 scored 1.0 on the evaluation which indicated he was at risk for elopement. Review of Resident #156's facility progress notes dated 05/15/2025 at 4:28 p.m., written by S2 DON read as follows: Resident #156 came outside of facility with facility staff & other residents to eat crawfish. Resident #156 noted very calm & cooperative during activity. Later resident noted agitated, uncooperative, & telling staff that he was leaving because he stayed here long enough, and it was time for him to go. Resident #156 noted pushing staff away & attempting to leave facility. S2 DON and S1 Administrator intervened. Resident #156 remained agitated (refused to go inside of building, pushed staff away, & continued to walk off attempting to leave facility). Resident #156 was questioned about where he was going & he stated that he was going back to his home in New [NAME]. Resident #156 requested to call the police to assist him with getting back home. S2 DON informed him that staff could assist him with calling his family to help him. After much encouragement, resident finally agreed to come back inside facility to call his sister. Resident #156 became more agitated after speaking with sister & stated that his sister was always against him. Emotional support provided with very little effectiveness noted. Increased anxiety & agitation with complaints of SOB (shortness of breath) noted. Resident #156's supervision increased to 1:1 at this time for safety. Review of Resident #156's facility progress notes dated 05/16/2025 at 1:00 p.m., written by S2 DON read as follows: Resident #156 left facility (exited hallway bathroom window) after eating breakfast this morning. Resident #156 was located and transported back to the facility in stable condition. Upon questioning, resident was noted alert & oriented x 4 with appropriate verbal responses. Resident #156 stated that he left facility to try to find a ride back to his home in New [NAME]. A follow up assessment was done with no complaints of discomfort & no s/s (signs and symptoms) of injury noted. S/S of frustration/agitation was noted from resident with expressions of dissatisfaction towards having to return to the facility. Resident #156 repeatedly stated, I'm a mechanic & I need to get back to my business. Resident #156 was reassured that staff was aware of his desire for discharge and was trying to ensure a safe discharge plan for him. Designated staff assigned 1:1 supervision for safety. Resident's primary MD and S14 NP were informed of resident leaving facility & of his current status. Review of a police department report revealed in part ., on 05/16/2025 at approximately 9:29 a.m., this officer was dispatched in reference to a vehicle being in the ditch. The vehicle in question was the same vehicle that was observed in the ditch. Police officers went back to the person who stole the vehicle. While speaking, Resident #156 stated he was trying to get to New [NAME], La. Resident #156 was transported to be booked on the following charges theft of a motor vehicle, criminal damage to property, and illegal possession of stolen things. While in police custody it was learned that Resident #156 was missing person from a local nursing home. Interview with S14 NP on 05/28/2025 at 9:17 a.m. revealed she came to visit Resident #156 on 05/16/2025 at 6:30 a.m. after being notified on 05/15/2025 of Resident #156 trying to leave the facility. S14 NP stated she ordered an injection of Hydroxyzine (Antihistamine) and placed him on 1:1 supervision on 05/15/2025. S14 NP stated that during her visit with Resident #156 on 05/16/2025 he continued to voice to her that he wanted to go home. S14 NP stated she discussed with him that it wasn't a good idea to leave the facility against medical advice and Resident #156 agreed to remain in the facility. S14 NP stated Resident #156 was cooperative and calm during her visit on 05/16/2025. S14 NP stated Resident #156 didn't exhibit any active exit seeking behaviors at the time of her visit but was adamant about going home. S14 NP stated once Resident #156 agreed to remain in the facility, she notified staff of his mood, and lifted his 1:1 supervision. Interview with S15 CNA on 05/28/2025 at 12:06 p.m. revealed she worked on 05/16/2025 during the 6:00 a.m.-2:00 p.m., shift when Resident #156 eloped. S15 CNA revealed she had last seen Resident #156 during breakfast that morning. S15 CNA stated during her observation of Resident #156 during breakfast, Resident #156 was calm with no abnormal behaviors. S15 CNA stated on 05/16/2025 at approximately 8:45 a.m., S2 DON approached her outside on the front porch to inquire if Resident #156 was outside. S15 CNA stated she notified S2 DON that Resident #156 did not go outside on the front porch after breakfast. S15 CNA was made aware by S2 DON that Resident #156 could not be located. S15 CNA stated she, S2 DON, and another CNA began looking throughout the entire facility, checking all resident rooms, laundry room, kitchen, and all exits. Interview with S1 Administrator on 05/29/2025 at 8:56 a.m., revealed on 05/16/2025 at 8:15 a.m. she realized Resident #156 was missing. S1 Administrator stated she went down to check on Resident #156 and noticed he wasn't in bed or in the dining room. S1 Administrator stated she alerted staff to begin searching for Resident #156 throughout the facility. S1 Administrator stated she went back to her office to review surveillance footage which showed Resident #156 entered the X-Hall bathroom, but never exited the bathroom. S1 Administrator stated she immediately increased census checks to every 30 minutes for all residents at high risk of elopement. S1 Administrator stated she initiated an in-service for all staff on 05/16/2025 that was completed on 05/20/2025 for Elopement and Wandering Residents as well as Facility Protocol for 1:1 Staff Supervision. Interview with S11 LPN on 05/29/2025 at 11:58 a.m., revealed she observed Resident #156 eating breakfast in the dining room on 05/16/2025 around 8:00 a.m. S11 LPN stated Resident #156 walked past her going towards his room in a good mood. S11 LPN stated Resident #156 had no complaints or any exit-seeking behaviors that morning. S11 LPN stated about 10 minutes later S1 Administrator approached her and asked where Resident #156 was. S11 LPN stated she and S1 Administrator immediately began to look in every room and could not locate him. S11 LPN stated Resident #156 was on 1:1 supervision during the night shift (05/15/2025) but it had been lifted on 05/16/2025 by S14 NP. The facility has implemented the following actions to correct the deficient practice: 1. All staff in-serviced on 05/16/2025 on elopement, wandering residents, and facility protocol for 1:1 supervision. The elopement policy was reviewed with all staff on Elopement and Wandering Residents. 