Every finding on record at Courtyard of Natchitoches

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 (Resident #1 and Resident #2) of 3 sampled residents. The facility failed to ensureA physician's order for hourly rounding was implemented for Resident #1; andA physician's order for 2 ounces (oz) of vodka per evening was administered, documented, and monitored appropriately for Resident #2. Review of facility policy with review date of 04/2026, titled Physician Orders, revealed in part. Purpose: To establish and outline a mechanism for accepting, confirming, acknowledging, coordinating, implementing, transcribing, and authenticating diagnostic and therapeutic orders. Procedure. Check each order as it is entered and implement each order in its entirety before proceeding to the next. Implement any lab, X-ray, and other intervention orders placed by the physician and document as appropriate.1.Review of Resident #1's medical record revealed an initial admission date of 10/31/2023 and a re-entry date of 06/21/2025, with diagnoses that included, in part. Unspecified Dementia with Behavioral Disturbance, Anxiety Disorder, and Dizziness.Review of Resident #1's Discharge Return Anticipated MDS with ARD of 07/27/2026 revealed Resident #1 had a Memory Problem. Resident #1's Cognitive skills for decision-making were moderately impaired, indicating poor decision-making; cues/supervision were required.Review of Resident #1's 08/2026 active physician orders revealed, in part, an order with a start date of 12/29/2025: hourly rounding to assist with toileting, positioning, and placement of personal items.Review of Resident #1's care plan, with an initiation date of 02/13/2026 and a next review date of 09/23/2026, revealed in part. Behavior: resident cursing at staff and taking off wandergaurd. Resident at risk for falls with multiple documented falls. Interventions included in part. Hourly rounding.Review of Resident #1's medical record revealed no documentation that reflected hourly rounding was being implemented and documented as performed.In an interview on 08/11/2026 at 10:31 a.m. S4 CNA revealed she had been employed at the facility for about 1 year and was familiar with Resident #1 and the care he required. S4 CNA stated Resident #1 required routine rounding every 2 hours. S4 CNA denied being aware of Resident #1 requiring increased rounding.In an interview on 08/11/2026 at 10:58 a.m. S5 CNA stated she was not currently assigned to Resident #1 but had cared for him recently. S5 CNA stated she was not aware that Resident #1 required increased rounding. S5 CNA stated that when caring for the resident, she rounds on him every 2 hours and as needed.In an interview on 08/11/2026 at 11:52 a.m. S3 ADON confirmed Resident #1 has physician orders for hourly rounding. S3 ADON revealed nurses chart the hourly rounding on the electronic medication administration record (EMAR). S3 ADON stated the CNAs know the resident requires hourly rounding, provide the hourly rounding, and the nurses ensure it is done and documented accordingly.On 08/11/2026 at 12:04 p.m. Resident #1's 07/2026 and 08/2026 EMAR was reviewed with S3 ADON at this time. S3 ADON confirmed the EMAR does not reflect any documentation that hourly rounding was being implemented for Resident #1. S3 ADON confirmed the physician's order for hourly rounding should be documented hourly, but was not. S3 ADON confirmed hourly rounding documentation was not documented anywhere else.In an interview on 08/12/2026 at 2:43 p.m., S6 LPN stated she was assigned to Resident #1, was familiar with him, and knew the care he requires. S6 LPN stated she was made aware that day Resident #1 was ordered hourly rounding.On 08/11/2026 at 12:27 p.m., findings of no documentation reflecting hourly rounding for Resident #1 were discussed with S2 DON. S2 DON confirmed there was no documentation reflecting that Resident #1 received hourly rounding as ordered, and there should be. 2.Review of Resident #2's electronic medical record revealed an initial admission date of 11/11/2025 and a re-entry date of 07/30/2026, with diagnoses including, in part. Chronic Obstructive Pulmonary Disease, Anaphylactic Shock, Chronic Kidney Disease, and Alcohol Abuse. Review of Resident #2's 08/2026 physician orders revealed the following active order: Order date: 11/12/2025 - May have 2oz Vodka per evening for Night Cap.Review of Resident #2's Care plan, with an initiation date of 11/14/2025 and a next review date of 11/11/2026, revealed the following: May have 2 oz of vodka every evening for a night cap. Interventions included: Resident will have no complications related to use of vodka nightly through the review date; Administer vodka as ordered by physician; and monitor for any adverse effects and notify physician.Review of Resident #2's 07/2026 and 08/2026 electronic medication administration record (EMAR) revealed no documentation of administration or monitoring of 2oz of vodka.In an interview on 08/12/2026 at 12:04 p.m., S3 ADON revealed she was familiar with Resident #2 and his care. S3 ADON revealed the resident does have a history of alcoholism and has a physician's order to receive 2 oz of Vodka every evening. S3 ADON stated the physician's order is carried out and documented on the EMAR. S3 ADON further stated Resident #2 receives the vodka nightly and does not miss.In an interview on 08/12/2026 at 12:17 p.m. with S7 LPN and S3 ADON, S7 LPN revealed she was familiar with Resident #2, had recently worked with Resident #2 during the night shift, and administered the resident's evening vodka. When asked how she administers the vodka, S7 LPN stated, I put 2 cups of ice and then fill the cup to the tip top. S7 LPN confirmed she does not measure the vodka before administration and pours the vodka from the bottle. S7 LPN confirmed she did not know the exact amount of vodka ordered for Resident #2. S7 LPN stated there was one specific glass in Resident #2's room used to administer his vodka. The surveyor requested S7 LPN and S3 ADON accompany the surveyor to Resident #2's room to identify the glass used to administer the vodka and demonstrate the method of administration.On 08/12/2026 at 12:24 p.m., S7 LPN, accompanied by S3 ADON, identified the routine glass she uses to administer Resident #2's vodka in Resident #2's room. The surveyor requested that the LPN demonstrate how she administers the vodka using the identified glass, ice, and water (in place of vodka) from Resident #2's hydration pitcher. The hydration pitcher used at the bedside for the mock demonstration was labeled with measurements in milliliters (mL). Before the demonstration, the surveyor, S7 LPN, and S3 ADON observed and agreed that the hydration pitcher contained 550 mL of water. During the demonstration, S7 LPN placed the glass on Resident #2's bedside table, filled the glass with ice, and poured water from the hydration pitcher into the glass. S7 LPN confirmed that she does not use a measuring device to determine the amount of vodka administered. S7 LPN stated she determines the amount based on the level of the vodka reaching the top of the ice in the glass. Following the demonstration, the hydration pitcher was observed to contain approximately 450 mL of water. The surveyor, S7 LPN, and S3 ADON agreed that 100 mL of liquid had been poured into the glass during the demonstration. Based on the demonstrated method of administration, approximately 100 mL (3.4 fluid ounces) of vodka would be administered. This amount was approximately 1.4 fluid ounces greater than the physician-ordered amount of 2 ounces.In an interview on 08/12/2026 at 12:38 p.m., S3 ADON revealed that, after observing S7 LPN's mock demonstration of Resident #2's vodka administration, Resident #2 would receive approximately 3.4 fluid ounces of vodka, which is approximately 1.4 fluid ounces greater than the physician-ordered amount of 2 ounces. S3 ADON confirmed that nursing staff should use a measuring device to ensure Resident #2 received the amount of vodka specified in the physician's order, and had not been. In an interview on 08/12/2026 at 12:40 p.m., S3 ADON confirmed Resident #2's vodka administration should be documented, including the amount administered and the timing of administration, to ensure the resident receives the physician-ordered amount. During review of Resident #2's 08/2026 EMAR with S3 ADON, S3 ADON confirmed there was no documentation showing the physician's order for Resident #2's 2oz of vodka was being administered, documented, or monitored, and there should have been.In an interview on 08/12/2026 at 4:51 p.m. S2 DON confirmed Resident #2's physician order for 2 oz of vodka in the evening was not being documented, administered, or monitored appropriately. S2 DON stated the facility should have documentation to reflect when and how much vodka Resident #2 was receiving, and did not.

Based on interview and record review, the facility failed to ensure a resident's drug regimen was free of chemical restraints and unnecessary medications for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to ensure:1. A resident receiving a psychotropic medication had an adequate indication for use; and2. Monitoring of a psychotropic medication for side effects and effectiveness was in place. Review of facility policy with a review date of 01/2026, titled Use Psychotropic Medications, revealed in part. 2. Psychotropic medications are to be used only when a practitioner determines that the medications is appropriate to treat a residents specific, diagnosed, and documented condition and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the residents response to the medication.1.Review of Resident #2's electronic medical record revealed an initial admission date of 11/11/2025 and a re-entry date of 07/30/2026, with diagnoses including, in part. Chronic Obstructive Pulmonary Disease, Anaphylactic Shock, Chronic Kidney Disease, and Alcohol Abuse. Review of Resident #2's 08/2026 physician orders revealed the following active order: Rexulti Oral Tablet 0.5 MG (Brexpiprazole) Give 2 milligrams (mg) by mouth one time a day for behavior.Review of Resident #2's Discharge Return Anticipated MDS with ARD 07/28/2026 revealed no psychiatric or mood disorders documented. Resident #2 received an antipsychotic medication. 2.Review of Resident #2's care plan, with an initiation date of 11/14/2025 and a next review date of 11/11/2026, revealed the following: The resident uses psychotropic medications (Rexulti), with interventions that included, in part. Monitor for side effects and effectiveness each shift.Review of Resident #2's medical record revealed no monitoring in place for side effects and effectiveness of the antipsychotic medication Rexulti.In an interview on 08/12/2026 at 11:55 a.m. Resident #2's electronic medical record was reviewed with S7 LPN. S7 LPN confirmed Resident #2 did not have any listed psychiatric diagnoses in his chart. S7 LPN revealed the resident was receiving the antipsychotic medication Rexulti daily, and the diagnosis attached to the order was behavior. S7 LPN revealed all psychotropic drugs are to be monitored each shift by the nurse and documented. S7 LPN confirmed Resident #2 did not have monitoring in place for the psychotropic medication Rexulti, and should have.In an interview on 08/12/2026 at 12:04 p.m. with S3 ADON, Resident #2's listed diagnosis and 08/2026 active orders in the electronic medical record were reviewed. S3 ADON confirmed Resident #2 did not have a listed diagnosis of dementia or any other psychiatric diagnosis. S3 ADON confirmed Resident #2 was ordered the antipsychotic medication Rexulti and did not have monitoring in place for the antipsychotic medication, but should have.In an interview on 08/12/2026 at 4:13 p.m. S2 DON stated when a resident is ordered an antipsychotic medication, an appropriate diagnosis and monitoring are to be attached to the order. S2 DON confirmed a diagnosis of behavior was not an appropriate diagnosis for the use of an antipsychotic medication.