2. Resident #156 was immediately assessed with no complaints of discomfort and no signs and symptoms of injuries noted upon return to the facility on [DATE] at 1:00 p.m. Designated staff were assigned to Resident #156 for 1:1 supervision for safety. S14 NP notified of Resident #156's return status, and a new order for Klonopin 0.5 mg was given to Resident #156 for anxiety. 3. Daily Elopement Risk Monitoring tool was started on 05/16/2025 for resident's identified as high risk for elopement in the facility. Monitoring tool reads as follows: S2 DON or designee will monitor residents at risk for elopement daily for 8 weeks then randomly to identify any issues with safety and/or plan of care for safety. 4. Residents identified as high elopement risk were ordered with increased visual checks every 30 minutes every shift which started on 05/16/2025, to be continued indefinitely. 5. A window audit was conducted on 05/16/2025 by S3 Maintenance Director on all resident bedroom windows, bathroom windows in facility, living area, and dining area. Facility completion date 05/23/2025.

Resident #25 Based on observation, interview, and record review, the facility failed to implement and monitor interventions to maintain proper hydration and nutrition for 2 (Resident #25 and Resident #8) of 2 residents reviewed for nutrition. The facility failed to: 1. Implement and monitor hydration consistent with Resident #25's assessed needs; and 2. Notify the Registered Dietician of Resident #8's change in nutritional needs. Findings: Review of an undated facility policy on 05/29/2025 at 7:12 p.m. titled, Intake and Output, Monitoring Fluids revealed the following in part .4. For residents with a physician's order for fluid encouragement, fluids will be encouraged as per the resident's care plan. 6. The following residents require measurement and documentation of intake and output. A. Residents with a physician's order for intake and output measurement. Review of an undated facility policy on 05/29/2025 at 7:12 p.m. titled, Hydration Program revealed the following in part .to provide all residents with sufficient fluid intake to maintain good hydration status. Resident #25 Review of Resident #25 medical record revealed an admitted [DATE] with diagnoses that included . Anorexia, Type 2 Diabetes Mellitus with Hypoglycemia without Coma, Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms, and Acute Kidney Failure. Review of Resident #25's 05/2025 physician's orders revealed in part . (02/23/2023) order date: Monitor I&O Qshift (daily estimate fluid needs equals 1500cc/ml). Review of Resident #25's care plan revealed the following in part . Initial date (03/04/2022) Focus: Potential for dehydration. Interventions: Monitor I&O Qshift, daily estimate fluid needs as ordered. Initial date (04/07/2025) Focus: The resident has dehydration or potential for fluid deficit. Interventions: Monitor and document intake and output as per facility policy. Review of Resident #25's medical record tasks charting revealed the nurses and CNAs were required to document in the clinical record the resident's total amount of oral fluid intake after every shift measured in cc/ml. Further review of the previous 30 days of oral fluid intake documentation revealed the following in part . -Nurse Documentation for 04/30/2025-05/29/2025: 8 days where the nurse did not document every shift and 10 days where the nurse and CNA documentation did not meet the minimum fluid intake requirement of 1500mls, as ordered. -CNA Documentation for 04/30/2025-05/29/2025: 17 days where the CNA did not document every shift, 9 days where the CNA and nurse documentation did not meet the minimum fluid intake requirement of 1500mls, as ordered, and 1 day where no documentation was found. In an interview and record review on 05/29/2025 at 4:10 p.m., S2 DON confirmed Resident #25 had active physician's orders to monitor intake and output every shift with a minimum daily fluid intake of 1500cc/ml. Further review of Resident #25's medical record for oral fluid intake in the last 30 days, S2 DON confirmed (the above findings) that the nursing staff and CNAs failed to document fluid intake every shift as ordered and that the daily fluid intake documented failed to meet the minimum requirement of 1500cc/ml as ordered, but should have. 51082 Resident #8 Findings: Review of the facility's undated policy titled Enteral Nutrition revealed in part . Adequate nutritional support through enteral feeding will be provided to all residents as ordered. Role of Dietitian: 3. The Dietitian, with input from the Physician and Nurse will: Determine whether the resident's current intake is adequate to meet his or her nutritional needs. Dietitian monitoring: 5. The Dietitian will monitor residents who are receiving enteral feedings, and will make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. Review of the facility's undated policy titled Registered Dietician-Consultant revealed in part .3. In general the Consultant Registered Dietician (RD) will visit the facility at least monthly to provide nutritional status assessments, review food service operation, and provide guidance and direction for the Dietary Manager (DM). 