Based on interview and record review the facility failed to ensure a resident received the necessary treatment and services to promote healing of a pressure ulcer for 1 (#1) of 3 (#2, #3) residents reviewed for Pressure Ulcer/Injury. The facility had a total census of 86 according to the Daily Census provided by the facility administrator.Findings:Review of Resident #1's electronic record revealed she was admitted to the facility on [DATE] with diagnoses including Pulmonary Embolus, Anorexia, Hypertension, UTI (Urinary Tract Infection), and Unspecified Dementia. On 03/17/2026 a new diagnosis was added for Pressure Ulcer of Sacral Region, unstageable.Review of Resident #1's hospice record revealed that a visit was conducted by hospice and a new wound to the sacrum was found on 03/14/2026. S1 Facility Nurse was present at the time and was made aware of a new wound order for Dakin's gauze to the wound bed.Review of Resident #1's handwritten Physician's Telephone Orders revealed in part:03/14/2026 at 12:30 p.m. Dakin's gauze to wound bed-sacrum written by the hospice nurse.03/17/2026, 12:00 p.m. Unstageable pressure ulcer to sacrum: cleanse with Vashe, pat dry with gauze, apply Dakin's Solution moistened gauze and cover with dry dressing daily and prn (as needed) soilage or dislodgment written by S2 Treatment Nurse.03/16/2026, 4:50 p.m. Turn and reposition side to side only every 2 hours per posted turn schedule written by S2 Treatment Nurse.Review of S2 Treatment Nurse's Progress Note dated 03/18/2026 at 9:50 a.m. revealed a skin evaluation reflecting in part, a Pressure Ulcer/Injury to the sacrum, unstageable, with a length of 4.5, a width of 5.0, and depth of 0 (Measurements did not include the type unit used for measuring, such as centimeters). Slough to wound bed with serosanguinous drainage, and erythema to the peri-wound area.Review of Resident #1's March 2026 TAR (Treatment Administration Record) revealed the wound care order for the unstageable pressure ulcer on 03/18/2026. There was no documentation reflecting turning and repositioning side to side only every 2 hours per posted turn schedule.During an interview on 05/12/26 at 9:25 a.m., S2 Treatment Nurse stated that on 03/16/2026 she was notified by the hospice nurse that Resident #1 had a new sacral wound with new wound care orders. S1 Facility Nurse was present with the hospice nurse when the pressure ulcer was discovered and the hospice nurse notified S1 Facility Nurse of the wound care orders. S2 Treatment Nurse stated the hospice nurse called her on Monday, 03/16/2026 to discuss the pressure ulcer findings.During a telephone interview on 05/12/2026 at 3:39 p.m. with the hospice nurse, she confirmed that Resident #1's sacral pressure ulcer was discovered on 03/14/26, that she received a telephone order for wound care that date, and that she informed S1 Facility Nurse of the new order on that date.During a telephone interview on 05/12/2026 at 3:59 p.m. with S1 Facility Nurse, she revealed that she worked weekends as the treatment nurse. She confirmed that she was present on 3/14/26 when the hospice nurse assessed Resident #1's sacral pressure ulcer and that orders were received for wound care that date.Review of Resident #1's hospice records dated 03/23/2026 at 10:40 a.m. and 03/24/2026 at 9:25 a.m. reflected the resident was found lying in her hospital bed on her back.During a telephone interview with the hospice nurse on 05/12/2026 at 3:45 p.m., she confirmed she had found Resident #1 lying on her back when she made some of her visits. The hospice nurse confirmed Resident #1 should not have been lying on her back due to the sacral pressure ulcer, and due to a physician's order for turning side to side only every 2 hours.During an interview on 05/13/2026 at 1:18 p.m. with S2 Treatment Nurse, she confirmed that the wound care documentation for Resident #1's sacral ulcer did not begin until 03/18/2026, and it should have started on 03/14/2026. S2 Treatment Nurse confirmed a new order was received on 03/16/2026 for Resident #1 to be turned and repositioned every 2 hours from side to side only. S3 Treatment Nurse confirmed there was no documentation on the March Treatment Administration Record of this change, and it should have been.

Based on interview and record review the facility failed to ensure a resident's comprehensive person-centered care plan was reviewed and revised for 1 (#1) of 3 (#2, #3) sampled resident's care plans reviewed. The facility had a total census of 86 according to the Daily Census provided by the facility administrator.Findings:Review of Resident #1's electronic record revealed an admit date of 10/08/2025 with diagnoses including Pulmonary Embolus, Anorexia, Hypertension, Urinary Tract Infection, and Unspecified Dementia. On 03/17/2026 a new diagnosis was added for Pressure Ulcer of Sacral Region, unstageable.Review of Resident #1's hospice record revealed that a visit was conducted by hospice and a new wound to the sacrum was found. S1 Facility Nurse was present at the time and was made aware of a new wound order for Dakin's gauze to the wound bed.Review of Resident #1's handwritten Physician's Telephone Orders revealed in part:03/14/2026 at 12:30 p.m. Dakin's gauze to wound bed-sacrum written by the hospice nurse.03/16/2026, 4:50 p.m. Turn and reposition side to side only every 2 hours per posted turn schedule written by S2 Treatment Nurse.03/17/2026, 12:00 p.m. Unstageable pressure ulcer to sacrum: cleanse with Vashe, pat dry with gauze, apply Dakin's Solution moistened gauze and cover with dry dressing daily and prn (as needed) soilage or dislodgment written by S2 Treatment Nurse.Review of Resident #1's Care Plan reflected in part, a mild risk for pressure ulcer/pressure injury initiated 01/27/2025. There were no additional/revisions of the Care Plan to include an actual pressure ulcer, nor did it include the intervention of turning and repositioning side to side only every 2 hours per posted turn schedule.During an interview on 05/13/2026 at 1:44 p.m., S3 RN/MDS (Registered Nurse/Minimum Data Set) revealed Resident #1's Care Plan should have been revised to include the unstageable sacral pressure ulcer, discovered on 3/14/26 including the change of the intervention to turn and reposition side to side only every 2 hours per posted turn schedule, but was not.

Based on interviews and record reviews, the facility failed to provide education to the resident or resident representative and obtain consent from a resident's responsible party prior to administering the influenza vaccination for 1 (Resident #98) of 6 sampled residents reviewed for influenza vaccines.Findings: Review of the facility's policy titled, Pneumonia/Influenza Vaccinations with a revision date of 01/2025 revealed in part.Policy: In keeping with the policies of a hospital as a whole, the facility has adopted the following protocol regarding Pneumonia and Influenza vaccinations. 1. Contact Resident and Family and explain importance of vaccinations. 2. Obtain signed consent from resident and/or family. Review of Resident #98's clinical record revealed an admission date of 04/15/2015 with a re-entry date of 09/04/2025 with diagnoses that included in part.Chronic Kidney Disease, Stage 5; End Stage Renal Disease; Pneumonia, Schizophrenia; and Bipolar Disorder. Further review revealed Resident #98's Responsible Party was listed as her Health Care Proxy. Review of Resident #98's Significant Change MDS with an ARD of 09/10/2025 revealed a BIMS summary score of 03, which indicated severe intact cognition. Review of Resident #98's Physician's Orders revealed in part. start date-10/06/2025--Fluzone High-Dose Intramuscular Suspension Prefilled Syringe 0.5 ML (Influenza Virus Vaccine Split High-Dose Preservative Free. Inject 0.5 ml intramuscularly one time only for vaccine until 10/06/2025. Review of Resident #98's 10/2025 eMAR revealed Resident #98 was administered Fluzone High-Dose Influenza Virus Vaccine on 10/06/2025 at 1:00 p.m. Review of Resident #98's Care Plan read in part.Focus: Refuses vaccines: allergic to some components. Interventions: Assess for consent or refusal of vaccines upon admit and periodically with resident and responsible party (initiated: 08/08/2024). Focus: Short term memory deficit (date initiated: 08/08/2024). Intervention: assess mental status every shift and as needed; Reorient and redirect as needed. Review of Resident #98's Influenza Vaccination Request and Consent form dated on 10/10/2025 and signed by Resident #98's Responsible Party read in part.NO: I do not wish to receive the Influenza vaccine at this or any other time on an annual basis. Review of Resident #98's medical records revealed no documented evidence of a signed consent form signed by Resident #98 or her Health Care Proxy, a refusal of the vaccination, or education explaining the benefits/risks prior to Resident #98 receiving the Influenza vaccine on 10/06/2025. In an interview on 01/06/2026 at 2:37 p.m., S7 LPN stated that on 10/06/2025 she was given instructions from S5 IC Nurse to administer vaccinations to all the residents in the facility. S7 LPN stated she was given a list from S5 IC Nurse of all the residents who consented to receive the Influenza vaccine. S7 LPN confirmed she administered the Influenza vaccine to Resident #98 on 10/06/2025 but did not to ensure a consent was signed prior to administering the vaccine. In an interview on 01/06/2026 at 3:21 p.m., S2 ADON reviewed Resident #98's Influenza vaccination consent form dated 10/10/2025 and confirmed that Resident #98's Responsible Party signed the refusal after Resident #98 received the Influenza vaccination on 10/06/2025. In an interview on 01/07/2026 at 10:17 a.m., S5 IC Nurse acknowledged that an Influenza Vaccination consent/refusal and education should had been obtained for Resident #98 prior to administration of the vaccine on 10/06/2025, but was not.

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety by failing to ensure refrigerated food items were covered, labeled, and stored with an open and discard date after opening. This deficient practice had the potential to affect the 87 residents that received meals served from the facility's kitchen.Findings: On 01/05/2026 at 8:50 a.m. observations of the facility kitchen accompanied by S14 Dietary, revealed the following:An unsealed, unlabeled package of smoked ham lunch meat;An unsealed bag of lettuce with brown discoloration, and the label on the lettuce was illegible due to moisture;Unpackaged, undated, loose cheese slices; andAn unpackaged, unlabeled block of cheese labeled with a discard date of 01/04/2026.Interview on 01/05/2026 at 08:55 a.m. with S14 Dietary confirmed the above findings. S14 Dietary confirmed that all food stored in the cooler should have been labeled and dated in sealed packages, but were not. S14 Dietary confirmed the expired cheese should have been discarded, but was not. Interview on 01/06/2026 at 9:30 a.m. with S4 Dietary confirmed the above findings. S4 Dietary confirmed that food stored in the facility refrigerator should have been covered or sealed, labeled with an open and discard date, and discarded according to the discard date, but was not.

Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (Resident #11) of 3 residents investigated for PASARR in a final sample of 28 residents.Review of facility policy titled Resident Assessment - Coordination with PASARR Program with review date of 01/2025 read in part. This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure the individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. 6. The Social Services Director shall be responsible of keeping track of each residents PASARR screening status, and referring to the appropriate authority. 8. Any level II resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review. Review of Resident #11's demographic sheet revealed an initial admission date of 11/27/2024 with a diagnosis that included Personal History of other Mental and Behavioral Disorders, Anxiety Disorder, and Major Depressive Disorder. Resident #11 had a diagnosis of Delusional Disorder with onset date of 03/27/2025 and Schizoaffective Disorder, Depressive type, with onset date of 05/13/2025. Review of Resident #11's Annual MDS with ARD 11/05/2025 revealed in part. Resident #11 had a BIMS score of 13, indicating intact cognition.Review of Resident #11's medical record revealed a document titled OBH-PASRR Level II Evaluation Summary & Determination Notice dated 11/15/2024. Document read in part. The Individual does not have a serious mental illness, and a level II is not required. Applicant has a diagnosis of Anxiety and Depression. There was no intensive behavioral health treatment reported. Review of Resident #11's medical record revealed Resident was sent out of the facility on 03/13/2025 for psychiatric evaluation due to a change in mental status. Further review revealed Resident #11 had an inpatient psychiatric admission from 03/13/2025 through 03/27/2025. Further review of Resident #11's record revealed there was no evidence that a new review or a Level II PASARR had been submitted to the appropriate state-designated authority after the new diagnosis of Delusional Disorder on 03/27/2025 or Schizoaffective Disorder on 05/13/2025.In an interview on 01/06/2026 at 10:38 a.m. S6 SSD revealed she was responsible for sending referrals to the appropriate state-agencies for Level II PASARR evaluations. S6 SSD reviewed Resident #11's diagnoses list at this time and confirmed Resident #11 had new diagnoses of Delusional Disorder and Schizoaffective Disorder since the last Office of Behavioral Health (OBH) PASRR Level II Evaluation. S6 SSD confirmed the facility did not send a new referral for Resident #11 to the appropriate state-agency for a Level II Evaluation after new diagnoses of Delusional Disorder and Schizoaffective Disorder, and should have.

Based on record review and interview, the facility failed to ensure a resident's drug regimen was free from unnecessary medications by failing to have a documented medical condition and by failing to monitor for side effects and behaviors of psychotropic medications for 1 (Resident #8) of 5 residents reviewed for unnecessary medications.Findings: Review of a facility policy titled Antipsychotic Drug Use with a revision date of 02/02/2017, revealed in part.Policy: Residents of our facility will not receive unnecessary anti-psychotic drugs.Procedure: Behaviors for which anti-psychotics drugs should not be used include: Insomnia.Review of Resident #8's medical chart revealed an admission date of 07/24/2025 with diagnoses that included in part.Other Unspecified Anxiety Disorder, Insomnia, and Blindness of Both Eyes.Review of Resident #8's Quarterly MDS with an ARD of 10/15/2025 revealed a BIMS score of 6 indicating severe cognitive impairment. The MDS revealed Resident #8 had received an Anti-psychotic with no indication noted.Review of Resident #8's care plan with a Target Date of 01/14/2026 revealed in part.The Resident uses psychotropic medications (Seroquel), with interventions that included in part.Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift.Review of Resident #8's physician orders for 01/2026 revealed in part.Seroquel Oral tablet 25 MG by mouth at bedtime related to Insomnia, Unspecified with a start date of 08/03/2024.Review of a facility form dated 09/21/2025 and titled, Medication Drug Review' revealed in part.Resident #8, no supporting diagnoses for current medication Seroquel-3rd request. The form was signed by S15 DON on 09/22/2025.Review of a facility form dated 09/21/2025 and titled, Doctor Report revealed in part.After reviewing this resident's drug regimen we found the following items that must be addressed: Resident is on Seroquel Therapy-Please select one of the following acceptable diagnoses: Bipolar. Formed signed by the Pharmacist on 09/21/2025 and the Physician and S15 DON on 10/2025.Interview and record review on 01/07/2026 at 11:41 a.m. of Resident #8's medication drug review with S2 ADON revealed the consultant pharmacist requested for Resident #8's psychotropic medication (Seroquel) to be updated to reflect a supporting diagnosis. S2 ADON confirmed that Resident #8's medical chart was not updated to reflect the diagnosis of Bipolar, in which the physician had written in 10/2025; and the facility was not monitoring Resident #8 for any side effects or behaviors of psychotropic medications, but should have been.

Based on observation, record review, and interview the facility failed to ensure the resident's right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. The facility failed to ensure 1 (Resident #54) of 28 sampled residents was provided a wheelchair appropriate for her size. Findings: Review of Resident #54's medical record revealed an admit date of 02/26/2024 with diagnoses that included in part.Edema, Quadriplegia Unspecified, Acute Pain, Muscle Spasm, Central Cord Syndrome At Unspecified Level Of Cervical Spinal Cord, and Seizures.Review of Resident #54's Quarterly MDS with an ARD of 10/22/2025 revealed she had a BIMS score of 15 indicating intact cognition. The MDS revealed Resident #54 had bilateral upper and lower extremity impairments, and used a wheelchair for mobility. The MDS revealed Resident #54 required set up or clean up assistance with eating, and was dependent for 2 person assistance with personal hygiene, transfers and toileting.Review of Resident #54's care plan with a Target Date of 01/21/2026 revealed in part.1. The resident has limited physical mobility related to Central Cord Syndrome with interventions that included in part.Monitor/document/report PRN any signs and symptoms of immobility; contractures forming or worsening.2. The Resident is at risk for pressure ulcers/injuries with interventions that included in part.Avoid scratching and keep hands and body parts from excessive moisture. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Observation and interview on 01/05/2026 at 10:30 a.m. with Resident #54 revealed she was in her room sitting in a wheelchair. Resident #54 had no space between her hips and the sides of the wheelchair. Resident #54 stated her wheelchair was too small and was rubbing against her hips. Resident #54 stated she had notified S1 Administrator, over a month ago, that her wheelchair was too small because she had gained weight. Interview on 01/06/2026 at 9:00 a.m. with S10 CNA revealed Resident #54 had complained of her wheelchair being too small and rubbing against her hips. Interview on 01/06/2026 at 9:16 a.m. with S11 CNA revealed. Resident #54 had notified her over a month ago about her wheelchair being too small and it was hurting her hips. S11 CNA stated she notified S1 Administrator of Resident #54's complaint. S11 CNA stated S1 Administrator went to Resident #54's room and she showed her Resident #54's wheelchair was too small. Observation of Resident #54 on 01/06/2026 at 1:10 p.m. revealed 3 CNA assisting her from wheelchair via Hoyer lift onto her bed. Resident #54 observed to have redness and indentions to bilateral hips from pressing against the sides of her wheelchair. Observation and Interview on 01/06/2025 at 1:15 p.m. with S9 LPN in Resident #54's room confirmed Resident #54 had redness and indentions to bilateral hips from her wheelchair pressing against the side of her hips. Interview on 01/06/2026 at 1:30 p.m. with S12 RCNA revealed she had noticed Resident #54's wheelchair being too small for her. S12 RCNA revealed resident had edema sometimes and she had gained weight. Interview on 01/06/2026 at 1:35 p.m. with S13 PTA revealed residents are screened every 3 months and as needed. S13 PTA stated Nursing had not notified Therapy of Resident #54's wheelchair being too small. Interview on 01/06/2026 at 1:40 p.m. with S1 Administrator revealed she had filled out a requisition form and had sent it to the hospital for approval, so Resident #54 could get a bigger wheelchair. S1 Administrator stated the requisition had been cancelled (the hospital did not approve the new wheelchair). S1 Administrator confirmed no other measures had been implemented to obtain an appropriate sized wheelchair for Resident #54, and it should have.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in a secure manner by failing to ensure medications were not left at the bedside for 1 (Resident #48) resident of 28 sampled residents.Findings: Review of Resident #48's Clinical Record revealed an admit date of 05/12/2025 with diagnoses which included: Chronic Obstructive Pulmonary Disease, Primary Insomnia, Depression, and Nicotine Dependence. Review of Resident #48's Quarterly MDS with an ARD of 11/19/2025 revealed a BIMS score of 15, which indicated intact cognition. Resident #65 was independent for bed mobility, transfers, eating, and toileting. Further review of the medical record revealed there were no physician's orders to allow Resident #48 to store any medications in the room at the bedside. In an interview and observation on 01/05/2026 at 11:09 a.m. revealed Diclofenac Arthritis Cream placed on Resident #48's bedside table. Resident #48 stated she was running low on this cream and needed some more. In an interview and observation on 01/07/2026 at 11:13 a.m., Resident #48 stated she would like some more cream for her left side. Accompanied Resident #48 to her bathroom and observed Diclofenac Arthritis Cream, Nystatin Cream, and Hydrocortisone Cream placed on a table next to Resident #48's toilet. Resident #48 stated that she got them from the nurse (didn't remember which nurse). Resident #48 stated one nurse would give her some cream in a medicine cup. In an observation and interview on 01/07/2026 at 12:19 p.m., S2 ADON accompanied surveyor to Resident #48's bedroom. S2 ADON confirmed that the Diclofenac Arthritis Cream, Nystatin Cream, and Hydrocortisone Cream should not be left unattended in Resident #48's bathroom.