4. All residents will be assessed upon initial admission and at least annually thereafter. Residents meeting the following criteria will be assessed monthly unless otherwise agreed upon and documented by the RD and physician: d. Residents who have had enteral tube placement since the last RD assessment. 5. The RD will provide the Administrator and DM with written, dated, and signed reports of each consultation visit. The report will contain the RD's significant findings, recommendations, and plans for implementation of the recommendations as applicable. 6. The DM is responsible to prepare a list of residents to be seen by the RD at each scheduled visit as well as provide the RD with access to resident information that will facilitate the RD's assessment in addition to the medical record. 7. The DM is responsible for maintaining a record of RD consultant assessments in a manner that provides easy identification of which residents are due for reassessment such as annual RD visit logs. 8. The Director of Nursing (DON) or DM should consult with the RD via telephone or fax if services are required prior to the next scheduled visit. The discussion and recommendations will be documented in the resident's medical record. 9. The DON or designee is responsible for the implementation of the RD's recommendations to the nursing department and the Dietary Manager is responsible for implementation of the recommendations to the Dietary Department. 10. The DON or designee will promptly notify the physician of any recommendations for order changes. Review of the facility's undated policy titled Weight Monitoring revealed in part .Weight loss: 4. A weight loss of 5% in 30 days or less, 7.5% in 90 days or less, or 10% in 6 months or less will be considered significant regardless of resident's ideal body weight. 11. The DM will request and RD consult at next scheduled visit or request a telephone consult if indicated. Documentation: 21. Documentation of weight change review, physician notification, and responsible party notification will be documented in the medical record. Standardized assessment entitled Weight Change Evaluation may be used. Review of Resident #8's medical record revealed an admitted [DATE] with diagnoses that included in part .Acute and Chronic Respiratory Failure with Hypoxia, Pneumonitis due to Inhalation of Food and Vomit, Encounter for attention to Gastrostomy, Severe Protein-Calorie Malnutrition, and Abnormal Weight loss. Review of Resident #8's Quarterly MDS with an ARD of 08/02/2025 revealed a BIMs score of 5, which indicated severe cognitive impairment. The MDS revealed Resident #8 required parenteral feeding via Peg tube. Review of Resident #8's 05/2025 Physicians orders revealed: 04/22/25-enteral feed: every shift enteral: flush feeding tube with (50 cc) of water every 1 hour per volumetric feeding pump 04/22/25-enteral feed: every shift- Diabetisource 1.2 AT 50cc/hour per. Continuous volumetric feeding pump. Review of Resident #8's care plan with a review date of 08/11/2025 revealed: Risk for malnutrition. 04/22/2025-Resident is NPO (nothing by mouth)/Peg tube status related to diagnosis of Dysphagia with aspiration noted. 04/30/2025-returned from hospital with significant weight loss noted over past month (19 pounds) . Intervention included in part .04/30/2025 Refer to RD for evaluation as indicated, significant weight loss noted. Review of Resident #8's weights revealed: 05/20/2025 - 158.0 lbs. (pounds) 04/30/2025 - 162.0 lbs. 04/21/2025 - 175.0 lbs. 04/08/2025 - 181.0 lbs. 03/17/2025 - 179.0 lbs. 03/11/2025 - 181.0 lbs. Review of Resident #8's Dietary Admission Assessments revealed in part . 04/21/2025-weight in pounds: 181, current diet: Diabetisource 1.50 at 50 cc/hr (mils per hour). Risk for malnutrition due to need for feeding tube, Recommended continue with same plan of care. Electronically signed by S8 Dietary Manager. 04/30/2025-weight in pounds: 175, current diet: Diabetisource 1.50 at 50 cc/hr (mils per hour). Risk for malnutrition due to need for feeding tube, Recommended continue with same plan of care. Electronically signed by S8 Dietary Manager. 05/19/2025-weight in pounds: 162, current diet: Diabetisource 1.50 at 50 cc/hr (mils per hour). Risk for malnutrition due to need for feeding tube, Recommended continue with same plan of care. Electronically signed by S8 Dietary Manager. Review of Resident #8's weight change evaluation form completed by S2 DON revealed in part .Resident #8 had a weight loss of 19 pounds in 1 month. Notes: total 19 pound weight loss in past month noted on return from hospital on 04/30/2025 status post recent history of aspiration pneumonia with NPO status and new peg tube placement noted. Plan: continue tube feeding, refer to RD for evaluation. Other: referral to RD for review, care plan updated. On 05/29/2025 after further review of Resident #8's medical record there was no evidence of documentation of the RD's evaluation or referral sent for Resident #8's significant weight loss. Telephone interview on 05/29/2025 at 12:46 p.m., with S10 Registered Dietician (RD) revealed she came to the facility on ce or twice a month to assess residents. S10 RD revealed that the facility would email her names of residents needing to be seen by her during her visit. S10 RD stated she reviewed residents' weights on a monthly basis. S10 RD stated Resident #8's significant weight loss was due to his multiple hospitalization s. S10 RD confirmed that she did not receive any evaluation request or referrals regarding Resident #8's significant weight loss from the facility upon his return from the hospital. Interview on 05/29/2025 at 2:03 p.m. with S2 DON revealed she was responsible for notifying S2 RD of changes in resident's weights via a referral or request for an evaluation. S2 DON stated she sent out a referral and requested an evaluation from S10 RD concerning Resident #8's significant weight loss. S2 DON could not provide documentation of an evaluation or referral sent to S10 RD concerning Resident #8's significant weight loss.