Based on observation, interview, and record review, the facility failed to honor and accommodate food preferences for 2 (Resident #5 and Resident #29) of the 7 residents reviewed for dining. The deficient practice had the potential to affect 87 residents who consumed meals from the kitchen.Review of facility policy titled Promoting/Maintaining Resident Self-Determination dated 04/2025 read in part. It is the practice of this facility to protect and promote resident rights by facilitating resident self-determination through support of resident choice. The facility will ensure that each resident has the opportunity to exercise his/her autonomy regarding those things that are important in his/her life such as interest and preferences. 9. The facility will accommodate the resident preferences to the extent possible and as agreed upon by the resident sponsor and physician. Resident #5Review of Resident #5's electronic medical record revealed an initial admission date of 06/09/2016 with diagnoses that included, in part, Type 2 Diabetes Mellitus without complications, Anxiety Disorder, and Essential Primary Hypertension.Review of Resident #5's Annual MDS with ARD 11/5/2025 revealed in part. Resident #5 had a BIMS score of 15, indicating intact cognition. An observation on 01/06/2026 at 11:28 a.m. revealed Resident #5 sitting up in her wheelchair in her room with a lunch tray present in front of her. Resident #5's plated meal included chicken pasta with a white cream sauce, broccoli, and garlic breadstick. Resident chicken pasta was observed untouched by Resident #5. In an interview on 01/06/2026 at 11:28 a.m. Resident #5 revealed she does not like meat in her pasta and would not eat her chicken pasta with white cream sauce. Review of Resident #5's meal ticket on lunch tray at this time read in part. Dislikes: beef and meat in pasta. On 01/06/2026 at 11:32 a.m. S8 LPN accompanied the surveyor to Resident #5's room. S8 LPN confirmed that Resident #5 had a dislike of meat in pasta on her meal ticket. S8 LPN confirmed Resident #5 was served food that did not honor her preferences and should not have been. In an interview on 1/06/2026 at 11:40 a.m., review of Resident #5's meal ticket and the above findings were discussed with S1 Administrator. S1 Administrator acknowledged Resident #5 was served food that did not honor her preferences and should not have been.Resident #29Review of Resident #29's electronic medical record revealed an initial admission date of 09/04/2024 with diagnoses that included, in part, Multiple Myeloma and Chronic Kidney Disease. Review of Resident #29's Annual MDS with ARD 12/5/2025 revealed in part. Resident #29 had a BIMS score of 15, indicating intact cognition.An observation on 01/06/2026 at 11:16 a.m. revealed of Resident #29 eating lunch in dining area. Resident #29 observed to be eating well, with the exception of the broccoli plated. Interview with Resident #29 at this time revealed that he did not like broccoli and did not eat it. Review of Resident #29's meal ticket on his lunch tray at this time read in part . Dislikes: Broccoli. The resident did not have an alternate vegetable served to him at this time.In an interview on 01/06/2026 at 11:17 a.m. review of Resident #29's meal ticket and meal tray with S9 LPN. S9 LPN confirmed that Resident #29's meal ticket listed broccoli as a dislike. S9 LPN confirmed that the Resident was served food that did not honor his preferences and should not have been. In an interview on 01/06/2026 at 11:25 a.m. S1 Administrator confirmed Resident #29 was served food that did not honor his preferences and should not have been.

Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure physician's diet orders were followed for 1 (Resident #48) of 1 sampled residents. Total sample size was 28. Findings: Review of Resident #48's Clinical Record revealed an admit date of 05/12/2025 with diagnoses which included: Chronic Obstructive Pulmonary Disease, Primary Insomnia, Depression, and Nicotine Dependence. Review of Resident #48's Quarterly MDS with an ARD of 11/19/2025 revealed a BIMS score of 15 indicating intact cognition. Resident #65 was independent for bed mobility, transfers, eating, and toileting. Review of Resident #48's 01/2026 Physician Orders revealed the following, in part:10/22/2025-Regular diet, Regular texture, Regular/Thin consistency-Single cup sips only no straws, no dry or particulate food (bread, rice, etc) for having swallowing problems Review of Resident #48's Care Plan read in part: The resident has Aspiration *NO straws, bread, or rice* (initiated 10/24/2025). Review of Resident #48's Physician Progress notes dated 10/22/2025 read in part: Resident #48 had MBS (Modified Barium Swallow Study) since last encounter revealing she had some aspiration of liquids but improved when avoiding straws and if single cups sips only and avoiding dry or particulate foods such as breads and rice. Review of Resident #48's Change in Diet Form dated 10/22/2025 read in part: Special Request: Sips only from cups, no straws, or particulate food (bread, rice, etc.,) An observation and interview on 01/05/2026 at 11:09 a.m. revealed Resident #48 preparing to eat lunch. Lunch tray revealed a BLT sandwich. Resident #48 stated oh yea I'll eat this. Resident #48 stated she always gets a BLT sandwich during meal service because that's all she'll eat. An observation and interview on 01/07/2026 at 8:30 a.m., Resident #48 stated she does have trouble swallowing at times and is always served bread on her sandwiches during meal service. Resident #48 stated she doesn't know why she's always served bread since she can't eat it. An observation and interview on 01/07/2026 at 11:13 a.m. revealed mashed potatoes, bread, and baked turkey on Resident #48's lunch tray. Meal ticket observed which stated Regular. Resident #48 stated see they served me this bread again. Interview on 01/07/2026 at 11:19 a.m., S7 LPN stated Resident #48 was on a regular diet and that anytime a diet is changed, staff completes a change of diet form, and sends it to dietary staff so the meal ticket can reflect the new diet order. This surveyor accompanied S7 LPN to her computer and reviewed physician diet orders. S7 LPN acknowledged that the physician orders specified No bread, rice, or straws for Resident #48. S7 LPN confirmed that Resident #48 was served bread during meal services and shouldn't be. Interview on 01/07/2026 at 11:33 a.m., S2 ADON acknowledged Resident #48's current physician orders stated No bread, rice, or straws. S2 ADON stated that anytime a resident's diet is change, staff updates, and sends a change of diet form to dietary, and then it's uploaded on the resident's meal ticket. S2 ADON confirmed that Resident #48 shouldn't have been served bread during meal services and that Resident #48's meal ticket did not reflect current physician diet orders but should have. Interview on 01/07/2026 at 12:06 p.m., S4 Dietary stated when a change in diet form is completed and uploaded in the hospital portal, the changes should reflect on the meal ticket. S4 Dietary confirmed that Resident #48 is served bread every day and doesn't believe Resident #48 signed a waiver. Interview on 01/07/2026 at 12:50 p.m., S3 ST revealed that Resident #48 was not cleared by a physician to eat bread and she had a previous MBS study done which indicated she is not to be served bread, rice, or have straws.

Based on observations, interviews and record review the facility failed to ensure the interdisciplinary team assessed and determined if a resident was clinically appropriate for self-administration of medication for 1 resident of 1 (Resident #48) sampled residents. Total sample size was 28. Findings: Review of a facility policy titled Resident Self-Administration of Medications with a review date of 02/2025 revealed in part.Policy Explanation and Compliance Guidelines: 3. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility. 4. The results of the interdisciplinary team assessment are recorded on the Self-Administration Assessment form, which is placed in the resident's medical record. Review of Resident #48's Clinical Record revealed an admit date of 05/12/2025 with diagnoses which included: Chronic Obstructive Pulmonary Disease, Primary Insomnia, Depression, and Nicotine Dependence. Review of Resident #48's Quarterly MDS with an ARD of 11/19/2025 revealed a BIMS score of 15, which indicated intact cognition. Resident #65 was independent for bed mobility, transfers, eating, and toileting. Review of Resident #48's care plan with a target date of 02/04/2026 and revision date of 11/06/2025 revealed in part .Focus: The resident has a physician's order for (unsupervised) self-administration of the following medications: Carboxymethylcellulose Eye drops (initiated 09/04/2025) Further review of the medical record revealed there were no physician's orders to allow Resident #48 to store any medications in the room at the bedside. Review of Self-Administration of Medication assessment form dated 08/19/2025 revealed Resident #48 was fully capable to self-administer eye drops. Topical medications (including patches) were not selected for Resident #48 being capable to self-administer. In an interview and observation on 01/05/2026 at 11:09 a.m. revealed Diclofenac Arthritis Cream placed on Resident #48's bedside table. Resident #48 stated she was running low on this cream and needed some more. In an interview and observation on 01/07/2026 at 11:13 a.m., Resident #48 stated she would like some more cream for her left side. Accompanied Resident #48 to her bathroom and observed Diclofenac Arthritis Cream, Nystatin Cream, and Hydrocortisone Cream placed on a table next to Resident #48's toilet. Resident #48 stated she administers the creams herself and that she got them from a nurse (didn't remember which nurse). Resident #48 stated a nurse would give her some cream in a medicine cup. In an observation and interview on 01/07/2026 at 12:19 p.m., S2 ADON accompanied surveyor to Resident #48's bedroom. S2 ADON confirmed that the Diclofenac Arthritis Cream, Nystatin Cream, and Hydrocortisone Cream should not be left unattended in Resident #48's bathroom. S2 ADON reviewed Self-Administration of Medications assessment with Surveyor and confirmed that Resident #48 was only allowed to self-administer eye drops and not topical creams.

Based on interviews, and record reviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices. The facility failed to ensure documentation on the Medication Administration Report (MAR) was accurate for 2 (Resident #2 and Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident R5) sampled residents. Review of the facility's policy entitled Administration of Medicines revised 03/2025 revealed, in part.the facility is to maintain a record of all medications administered. Staff is to time and initial each medication on the MAR after the medication is given.Review of the facility's policy entitled Medication Administration Electronic Documentation revised 03/2025 revealed, in part.Every resident has an electronic Medication Administration Record (E-MAR) for the purpose of proper administration and recording of all medications. The E-MAR is a permanent, legal document and is a part of the Electronic Health Record. Resident #2Review of Resident #2's medical record revealed an initial admission date of 08/30/2024 with diagnoses including, in part.Repeated Falls, Tremor, Protein-Calorie Malnutrition, Osteoarthritis, Hypothyroidism, Disorder of the Skin and Subcutaneous Tissue, Dementia, Anxiety, Hyperlipidemia and Glaucoma.Review of Resident #2's Annual MDS with ARD of 09/03/2025 revealed a BIMS Score of 03, indicating severe cognitive impairment.Review of Resident #2's current physician's orders revealed, in part. 09/10/2025 Levothyroxine 100mcg po daily r/t Hypothyroidism; 08/08/2025 Donepezil 10mg give 1/2 tablet po in the evening r/t Dementia and Anxiety; 08/05/2025 Latanoprost Ophthalmic Solution 0.005% instill 1 drop in both eyes at bedtime r/t Glaucoma; 11/04/2024 Observe closely for significant side effects of Anti-Depressant medication.every shift; 10/14/2024 Observe closely for significant side effects of Anticoagulant medication.every shift; 10/08/2024 Resident to wear pillow heel boots with heels floated while in bed every shift; 09/09/2024 Naturewell Retinol Cream apply topically to arms, hands, and face daily r/t Disorder of the Skin and Subcutaneous Tissue; 09/09/2024 Overlay on mattress to help prevent pressure points every shift; 09/05/2024 Supplement of choice TID with meals r/t Unspecified Protein-Calorie Malnutrition; 08/31/2024 Atorvastatin 20mg give one tablet po daily r/t Hyperlipidemia; and 08/30/2024 Memantine 10mg give 1/2 tablet po BID r/t Dementia and Anxiety.Review of Resident #2's 09/2025 MAR revealed, in part.on 09/06/2025 time and initials were not recorded on the night shift for: Overlay on mattress to help prevent pressure points every shift; Observe closely for significant side effects of Anticoagulant medication.every shift; Observe closely for significant side effects of Anti-Depressant medication.every shift; and Resident to wear pillow heel boots with heels floated while in bed every shift.On 09/07/2025 at 6:00 a.m. time and initials were not recorded for Levothyroxine.On 09/08/2025 at 6:00 a.m. time and initials were not recorded for Levothyroxine.Review of Resident #2's 08/2025 MAR revealed, in part.on 08/29/2025 time and initials were not recorded on the evening shift for: Overlay on mattress to help prevent pressure points every shift; Observe closely for significant side effects of Anticoagulant medication.every shift; Observe closely for significant side effects of Anti-Depressant medication.every shift; and Resident to wear pillow heel boots with heels floated while in bed every shift.On 08/28/2025 at 5:00 p.m. time and initials were not recorded for Supplement of choice.On 08/29/2025 at 7:00 p.m. time and initials were not recorded for Donepezil.On 08/29/2025 at 8:00 p.m. time and initials were not recorded for Atorvastatin, Latanoprost Ophthalmic Solution, Memantine, or Naturewell Retinol Cream. Resident #4Review of Resident #4's medical record revealed an admission date of 12/17/2014 with diagnoses including, in part.Diabetes and Hypothyroidism.Review of Resident #4's Annual MDS with an ARD of 08/06/2025 revealed a BIMS Score of 15, indicating intact cognition.Review of Resident #4's physician's orders revealed, in part. 08/07/2025 Levothyroxine 25mcg po every day r/t Hypothyroidism; 09/30/2024 Novolin R Injection Solution inject as per sliding scale subcutaneously BID r/t Diabetes; 08/09/2024 Observe closely for significant side effects of Anticoagulant medication every shift; 08/09/2024 Observe closely for significant side effects of Anticonvulsant medication every shift; 07/01/2024 Blood glucose monitoring one time a day; and 06/26/2024 Encourage fluid intake by mouth every shift.Review of Resident #4's 09/2025 MAR revealed, in part.on 09/06/2025 time and initials were not recorded on the night shift for: Encourage fluid intake by mouth every shift; Observe closely for significant side effects of Anticoagulant medication every shift; and Observe closely for significant side effects of Anticonvulsant medication every shiftOn 09/07/2025 at 6:00 a.m. time and initials were not recorded for blood glucose monitoring, Levothyroxine, and Novolin R.On 09/08/2025 at 6:00 a.m. time and initials were not recorded for blood glucose monitoring, Levothyroxine, and Novolin R.Interview with S3ADM on 09/17/2025 at 1:35 p.m. confirmed the facility failed to ensure documentation on Resident #4's 09/2025 MAR, and Resident #2's 08/2025 and 09/2025 MARs was accurate, but should have.Interview with S11LPN on 09/17/2025 at 1:42 p.m. revealed she administered medications and performed all tasks as ordered for Resident #2 and Resident #4 on 09/06/2025, 09/07/2025, and 09/08/2025, but failed to ensure documentation on the MARs. S11LPN confirmed documentation on Resident #2 and Resident #4's 09/2025 MAR was not accurate, but should have been. Interview with S12LPN on 09/17/2025 at 2:00 p.m. revealed she administered medications and performed all tasks as ordered for Resident #2 on 08/29/2025, but failed to ensure documentation on the MAR. S12LPN confirmed documentation on Resident #2's 08/2025 MAR was not accurate, but should have been.

Based on observations and interviews, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure Cart X was locked and medications were stored in a safe and secure manner.Review of the facility's policy entitled Medication Storage revised 03/2025 revealed, in part.It is the policy of this facility to ensure all medications housed on our premises will be stored to ensure security. All drugs and biologicals will be stored in locked compartments. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.Observation of Hall B on 09/16/2025 at 8:55 a.m. revealed Cart X was unattended, and unlocked, with 3 of 8 drawers pulled open. This surveyor remained with Cart X until a staff member approached Cart X. The staff member identified herself as S7LPN.Interview with S7LPN on 09/16/2025 at 8:57 a.m. revealed Cart X was unattended and unlocked on Hall B, with 3 drawers pulled open. S7LPN revealed medication carts were to be locked, with all drawers closed, when left unattended. S7LPN confirmed the medications on Cart X were not stored in a safe a secure manner, but should have been.Interview with S2DON on 09/16/2025 at 10:45 a.m. revealed medication carts were to be locked when unattended to ensure medications were stored in a safe and secure manner.

Based on observation, interview, and record review, the facility failed to ensure the privacy and confidentiality of medical records for 1 (Resident R5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident R5) sampled residents.Review of the facility's policy entitled Sanctions for (facility name) to Comply to HIPAA Privacy Standards revised 06/2016 revealed, in part.all workforce members are required to adhere to the HIPPA Privacy Standards and prevent unauthorized disclosure of Protected Health Information (PHI). Workforce members will protect health information from unauthorized disclosure. Leaving PHI in public areas is a violation of HIPPA Privacy Standards.Observation of Hall B on 09/16/2025 at 8:55 a.m. revealed Cart X was unattended, with the electronic medical record (EMR) screen open and Resident R5's PHI visible. The surveyor remained with Cart X until a staff member approached Cart X. The staff member identified herself as S7LPN.Interview with S7LPN on 09/16/2025 at 8:57 a.m. revealed she left Cart X unattended on Hall B, with Resident R5's PHI visible on the computer screen. S7LPN confirmed she did not ensure the privacy and confidentiality of Resident R5's PHI, but should have. Interview with S2DON on 09/16/2025 at 10:45 a.m. revealed staff were to ensure the privacy and confidentiality of resident PHI by locking computer screens when leaving them unattended.