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. The deficient practice had the potential to effect all of the residents who received meals from the kitchen. There were 55 residents who resided in the facility. The facility failed to ensure: 1. Food items in pantry were stored in a sealed container; 2. Opened food items in refrigerator and freezer were labeled with an open date and stored in a sealed container; and 3. Snacks considered potentially hazardous food were stored appropriately. Findings: A review of the facility's undated policy titled, Storage: Freezer revealed in part . Keep all frozen foods tightly wrapped or packaged to prevent freezer burn . Label and date all items. A review of the facility's undated policy titled, Storage: Refrigerator revealed in part . Keep refrigerated foods wrapped or covered and in sanitary containers. A review of the facility's undated policy titled, Storage: Dry Food revealed in part .Keep all containers tightly closed from insects, rodents, and dust. Dry foods can be contaminated, even if they don't need refrigeration. 1. During the initial tour of kitchen performed on 05/27/2025 from 08:30 a.m. to 09:25 a.m., observation of the indoor pantry revealed (1) 20 pound box of spaghetti noodles opened. S8 Dietary manger confirmed spaghetti noodles should have been labeled with an open date and stored in a sealed container and was not. 2. During the initial tour of kitchen performed on 05/27/2025 from 08:30 a.m. to 09:25 a.m., observation of freezer # 3 revealed (1) two gallon zip lock bag of waffles not labeled with an open date, observation of cooler # 2 revealed (1) 15 pound box of bacon open to air, and observation of cooler #1 revealed (1) bag of liquid eggs opened and not labeled with an open date. On 05/27/2025 at 10:25 a.m. interview with S8 Dietary manger was conducted. S8 Dietary manager confirmed the following: (1) two gallon zip lock bag of waffles located in freezer #3 was not labeled with an open date and should have been. (1) 15 pound box of bacon in cooler #2 was left open to air and should not have been. (1) bag of liquid eggs located in cooler #1 was not labeled with an open date or stored in a sealed container and should have been. 3. Interview with S8 Dietary Manager on 05/29/2025 at 09:07 a.m. revealed the facility did not have separate snack refrigerators. S8 Dietary Manager revealed snacks are stored and served from hydration carts at 09:30 a.m., 02:30 p.m., and 07:00 p.m. daily. S8 Dietary Manager revealed the hydration cart prepared at 07:00 p.m. daily included all snacks that were readily available to the residents till 5:00 a.m. the next day. S8 Dietary Manager revealed content of the 07:00 p.m. hydration cart consisted of juice, water, graham crackers, peanut butter crackers, and premade sandwiches that were stored in an ice cooler. S8 Dietary Manager revealed types of sandwiches stored in ice cooler on 07:00 p.m. hydration cart included peanut butter and jelly, turkey, bologna, and pimento cheese sandwiches. S8 Dietary Manager stated (2) two gallon zip lock bags were filled with ice and placed in ice cooler to keep sandwiches cool until sandwiches were discarded at 05:00 a.m. the next day. On 05/29/2025 at 09:18 a.m. observation of snack ice cooler revealed a 25 quart portable ice cooler that was not temperature regulated. On 05/29/2025 at 10:52 a.m. interview with S8 Dietary Manager revealed temperatures were not being monitored for ice cooler that stored sandwiches between 07:00 p.m. and 5:00 a.m. daily. S8 Dietary Manager confirmed turkey and pimiento cheese sandwiches were considered potentially hazardous food and should be stored in a monitored temperature regulated refrigerator and they were not.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This failed practice had the potential to effect the 55 residents who resided in the facility. The facility failed to: 1. Ensure Enhanced Barrier Precautions (EBP) were utilized for 1 (Resident #19) of 1 residents reviewed for infection control; 2. Ensure the facility laundry department was free of lint and dust; and 3. Ensure S9 Treatment Nurse followed proper hand hygiene practices during wound care for 1 (Resident #11) of 1 residents review for pressure ulcers. Findings: Review of a facility policy on 05/29/2025 at 7:12 p.m. titled, Enhanced Barrier Precautions with a revision date of 01/2025 revealed the following part .It is the policy of this facility to implement Enhanced Barrier Precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO). 46. Enhanced Barrier Precautions- a. nursing staff will place residents with any applicable conditions or device on EBP. Applicable devices: i. Wounds and/or indwelling devices (feeding tubes) even if the resident is not known to be infected or colonized with MDRO. 48. High contact resident care activities included: transferring. 1. Resident #19 Review of Resident #19's medical record revealed and admitted [DATE], with diagnoses that included in part .Alzheimer's Disease with Late Onset, Gastrostomy Malfunction, Major Depressive Disorder, and Gastrostomy Status. Review of Resident #19's 05/2025 physician's orders revealed an order for Enhanced Barrier Precautions related to peg tube device with an order date of 08/04/2022. Review of Resident #19's care plan revealed in part .Start date (02/16/2024) Focus: Remains free from skin breakdown. Intervention: (08/02/2022) Enhanced Barrier precautions related to peg tube device. Observation on 05/27/2025 at 10:05 a.m., revealed Resident #19 transported via geri-chair to his room by S13 CNA. S12 CNA was observed exiting Resident #19's room, retrieving the facility's mechanical lift and reentering the resident's room accompanied by S13 CNA to transfer the resident from geri-chair to bed. Observation revealed no evidence of gown usage by S12 CNA at this time. Observation of the exterior of Resident #19's room door revealed EBP signage posted and PPE (gowns and gloves) available for use. In an interview on 05/27/2025 at 10:25 a.m., S12 CNA revealed that she and S13 transferred Resident #19 from geri-chair to bed via mechanical lift. S12 CNA confirmed she only wore gloves during the transfer and should have worn a gown also, but did not. In an interview on 05/29/2025 at 5:00 p.m., S2 DON revealed she expected all staff to wear gown and gloves for any resident on Enhanced Barrier