Based on interview and record review, the facility failed to ensure an investigation of an allegation of misappropriation of resident property/funds was thoroughly investigated for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for misappropriation. Findings: Review of a facility policy on 06/09/2025 at 9:18 a.m. titled, Abuse Protection and Prevention Program with a revision date of 02/2013 revealed the following in part . Our residents have the right to be free from abuse, neglect and misappropriation of resident property. D. Timely and thorough investigations of all reports and allegations of abuse. Misappropriation of property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 10. Upon receiving information concerning a report of abuse, the director of nursing will designate an associate to monitor the resident's emotions concerning the incident as well as the resident's reactions to his/her involvement in the investigation to assure the resident feels he/she is protected from harm during an investigation. Review of Resident #1's medical record revealed a re-entry admission date of 05/07/2024, with diagnoses that included in part . Fusion of Spine of the Cervical Region, Seizures, Quadriplegia, and Depression. Review of Resident #1's Quarterly MDS with an ARD of 04/23/2025 revealed a BIMS score of 15, which indicated intact cognition. Review of Resident #1's care plan with an initiated date of 08/28/2024 revealed the following part .date initiated (05/22/2025): Focus: Resident gives money to associates to keep for her. Interventions: Staff will encourage resident to give money to appropriate staff member to put up in a safe place. Review of a facility investigation/incident report completed by S1 Administrator on 05/20/2025 at 12:35 p.m. revealed the following in part .Incident Description: S1 Administrator and S2 SSD interviewed Resident #1 regarding allegations of money being taken from Resident #1 by an associate. Resident #1 revealed to S1 Administrator and S2 SSD that she asked S7 Rehab Tech to hold $12,000 dollars for her in 11/2024. Resident #1 told S1 Administrator and S2 SSD in the interview, that weeks after 11/2024, S7 Rehab Tech told Resident #1 the money she was holding for Resident #1 was stolen from S7 Rehab Tech's home. Review of a facility investigation/incident report completed by S1 Administrator on 05/20/2025 at 12:35 p.m. revealed the following in part . Incident Investigation: 05/20/2025 at 12:30 p.m.: S7 Rehab Tech, accused, confirmed allegations. 05/21/2025: Education to all staff. 05/21/2025: Interview with four cognitive residents regarding allegations of staff keeping money, asking for money, or taking money from residents. All four residents denied that any staff had ever approached them about money. In an interview on 06/09/2025 at 10:15 a.m., S1 Administrator revealed the following in part .in regards to the investigation of Resident #1 and S7 Rehab Tech's incident, an in-service was completed with the staff on duty regarding misappropriation of property and S8 DON completed random interviews with residents who resided on Resident #1's hall regarding the allegations. S1 Administrator stated on multiple occasions to this surveyor .she did not have to do much of an investigation because S7 Rehab Tech admitted to taking Resident #1's money. Review of S8 DON's statement written on 05/21/2025 revealed the following in part . S8 DON spoke with three residents that resided in the facility regarding issues with staff and money All three residents were asked if any of our staff ever asked for money, if the residents had any money missing, and if staff ever asked to hold money for them .all three residents answered no to all above questions. In an interview on 06/09/2025 at 1:15 p.m., Resident #1 revealed the following in part . Resident #1 reported S7 Rehab Tech to S1 Administrator and S2 SSD on 05/20/2025. Following reporting the incident on 05/20/2025, S2 SSD came to visit her occasionally regarding the incident but no other staff had checked on her regarding the incident. In an interview on 06/09/2025 at 2:40 p.m., S5 CNA Supervisor revealed the following in part .S5 CNA Supervisor could not describe, define, or give an example of misappropriation of resident property/funds. S5 CNA confirmed she did not know what this meant and was unaware this was a form a resident abuse. In an interview on 06/09/2025 at 3:08 p.m., S2 SSD revealed the following in part .S2 SSD stated she was on vacation when S8 DON completed in-servicing regarding the incident on 05/20/2025. S2 SSD confirmed she had not received any in-servicing since returning to work regarding misappropriation of resident funds/property. In an interview on 06/10/2025 at 10:25 a.m., S4 CNA revealed the following in part .S4 CNA was only aware of physical abuse and no other forms of resident abuse. After education provided, S4 CNA confirmed she was not aware of verbal, mental, sexual, misappropriation of resident funds/property and that these were all forms of resident abuse. S4 CNA confirmed she did not have in-servicing following Resident #1's incident on 05/20/2025 and was not educated regarding misappropriation of resident funds/property. In an interview on 06/10/2025 at 11:08 a.m., S6 Rehab Director revealed the following in part .S6 Rehab Director completed an in-service on 05/21/2025 to his therapy staff regarding ethics including misappropriation of resident funds/property. S6 Rehab Director confirmed he did not in-service/educate all of his therapy staff regarding misappropriation of resident funds/property, but should have. In an interview on 06/10/2025 at 1:05 p.m., S1 Administrator revealed the following in part .S1 Administrator was responsible for Resident #1's investigation on 05/20/2025. S1 Administrator stated S8 DON completed three resident interviews on 05/21/2024 and in-serviced the staff on duty regarding ethics including misappropriation of resident funds/property. S1 Administrator stated there was not much of an investigation because S7 Rehab Tech admitted to taking Resident #1's money, the allegation was substantiated by the facility, and S7 Rehab Tech was suspended immediately and then terminated. S1 Administrator closed and completed the investigation. S1 Administrator confirmed that not all cognitive residents were interviewed, not all facility staff and therapy staff were in-serviced, and Resident #1 did not have safety/monitoring checks throughout the investigation. S1 Administration confirmed she and the facility did not complete a thorough investigation and should have provided safety/monitoring rounds to all residents, in-servicing to all facility/therapy staff, and monitored Resident #1 for any negative effects following the incident on 05/20/2025, but did not.

Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of property/funds for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for misappropriation. The facility failed to prevent misappropriation of Resident #1's funds by S7 Rehab Tech. Findings: Review of a facility policy on 06/09/2025 at 9:18 a.m. titled, Abuse Protection and Prevention Program with a revision date of 02/2013 revealed the following in part .Our residents have the right to be free from abuse, neglect and misappropriation of resident property. Misappropriation of property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Review of Resident #1's medical record revealed a re-entry admission date of 05/07/2024, with diagnoses that included in part . Fusion of Spine of the Cervical Region, Seizures, Quadriplegia, and Depression. Review of Resident #1's Quarterly MDS with an ARD of 04/23/2025 revealed a BIMS score of 15, which indicated intact cognition. Review of Resident #1's care plan with an initiated date of 08/28/2024 revealed the following in part .date initiated (05/22/2025): Focus: Resident gives money to associates to keep for her. Interventions: Staff will encourage resident to give money to appropriate staff member to put up in a safe place. Review of a facility investigation/incident report completed by S1 Administrator on 05/20/2025 at 12:35 p.m. revealed the following in part .Incident Description: S1 Administrator and S2 SSD interviewed Resident #1 regarding allegations of money being taken from Resident #1 by an associate. Resident #1 revealed to S1 Administrator and S2 SSD that she asked S7 Rehab Tech to hold $12,000 dollars for her in 11/2024. Resident #1 told S1 Administrator and S2 SSD in the interview, that weeks after 11/2024, S7 Rehab Tech told Resident #1 the money she was holding for Resident #1 was stolen from S7 Rehab Tech's home. Resident #1 stated S7 Rehab Tech did not report the crime or repay Resident #1's money stolen. Review of Resident #1's statement written on 05/20/2025 revealed the following in part . on 11/06/2024, Resident #1 went to the bank and cashed a check for $12,434.29 dollars. S7 Rehab Tech counted money on Resident #1's bed. S7 Rehab Tech put $7,000 dollars in one envelope to distribute to Resident #1's mother and sister and $5,000 dollars in another envelope to hold for Resident #1. S7 Rehab Tech proceeded to take all the money home to hold for Resident #1. On 12/03/2024, S7 Rehab Tech brought $800.00 dollars of the $5,000.00 dollars for Resident #1 to distribute to her family members as Resident #1 wished. S7 Rehab Tech also agreed to pay Resident #1's monthly cell phone bill since 12/2024. Sometime in 01/2025, S7 Rehab Tech told Resident #1 someone broke into S7 Rehab Tech's house and stole Resident #1's money. S7 Rehab Tech told Resident #1 she would repay her when S7 Rehab Tech filed her income taxes. Since 01/2025, S7 Rehab Tech has blocked Resident #1's phone number and has avoided speaking to Resident #1 regarding the above events. Review of S1 Administrator and S6 Rehab Director's statement written on 05/20/2025 at 12:30 p.m. revealed the following in part . S1 Administrator and S6 Rehab Director interviewed S7 Rehab Tech regarding the events involving Resident #1. S7 Rehab Tech stated she agreed to hold Resident #1's money. S7 Rehab Tech stated the total amount of money was $8,000 dollars and denied it being $12,000 dollars as Resident #1 stated. S7 Rehab Tech stated she told Resident #1 that someone broke into her home and stole the black box where S7 Rehab Tech kept Resident #1's money. S7 Rehab Tech stated she did not file a police report regarding the crime because S7 Rehab Tech did not want to explain why she had Resident #1's money. S7 Rehab Tech stated she told Resident #1 she would repay Resident #1 as soon as she could. S7 Rehab Tech stated she paid for Resident #1's phone bill and bought Resident #1 things she needed. Review of S7 Rehab Tech's statement written on 05/20/2025 at 12:30 p.m. revealed the following part .in 11/2024, Resident #1 asked S7 Rehab Tech to hold money for her and gave S7 Rehab Tech an envelope with $8,000 dollars. S7 Rehab Tech stated two weeks before Christmas, someone broke into S7 Rehab Tech's home and stole the black lock box with Resident #1's money. S7 Rehab Tech stated she would try to purchase items Resident #1 needed and told Resident #1 she would pay Resident #1 back as soon as she could. S7 Rehab Tech stated Resident #1 did not want the facility to know Resident #1 received the money. S7 Rehab Tech did not call anyone when the money was stolen from her home because S7 Rehab Tech did not know how to explain where the money came from and who it was for. S7 Rehab Tech stated it was her own fault, she should have never taken Resident #1's money, and she should have never made these arrangements with Resident #1. In an interview on 06/09/2025 at 10:15 a.m., S1 Administrator revealed the following in part .on 05/20/2025 there was a rumor going around the facility that Resident #1 allowed a staff member to hold money for Resident #1 and now the money was missing. S1 Administrator and S2 SSD interviewed Resident #1 on this day and Resident #1 revealed this rumor to be true. S1 Administrator stated that she and S6 Rehab Director then interviewed the accused, S7 Rehab Tech. S7 Rehab Tech admitted to holding $8,000 cash for Resident #1 and then her house was broken into and Resident #1's money was stolen. In an interview on 06/09/2025 at 1:15 p.m., Resident #1 revealed the following in part . Resident #1 confirmed the events that occurred in her previous written statement on 05/20/2025. Resident #1 stated she was receiving a car accident settlement and she thought if the nursing home knew about the money the facility would take the money, Resident #1's stay at the facility would be jeopardized, and/or Resident #1's insurances would be discontinued. Resident #1 was worried about this, so Resident #1 trusted S7 Rehab Tech to hold the settlement money, distribute the money as Resident #1 wished, and buy certain things for Resident #1. Resident #1 stated that S7 Rehab Tech agreed to these arrangements. Resident #1 stated, in 11/2024, she received the settlement check, cashed it at the bank, and gave $12,000 dollars cash for S7 Rehab Tech to hold for Resident #1. Resident #1 stated that during this time, S7 Rehab Tech would distribute her money as she wished. Resident #1 stated, in 12/2024 before Christmas, S7 Rehab Tech told Resident #1 that her home was broken into and Resident #1's money was stolen. S7 Rehab Tech promised Resident #1 she would repay her when S7 Rehab Tech received her income tax return. Since 12/2024, Resident #1 would attempt to talk to S7 Rehab Tech about when she would pay Resident #1 back. Resident #1 stated S7 Rehab Tech responses were always some excuse. Resident #1 expected to get paid back from S7 Rehab Tech for the remaining money that was stolen from S7 Rehab Tech's home. Resident #1 revealed that S7 Rehab Tech never stated how much money was actually stolen from S7 Rehab Tech's home or speak of the details of the home invasion/theft. Resident #1 stated, S7 Rehab Tech did not file a police report because S7 Rehab Tech told Resident #1 she did not want to explain why she had thousands of dollars. Resident #1 never spoke of the events/arrangements until 05/20/2025 because S7 Rehab Tech was avoiding Resident #1 and still did not repay Resident #1 for the stolen money. On 05/20/2025, Resident #1 stated she spoke to nursing staff, S1 Administrator, S2 SSD, and the police about the events that took place with S7 Rehab Tech. Resident #1 stated she had not seen or heard from S7 Rehab Tech since 05/20/2025 and had not been repaid for the funds stolen from S7 Rehab Tech's home. Resident #1 revealed S7 Rehab Tech had blocked Resident #1's phone number and blocked Resident #1's daughter's phone numbers. In an interview on 06/09/2025 at 3:08 p.m., S2 SSD revealed the following in part .S2 SSD accompanied S1 Administrator to Resident #1's room to be a witness of an interview. S2 SSD revealed Resident #1 stated the same events and arrangements (mentioned above) Resident #1 and S7 Rehab Tech agreed to. In an interview on 06/10/2025 at 11:08 a.m., S6 Rehab Director revealed the following in part .S6 Rehab Director confirmed his previous statement written on 05/20/2025. S6 Rehab Director stated on 05/20/2025 he participated in an interview with S1 Administrator and S7 Rehab Tech. In the interview, S7 Rehab Tech admitted to holding $8,000 dollars for Resident #1 (in 11/2024) and then the money being stolen from S7 Rehab Tech's home (in 12/2024). In an interview on 06/10/2025 at 1:05 p.m., S1 Administrator revealed the following in part .S1 Administrator confirmed her previous statement written on 05/20/2025. S1 Administrator confirmed after S1 Administrator completed Resident #1's investigation, the allegation of misappropriation of funds/property was substantiated by the facility. S1 Administrator confirmed Resident #1's funds were misappropriated by S7 Rehab Tech.