Precautions during direct care, such as a transfer. S2 DON confirmed Resident #19 had a peg tube and required EBP during direct care. S2 DON confirmed S12 CNA should have worn both gown and gloves during Resident #19's transfer, but did not. 2. Observation on 05/27/2025 at 5:10 p.m. of the facility laundry department accompanied by S1 Administrator. Observation revealed two laundry dryers with an excessive amount of lint within the lint traps. There was excessive lint on the inside of the dryer walls and excessive lint in the surrounding areas of the lint traps. Observation revealed there was excessive lint and dust on the laundry department walls entirely, and excessive lint and dust hanging from the ceilings. S1 Administrator confirmed the findings did not provide a safe, clean, and sanitary environment, and the laundry staff should have cleaned the laundry/dryer area, but did not. 52255 3. Resident #11 A review of Resident # 11's medical record revealed an initial admitted [DATE] and re-admitted [DATE] with diagnoses that included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Atherosclerosis of native arteries of extremities with intermittent claudication of bilateral legs, Phantom Limb Syndrome with pain, Peripheral Vascular Disease, acquired absence of right leg above knee, unspecified open wound of left great toe with damage to nail, subsequent encounter, cellulitis of left lower limb. On 05/28/2025 at 10:00 a.m. review of Resident #11's annual Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 02/24/2025, revealed Resident #11 had a BIMS score of 10, which indicated moderate cognitive impairment and had an open lesion on the foot. On 05/28/2025 at 11:04 a.m. review of Resident # 11's care plan with initiation date of 09/06/2024 revealed Resident #11 had actual skin impairment to the left great toe. Interventions included in part . Clean left foot great toe wound with NS/WC (normal saline/wound cleanser), apply iodine, let air dry, cover with dry dressing daily until healed. On 05/28/2025 at 09:46 a.m. observation revealed S9 Treatment Nurse preparing Resident #11's wound care supplies on the wound care cart outside of Resident #11's room. Observation revealed the following in part . S9 Treatment Nurse removed a 4x4 gauze from the clean packaging and placed the 4x4 gauze directly on the computer keyboard on the wound care cart (contaminating the 4x4 gauze). Further observation revealed S9 Treatment Nurse continue to take the contaminated 4x4 gauze, soak it with normal saline, and then place the soaked, contaminated 4x4 gauze on top of other clean wound care supplies, which would be used for Resident #11's treatment. On 05/28/2025 at 09:55 a.m. observation of Resident #11's wound care performed by S9 Treatment Nurse revealed Resident #11's left great toe wound was cleansed with the contaminated 4x4 normal saline soaked gauze. On 05/28/2025 at 10:07 a.m. interview with S9 Treatment Nurse confirmed she contaminated Resident #11's 4x4 gauze during wound care preparation when she placed it directly on the computer keyboard. S9 Treatment Nurse confirmed she then used the contaminated wound care supplies to complete Resident #11's wound care to his left great toe. S9 Treatment Nurse confirmed she should have placed the 4x4 gauze on a clean barrier during wound care preparation to prevent contamination, but did not. S9 Treatment Nurse confirmed she should have discarded the contaminated 4x4 gauze before providing wound care to Resident #11, but did not.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests. The facility failed to provide an environment free of flies throughout the facility. This deficient practice had the potential to effect all 55 residents who resided in the facility. Findings: Review of an undated facility policy on 05/29/2025 at 7:12 p.m. titled, Pest Control Program revealed the following part .Facility will maintain an effective pest control program that eradicates and contains common household pests. 4. Facility will utilize a variety of methods in controlling certain seasonal pests, example flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations. In an interview on 05/27/2025 at 10:47 a.m., Resident #21 revealed he had seen flies and gnats in his room and in the dining area often. Resident #21 stated he reported the flies and gnats to staff previously, but nothing was done. Dining observation on 05/27/2025 at 11:48 a.m., revealed two flies flying throughout in the dining room. Observation revealed Resident #17 swat his bowl of chicken noodle soup because there was a fly crawling on the ledge of his soup bowl. In an interview on 05/27/2025 at 12:05 p.m., Resident #39 revealed he bought a fly swatter because he had flies and gnats in his room, and he often had to kill them. Resident #39 stated he always killed flies and gnats throughout the facility, thus the reason he bought a fly swatter. Resident #39 was observed with a fly swatter he carried with him. Review of Resident #39's Quarterly MDS with an ARD of 04/30/2025 revealed a BIMS score of 15, which indicated intact cognition. Dining observation on 05/28/2025 at 8:00 a.m., revealed two flies flying throughout in the dining room while multiple residents were eating breakfast. Observation revealed one fly crawling on the dining room table while a resident ate her breakfast, near her plate of food. In an interview on 05/28/2025 at 12:30 p.m., S3 Maintenance Director revealed he was aware the facility had flying insects inside the building, such as flies and gnats. S3 Maintenance Director stated that during the summer months, the flies and gnats were worse and he tried to deter the flying insects by using a hanging sticky trap/tray. S3 Maintenance Director confirmed there was a flying insect issue throughout the facility, but there should not have been. 52255 On 05/27/2025 at 11:30 a.m. observation of the facility kitchen revealed one live fly flying throughout the food preparation area. On 05/29/2025 at 09:08 a.m. observation of the facility kitchen revealed one live fly flying throughout the kitchen area. On 05/29/2025 at 10:52 a.m. interview with S8 Dietary Manager revealed the facility recently began having issues with live flies. S8 Dietary Manager confirmed she has observed live flies in kitchen area and the kitchen should always be free of flies or any other insects/pest, but was not.

Based on record review and interview the facility failed to ensure an allegation of physical abuse and allegation of neglect was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 2 (#6 and #156) of 30 Sampled Residents. Findings: Review of the facility's undated policy on 05/28/2025 at 08:30 a.m. titled Abuse Prevention and Investigation read in part . The facility defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This includes deprivation of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Physical abuse includes hitting, slapping, pinching, and kicking. Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Reporting: All alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately, but not later than 2 hours after the allegation is made if the alleged violation involves abuse or results in serious bodily injury OR within 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury to the administrator of the facility and to other officials including the state survey agency and adult protective services in accordance with state law through established procedures. Resident #6 Review of the medical record for Resident # 6 revealed he was admitted to the facility on [DATE]. Resident #6 had diagnoses that included in part . Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Major Depressive Disorder, Memory Deficit following CVA, and Dysphagia. Review of Resident #6's Quarterly MDS with an ARD of 03/25/2025 revealed a BIMS score of 13, which indicated cognition was intact. Review of a SIMS report completed by the facility revealed on 03/21/2025 at approximately 5:50 a.m. Resident #6 alleged S5 CNA had slapped him on his face. The facility was made aware of the allegation on 03/21/2025 at 8:30 a.m. The facility entered the allegation into SIMS reporting system on 03/21/2025 at 1:29 p.m. Interview on 05/29/2025 1:25 p.m. with S1 Administrator revealed she was responsible for SIMS reporting for the facility. S1 Administrator revealed the alleged staff to resident physical abuse occurred on 03/21/2025 at approximately 5:50 a.m., and she was made aware of the allegation on 03/21/2025 at 8:30 a.m. S1 Administrator revealed she entered the incident into SIMS on 03/21/2025 at 1:29 p.m. S1 Administrator confirmed that the incident of alleged staff to resident abuse was not entered into the SIMS within the required timeframe, but should have been. 51082 Resident #156 Review of Resident #156's medical record revealed an admitted [DATE], with diagnoses that included, in part .Cerebral Infarction due to Thrombosis of Right Posterior Cerebral Artery, Cocaine Abuse with Cocaine-Induced Mood Disorder/Sleep Disorder, and Anxiety Disorder. Review of Resident #156's Admission MDS with an ARD of 05/02/2025, revealed a BIMS score of 04, which indicated severe cognitive impairment. The MDS revealed Resident #156 was independent for transfers and used a walker for mobility. Review of Resident #156's Care plan with a target completion date of 08/11/2025, read in part .Elopement risk related to reported history of Altered Mental Status, Cocaine use with wandering attempts to leave hospital noted. 05/15/2025-Elopement attempt noted: willfully attempted to leave facility without notifying staff, wanted to be discharged back home. Interventions included in part; Elopement precautions: Census checks every 1 hour, each shift related to history of Delirium and wandering (initiated on 05/02/2025). Supervision increased to 1:1 for safety. Vistaril injection IM (intramuscular)1 time as ordered per S14 NP for anxiety. (initiated on 05/15/2025). Review of Resident #156's facility progress notes dated 05/16/2025 at 1:00 p.m., written by S2 DON read in part: Resident #156 left facility (exited X-hall bathroom window) after eating breakfast this morning. He was located & transported back to the facility in stable condition. Upon questioning, resident was noted alert & oriented x 4 with appropriate verbal responses. Resident #156 stated that he left facility to try to find a ride back to his home in New [NAME]. Review of a SIMS report completed by the facility revealed on 05/16/2025 at approximately 8:15 a.m. Resident #156 eloped from the facility. The facility was made aware of the elopement on 05/16/2025 at 8:30 a.m. The facility entered the allegation into SIMS reporting system on 05/16/2025 at 6:18 p.m. Interview with S1 Administrator on 05/29/2025 at 8:56 a.m., revealed on 05/16/2025 at approximately 8:15 a.m. Resident #156 eloped from the facility. S1 Administrator revealed she was made aware of the elopement on 05/16/2025 at approximately 8:30 a.m. S1 Administrator confirmed she did not report Resident #156's elopement out of the facility within the 2 hour required timeframe, but should have.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to provide a necessary communication aid for 1 (#35) of 1 Resident reviewed for communication. The total sample size was 30. Findings: Review of Resident #35's Electronic Health Record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included in part . Type 2 Diabetes Mellitus, Major Depressive Disorder, Unspecified Dementia, and Generalized Anxiety Disorder. Review of Resident #35's Quarterly MDS with an ARD date of 05/21/2025 revealed Resident #35 had BIMS of 8 (Moderate Cognitive Impairment). Resident #35's ability to understand others was documented as- sometimes. Review of Resident #35's Comprehensive Person Centered Care Plan revealed resident had difficulty communicating related to language barrier. Interventions included: Provide a communication board. Interview and observation on 05/27/2025 at 12:14 p.m. with Resident #35 revealed he had difficulty understanding English, and did not speak English. Resident #35 shook his head no, when asked if he could understand English. Observation of Resident #35's room at that time revealed there was no communication aid/board to assist in communication with resident. Interview on 05/28/2025 at 8:40 a.m. with S7 CNA revealed she was assigned care of Resident #35. S7 CNA stated Resident #35 did not speak English and understood very little English. S7 CNA stated she determined Resident #35's needs by pointing and guessing at things until resident would shake his head yes or no. S7 CNA stated she never used a communication aid or picture board with Resident #35 because he did not have one. Observation on 05/28/2025 at 8:50 a.m. of Resident #35's room revealed there was no communication aid to assist in communication with resident. Interview on 05/28/2025 at 8:54 a.m. with S4 LPN revealed Resident #35 had difficulty with communication as he could not speak English. S4 LPN stated she communicated with Resident #35 by using gestures. S4 LPN confirmed Resident #35 did not have a communication board, or any type of communication aid in his room to assist with communication. S4 LPN revealed Resident #35 would benefit from a communication board to assist in communication.