Based on observations, record reviews, and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 2 (#1, #3) of 3 (#1, #2, #3) residents reviewed for restraints. The facility failed to ensure: 1. A physician's order was obtained, a consent was signed and a risk assessment was completed for a Geri-chair for Resident #1, 2. A physician's order was obtained, a consent was signed and a risk assessment was completed for a pommel cushion for Resident #3, and 3. A restraint policy was developed. Findings: Review of the facility's policy and procedures failed to reveal a policy for restraints and bed rails. Resident #1 Review of Resident #1's medical records revealed an admit date of 01/16/2025 with the following diagnoses, including in part: infection and inflammatory reaction due to internal left knee prosthesis/subsequent encounter, chronic kidney disease stage 2 (mild), and chronic thromboembolic pulmonary hypertension. Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 10 indicating moderately impaired cognition. Review of Resident #1's care plan revealed - needs assistance with ADLs (activities of daily living) . Assist x 1 staff member for bathing, dressing eating, grooming, mobility and toileting .Resident uses Gerichair for mobility (initiated 01/17/2025 and revised on 05/28/2025). Review of Resident #1's medical record failed to reveal a physician's order, a consent, and a risk assessment for Gerichair. Observation on 05/27/2025 at 2:20 p.m. revealed Resident #1 reclining with feet up in Gerichair. Observation on 05/28/2025 at 11:45 a.m. revealed Resident #1 reclining with feet up in Gerichair. Resident #3 Review of Resident #3's medical records revealed an admit date of 01/13/2021 with the following diagnoses, including in part: unspecified dementia/unspecified severity without behavioral disturbance/psychotic disturbance/mood disturbance and anxiety, difficulty in walking, muscle weakness (generalized), history of falling an and insomnia unspecified. Review of Resident #3's MDS assessment dated [DATE] revealed a BIMS score of 3 indicating severely impaired cognition. Review of Resident #3's care plan revealed the resident has had a history of falls related to poor balance: Pommel cushion in wheelchair (initiated 05/28/2025). Review of Resident #3's medical record failed to reveal a physician's order, a consent, and a risk assessment for pommel cushion. During an interview on 05/28/2025 at 11:50 a.m. S3 LPN (licensed practical nurse) reported Resident #3 had the pommel cushion in her wheelchair because she willf all asleep and slide out of it. Observation on 05/28/2025 at 11:50 a.m. revealed Resident #3 sitting up in wheelchair in with pommel cushion in place. During an interview on 05/28/025 at 10:00 a.m. S2 Director of Nursing reported the facility had not obtained consents or physician's orders for restraints to include Gerichairs and pommel cushions. During an interview on 05/28/2025 at 10:45 a.m. S1 Administrator acknowledged the facility had not implemented restraint risk assessments, obtained consents or physician's orders. S1 Administrator further acknowledged the facility did not have a policy for restraints.

Based on observations, record reviews and interviews, the facility failed to: 1) ensure residents had a physician's order for side rails, 2) obtain informed consent from the resident or resident's representative for side rail use, and/or 3) assess residents for the risk of entrapment from bed rails and 4) ensure a policy was developed for the use of bed rails prior to the installation of bed rails for 3 (#1, #2, #3) of 3 (#1, #2, #3) residents reviewed for bed rails. Findings: Review of the facility's policy and procedures failed to reveal a policy for bed rails. Resident #1 Review of Resident #1's medical records revealed an admit date of 01/16/2025 with the following diagnoses, including in part: infection and inflammatory reaction due to internal left knee prosthesis/subsequent encounter, chronic kidney disease stage 2 (mild), and chronic thromboembolic pulmonary hypertension. Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 10 indicating moderately impaired cognition. Review of Resident #1's medical record failed to reveal a physician's order, a consent, care plan problem and approach and a risk assessment for assist rails x 2. Observation on 05/28/2025 at 8:30 a.m. revealed Resident #1 sitting up in bed with assist rails up x 2. Observation on 05/28/2025 at 3:00 p.m. revealed Resident #1 asleep in bed with assist rails up x 2. Resident #2 Review of Resident #2's medical records revealed an admit date of 11/29/2016 with the following diagnoses, including in part: depression unspecified, generalized anxiety disorder, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, overactive bladder and weakness. Review of Resident #2's medical record failed to reveal a physician's order, a consent, care plan problem and approach and a risk assessment for assist rails x 2. Observation on 05/27/2025 at 2:30 p.m. revealed Resident #2 lying in bed with assist rails up x 2. Observation on 05/28/2025 at 8:35 a.m. revealed Resident #2 lying flat in bed with assist rails up x 2. During an interview on 05/28/2025 at 1:10 p.m. S3 LPN (licensed practical nurse) reported Resident #2 had intermittent confusion and would forget to ask for help when going to the bathroom. S3 LPN further reported the resident has had a decline in her cognitive ability. Observation on 05/28/2025 at 3:00 p.m. revealed Resident #2 asleep in bed with assist rails up x 2. Resident #3 Review of Resident #3's medical records revealed an admit date of 01/13/2021 with the following diagnoses, including in part: unspecified dementia/unspecified severity without behavioral disturbance/psychotic disturbance/mood disturbance and anxiety, difficulty in walking, muscle weakness (generalized), history of falling and insomnia unspecified. Review of Resident #3's MDS assessment dated [DATE] revealed a BIMS score of 3 indicating severely impaired cognition. Review of Resident #3's medical record failed to reveal a physician's order, a consent, care plan problem and approach and a risk assessment for assist rails x 2. Observation on 05/28/2025 at 8:45 a.m. revealed Resident #3 sitting up in bed asleep with assist rails up x 2. During an interview on 05/28/025 at 10:00 a.m. S2 DON (Director of Nursing) reported the facility had not obtained consents or physician's orders for assist rails. S2 DON further acknowledged residents were not care planned for assist rails. During an interview on 05/28/2025 at 10:45 a.m. S1 Administrator acknowledged the facility had not implemented assist rail risk assessments, obtained consents or physician's orders. S1 Administrator further acknowledged the facility did not have a policy for bed rails.