Based on record review and interview, the facility failed to ensure 8 (S2Licensed Practical Nurse (LPN), S3LPN, S4Certified Nursing Assistant (CNA), S5CNA, S6CNA, S7CNA, S8CNA, S9CNA,) out of 8 (S2Licensed Practical Nurse (LPN), S3LPN, S4Certified Nursing Assistant (CNA), S5CNA, S6CNA, S7CNA, S8CNA, S9CNA,) nursing/direct care staff records reviewed, were re-trained on their policy & procedure for abuse, after an incident of staff to resident verbal abuse occurred for 1 (#1) of 3 (#1, #2, and #3) sampled residents. This deficient practice had the potential to affect all 59 residents residing in the facility. Findings: A review of the facility's Policy & Procedure on Abuse revealed in part the following: Residents have the right to be free from abuse Training: Employees shall be trained in orientation, annually and as needed on the following topics which include: Prevention of Abuse, Neglect, and Exploitation Identifying what constitutes abuse Recognizing signs of abuse Review of Resident #1's medical record revealed he was admitted [DATE], with Diagnoses to include Schizoaffective Disorder, Essential Hypertension, Transient Cerebral Ischemic Attack, Cerebral Vascular Accident, and Depression. Review of Resident #1's Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/08/2024, revealed a BIMS (Brief Interview for Mental Status) score of 15 which indicated the resident was cognitively intact. Review of the facility's Investigation report revealed: Occurred: 04/28/2024 at 1:30 p.m. Discovered: 04/28/2024 at 1:30 p.m. S13RN (Registered Nurse) reported that around 1:30 p.m. she was down the hall by the activities room and heard Resident#1 and S12Ward Clerk exchanging words regarding cigarettes, as she got closer she could hear foul language being exchanged as Resident #1 and S12Ward Clerk were arguing about the cigarette schedule. S13RN intervened and instructed S12Ward Clerk to clock out and go home until further notice from S1Administrator. On 05/02/2024, after interviewing all the residents who smoked, I have concluded my investigation. The incident in question was an isolated incident and unfortunately, S12Ward Clerk acted impulsively and failed to conduct herself in a professional manner. Review of Resident #1's Nurses Note revealed, on 04/28/2024-the RN was down the hall near activity office when S12Ward Clerk and Resident #1 began arguing over the smoking schedule. S12Ward Clerk was in the nurse's station at the ward clerk area and Resident #1 was right outside the door of the station. Both were cursing and screaming at each other regarding the smoking schedule. S12Ward Clerk stood up screaming, F . you, I will hit you, you m .ther fu .er while lunging toward Resident #1. The resident then began to scream at S12Ward Clerk, what time you get off work? Meet me outside. S4CNA was present in the station and was standing between the two, after minutes of screaming and cursing at each other S4CNA got the two separated, and staff was able to calm Resident #1 down and take him out to smoke. Review of the facility's In-service training revealed on 04/29/2024 staff received training on abuse policy and smoking policy; however there was no documented evidence that S2LPN, S3LPN, S4CNA, S5CNA, S6CNA, S7CNA, S8CNA, and S9CNA received the in-service training. Interview on 05/13/2024 at 1:25 p.m. with S4CNA revealed she was at the nurse's station on 04/28/2024 when Resident #1 walked in the facility from outdoors after smoking. S4CNA stated Resident #1 asked S12Ward Clerk for a cigarette and S12 [NAME] Clerk refused. S4CNA stated Resident #1 told her she didn't know anything and called S12Ward Clerk a b .ch. S4CNA stated S12Ward Clerk then told Resident #1 if he called her that again she would slap him. S4CNA stated she then got between Resident #1 and S12Ward Clerk to prevent further escalation. S4CNA confirmed she did not receive re-training on abuse and neglect following this incident. Interview on 05/14/2024 at 9:45 a.m., S1Administrator stated the facility did not have any documented evidence the above mentioned staff were provided abuse and neglect training after the staff to resident incident of verbal abuse that occurred on 04/28/2024.

Based on record review and interview the facility failed to ensure a reportable incident was reported to the State Agency for 1 (Resident #18) of 2 (Resident #18 and Resident #20) sampled residents investigated for abuse. The facility failed to report an allegation of staff to resident abuse. Findings: Review of a policy and procedure titled, Abuse Prevention and Investigation, revealed in part: The appropriate State Agency will be notified per regulations for any abuse, suspected abuse, and injury of unknown origin using the State-Mandated Protocol for Reporting. Review of the EHR revealed Resident #18 was admitted to the facility on of 09/23/2022 with diagnoses that included: Unspecified Psychosis, Hypertensive Heart Disease, and Type 2 Diabetes Mellitus with Diabetic Nephropathy, Depression, Essential (primary) Hypertension, and Chronic Obstructive Pulmonary Disease. Review of Resident #18's Quarterly MDS with an ARD of 01/15/2024 revealed Resident #10 had moderate cognitive impairment with adequate vision and hearing. Interview on 03/18/2024 at 1:00 p.m. with Resident #18, during a resident council meeting, Resident #18 informed the surveyor he had been slapped by a CNA who was no longer employed at the facility. Resident #18 stated he reported being slapped to the ladies in the front office the day after it happened. Review of the facility's SIMS reports since last annual survey revealed there were no incidents logged related to abuse for Resident #18. Review of the facility's grievance log revealed a grievance dated 12/05/2023 revealed during resident rounds, Resident #18 reported to the Social Service Director that he was slapped by a CNA last evening (12/04/2023). SSD reported the allegation to S1 Adm. and S2 DON. In a telephone interview on 03/20/2024 at 8:47 a.m., Resident #18's RP stated the resident called (unable to recall date) one evening crying and stated that a staff had slapped him. Resident #18's RP stated on the next day, someone (not certain who) from the facility's office called her and informed her that Resident #18 stated that he had been slapped by a staff and the facility would be conducting an investigation. She stated they visited the facility later that day or the next day and Resident #18 stated to them that an aide had slapped him. In an interview on 03/19/2024 at 12:10 p.m., S2 DON confirmed Resident #18 did make a complaint to her on 12/05/2023 alleging S7 CNA had slapped him. S2 DON stated she and S1 Administrator interviewed Resident #18 after he reported the incident and explained that an investigation would be conducted and the incident would be reported to the state. S1 DON stated Resident #18 began waving his arms in the air and stated nothing happened to me and no one hit me, just leave it alone. In an interview on 03/20/2024 at 3:30 p.m., S1Administrator confirmed she did not report the alleged incident of S7 CNA slapping Resident # 18 to the state agency. S1 Administrator stated the incident was not reported because Resident #18 denied repeatedly that S7 CNA had slapped him. S1 Administrator stated that since Resident #18 had retracted his statement, a SIMS was not opened.

Based on observation, interview and record review the facility failed to ensure the MDS Assessment accurately reflected a residents' status during the observation period for 1 (Resident #49) of 1 residents sampled for dental. The total sample size was 23 residents. Findings: Review of Resident #49's clinical record revealed Resident #49 was admitted to the facility on [DATE]. Resident #49 had diagnoses that included Peripheral Vascular Disease, Obstructive Sleep Apnea, Asthma, and Essential Hypertension Review of Resident #49's Significant Change MDS Assessment with ARD 11/23/2023 indicated Resident #49 had, none of the above, checked on his dental assessment. Interview on 03/18/2024 at 10:1a.m. with Resident #49 revealed he had been having dental pain on and off to his right upper molar. Observation of Resident #49's oral cavity and dentition at the time of interview revealed 1 decayed right upper molar, 1 decayed left upper molar and 4-5 broken, decayed, front bottom teeth, all other teeth missing. Interview on 03/19/2024 at 5:45 p.m. with S2 DON revealed Resident #49's Oral/Dental section of the 11/23/2023 MDS Assessment had been completed and signed by a nurse working remotely. Observation on 03/19/2024 at 5:55 p.m. of Resident #49's oral cavity and dentition accompanied by S2 DON revealed the presence of decayed, missing, and broken teeth as observed on 03/18/2024. S2 DON confirmed the Significant Change MDS Assessment completed on 11/23/2023 did not accurately reflect Resident #49's dental status and should have.

Based on interview and record revealed the facility failed to develop and implement a comprehensive person-centered care plan for services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #18) sampled resident in a total sample of 23 residents. The facility failed to ensure a comprehensive care plan was developed for a resident newly diagnosed with Dementia. Findings: Review of the EHR revealed Resident #18 was admitted to the facility on of 09/23/2022 with diagnoses that included: Unspecified Psychosis, Hypertensive Heart Disease, and Type 2 Diabetes Mellitus with Diabetic Nephropathy, Depression, Essential (primary) Hypertension, and Chronic Obstructive Pulmonary Disease. Additional Diagnoses on 01/10/2024 included Unspecified Dementia, Unspecified severity with Agitation, and Dementia with other Behavioral disturbances. Review of 03/2024 physician orders for Resident #18 revealed: Memantine 5 mg po bid - Dx: Unspecified Dementia- 01/10/2024 Review of Resident #18's Quarterly MDS with an ARD of 01/15/2024 revealed a BIMS of 10 (moderately impaired cognition). Review of Resident #18's Care Plan with a target date of 04/15/2024 revealed no care plan was developed which addressed Dementia. In an interview on 03/20/2024 at 12:20 p.m. with S8 RN MDS Nurse revealed she and S3 RN MDS Nurse were responsible for residents care plans. S8 RN MDS Nurse confirmed Resident #18 was not care planned for Dementia and should have been.