Based on interview and record review, the facility failed to ensure that a resident was free from physical abuse by facility staff for 1 of 5 sampled residents (#1, #2, #3, #4 and #5). The facility's total census was 100 according to the Resident Census and Conditions of Residents form. The facility failed to: 1. protect a resident (#4) from physical abuse by the staff, 2. immediately report and thoroughly investigate physical abuse of a resident (#4) and 3. implement written policies and procedures that prohibit abuse of a resident (#4). This resulted in an Immediate Jeopardy situation which began on 12/22/12 at 12:45 p.m. when 2 facility staff witnessed a CNA hitting resident #4 on the head with a closed hand. The Immediate Jeopardy situation ended on 12/23/12 at 8:25 a.m. when the CNA was placed on 1:1 supervision by the RN supervisor. The facility Administrator was informed of the Immediate Jeopardy situation on 1/24/13 at 1:15 p.m. After removal of the Immediate Jeopardy situation, the deficiency remained at a S/S of "D". Findings: Review of the facility's abuse investigations within the last 3 months reflected an investigation into the physical abuse of resident #4 had been done. Review of the abuse investigation of resident #4 reflected documentation of a nurse's note dated 12/23/12 at 10:38 a.m. by S1 Admin which reflected on 12/22/12 at approximately 2:00 p.m. she was called by S3 RN. The RN reported that she had been informed by S5 LPN that S6 CNA was heard raising her voice to a resident. She also reported that S7 CNA had informed her that S5 LPN had something to report to her. Further review reflected S1 Admin counseled S6 CNA over the telephone for speaking in a loud voice. She reminded the CNA that she realized she spoke in loud tones but she needed to be quieter and more calm towards the resident. Further review reflected on 12/23/12 at approximately 8:00 a.m., S3 RN called S1 Admin again to report that upon further investigation, it was determined that S6 CNA had hit the resident on the side of her head with a closed fist on 12/22/12. The RN stated that the report she had received from S7 CNA that morning was that she and S5 LPN were sitting at the nurses' station desk on 12/22/12 and that when S5 LPN had reported that she had heard S6 CNA's loud voice, S7 CNA had actually seen S6 CNA hit the resident. S7 CNA reported that she assumed S5 LPN saw the CNA hit the resident as well and had reported it to S3 RN at that time but the LPN didn't. Further review reflected when notified on 12/23/12 that S6 CNA had actually hit the resident on 12/22/12, the Admin assigned S4 RN to supervise S6 CNA until the investigation could be completed. S3 RN then notified the DON. The Admin and DON arrived on site within 30 minutes to question S5 LPN, S7 CNA and the resident. The resident confirmed that she had been hit on the left side of the head with a closed fist. The resident was assessed for injury and S6 CNA was terminated. Review of S7 CNA's witness statement dated 12/23/12 reflected "on 12/22/12, I S7 CNA, observed S6 CNA go in resident #4's room and S6 CNA placed her left hand on resident #4's upper back and her right hand on the bottom part on resident #4's lower back and then she tried to get resident #4 off the bed but didn't. She turned resident #4 to face her and resident #4 was fussing saying she wanted to lay down. That's when S6 CNA hit resident #4 on the left side of her head with a closed hand fist. Then, S6 CNA turned and pulled the curtain close for about 10 seconds, the pulled the curtain open and went to the door and closed it. I don't know what happened after that because I got up and left." Review of S5 LPN's statement dated 12/23/12 reflected "on 12/22/12 resident #4 was getting into bed. S6 CNA went into resident #4's room and began yelling at her for getting into bed. S6 CNA then raised her right closed hand at resident #4 and with her other hand she pulled the curtain closed. I then seen her closed hand come down in a striking motion through the shadow from the curtain. Resident #4 then yelled stop hitting me. I went into the room to see what was going on. S6 CNA then began fussing at me for letting resident #4 back in bed. I then told resident #4 she could lay down if she wanted to. Resident #4 then began pointing at her head and said right here. I asked what about right here? She said right here, right here is where she hit me. I then went and reported the incident to S3 RN." Review of the resident's nurses' notes reflected there was no documentation by S5 LPN regarding the resident being hit by the CNA. Interview on 1/23/13 at 12:35 p.m. with S3 RN revealed that she was the RN supervisor on 12/22/12 and 12/23/12. She stated that on 12/22/12, S5 LPN reported that S6 CNA seemed to be in a bad mood and was not being friendly to the residents. She stated that the CNA was known to talk in a very loud tone of voice but she did notify S1 Admin of the LPN's report. The Admin spoke with the CNA on the telephone and counseled her about using a softer tone when speaking to the residents. Further interview revealed that the next morning, S7 CNA informed S3 RN that she thought the LPN had reported that S6 CNA had "bopped" the resident on the head the day before. S3 RN immediately called the Admin and assigned S4 RN to supervise S6 CNA until the Admin and DON arrived. Further interview with S3 RN confirmed that S5 LPN did not report that S6 CNA had hit the resident. She also stated that S7 CNA stated that she thought the LPN had witnessed the CNA hitting the resident and would report it, but she may have been looking down when it happened. Interview on 1/23/13 at 12:50 p.m. with S4 RN revealed that she was working as the treatment nurse on 12/22/12 and 12/23/12. She stated that she was not aware of an incident involving the resident until she arrived to work on 12/23/12 at about 8:00 a.m. She stated that when she entered the facility that morning, S3 RN called her into the office with her and S7 CNA. S3 RN called the Admin and reported to her that S7 CNA had informed her that S6 CNA had hit resident #4 the day before. She stated that S6 CNA was working the floor and S3 RN immediately sent her to supervise the CNA 1:1 as she continued to work. She stated it was about 15 minutes before she joined S6 CNA and another CNA as they made their rounds. Interview on 1/23/13 at 1:10 p.m. with S7 CNA revealed that on 12/22/12 she was sitting at the nurses' station desk with S5 LPN about an arms length from her. She stated S6 CNA ran into the resident's room and began to speak loudly to her. She could not understand what the CNA was saying but did hear the resident telling her that she did not tell her what to do. She stated she saw the CNA hit the resident and then heard the resident telling her not to hit her before the CNA closed the door. Further interview revealed that she told S5 LPN that she needed to go into the room and see what was going on, and the LPN immediately went into the room. She stated that she thought the LPN had seen the CNA hit the resident but she was eating and may not have. She also stated that she and the LPN never discussed the incident with each other. She stated that she did not ask the LPN if she saw the CNA hit the resident. Further interview with S7 CNA revealed that after the incident she went straight to S3 RN and told her that S5 LPN had something to report to her but did not give the RN any details. She stated that she did not tell the RN that the CNA had hit the resident because she thought the LPN would report it. She stated the next morning she heard that S6 CNA had received counseling from the Admin about her tone of voice with the residents. She realized that the LPN must not have seen the CNA hit the resident so she went at that time to report it to S3 RN. Observation on 1/23/13 at 1:25 p.m. revealed the nurses' station was clearly visible from the resident's room. Telephone interview on 1/23/13 at 2:05 p.m. with S5 LPN revealed that she was eating lunch on 12/22/12 at the nurses' station when she saw S6 CNA enter the resident's room and begin to yell at her to get out of the bed. She stated the CNA raised one hand up and pulled the curtain closed with the other. The sun was coming through the curtain and she was able to see the shadow of the CNA's hand as it came down towards the shadow of the resident's head. She stated she did not actually see the CNA hit the resident but it appeared through the curtain that she did. She went into the resident's room and the resident told her that the CNA had hit her on the head. She stated that she went immediately to S3 RN and reported to her that the CNA was screaming at the resident and had hit her. Further interview revealed that S6 CNA was called to the office by S3 RN on 12/22/12. She stated that the CNA returned from the office and continued working with the resident. She stated that after the CNA returned from the office, her attitude had not improved. She stated the CNA would make comments to her that she didn't care who she called and that she would do whatever she wanted. S5 LPN stated that she felt like the CNA was flaunting the fact that she had not gotten in trouble. Further interview revealed that she wondered why the CNA was still working with the resident but she decided that it was because she did not actually see the CNA's hand making contact against the resident's head. She stated that another CNA, whose name she couldn't remember, had also seen the resident being hit and she thought that she would be reporting it also. She confirmed that she and S7 CNA did not discuss the resident being hit by S6 CNA. Interview on 1/23/13 at 2:00 p.m. with S1 Admin confirmed that she had been called 12/22/12 by S3 RN to report that S6 CNA was talking too loudly to a resident. She counseled the CNA over the telephone with the RN present. She stated the next morning S3 RN called her to inform her that the CNA had hit the resident the day before. She immediately assigned S4 RN to 1:1 supervision with S6 CNA until she arrived at the facility and conducted an investigation. Upon completion of investigation, the physical abuse was substantiated and the CNA was terminated. Further interview with S1 Admin revealed she had reviewed the statement by S5 LPN and should have questioned it since the LPN documented that she had seen the CNA hit the resident and reported it to S3 RN. She stated that the LPN must have thought she told the RN but she hadn't because she felt sure the RN would've contacted her immediately. She also confirmed that S7 CNA did not tell the RN about the CNA hitting the resident on 12/22/12. She also confirmed that S5 LPN and S7 CNA did not confirm what they had seen with each other, or what would be reported when the incident occurred. Further interview on 1/23/13 at 2:10 p.m. with S3 RN confirmed the LPN did not report the CNA hitting the resident, and the CNA was allowed to continue working until her shift was over. Review of the Punch Detail Report for S6 CNA reflected she worked from 0600 (6:00 a.m.) until 2306 (11:06 p.m.) on 12/22/12 and from 0618 (6:18 a.m.) until 0942 (9:42 a.m.) on 12/23/12. Interview on 1/24/13 at 11:15 a.m. with S1 Admin revealed an inservice had been done that morning to address being specific with reporting resident abuse and protecting residents. She confirmed that the facility's policies were not followed for reporting the abuse and protecting the resident. Further interview on 1/24/13 at 12:00 p.m. with S3 RN revealed that S5 LPN's witness statement did not match what the LPN had reported to her on 12/22/12. She stated she was not made aware of the CNA hitting the resident until the morning of 12/23/12 when S7 CNA asked her if the LPN had reported that the CNA hit the resident. Further interview on 1/24/13 at 12:40 p.m. with S7 CNA confirmed she saw the CNA hit the resident on 12/22/12 at approximately 12:45 p.m. Review of the facility's Abuse Identification, Protection and Reporting policy reflected that all personnel must promptly report any incident or suspected incident of resident abuse. The policy also reflected that the person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the charge nurse with the following information: a. the name of the resident(s) involved, b. the date and time that the incident occurred, c. where the incident took place, d. the name(s) of the person(s) committing the incident, if known, e. the name(s) of any witnesses to the incident, f. the type of abuse committed, and g. other information requested by the charge nurse. Further review reflected that upon receiving reports of physical (or sexual) abuse, the charge nurse should immediately examine the resident and the findings recorded in the resident's medical record. Also, the charge nurse must obtain a written, signed and dated statement from the person reporting the incident. Review of the facility's Protection of Residents during Abuse Investigations policy reflected that during abuse investigations, residents would be protected from harm by the following measures: a. employees accused of participating in the alleged abuse should be immediately reassigned to duties that did not involve resident contact or suspended without pay until the findings of the investigation had been reviewed by the Administrator and b. should the employee(s) be reassigned to non-resident care duties, such assignment would not be any part of the building which the resident frequented. Review of the facility's Abuse Protection and Prevention Program policy reflected the abuse prevention program included timely and thorough investigations of all reports and allegations of abuse. Review of the inservice dated 1/24/13 at 0715 (7:15 a.m.) reflected S1 Admin and S2 DON had conducted an inservice regarding elderly abuse reporting, being specific on what staff witnesses and immediately reporting it, immediately protecting the victim from abuse and communication in reporting abuse. Further review reflected inservices were scheduled at 2:00 p.m. and 3:00 p.m. on the same subjects.

Based on interview and record review, the facility failed to ensure that an alleged violation involving physical abuse was immediately reported to the Administrator of the facility and the alleged violation was thoroughly investigated for 1 of 5 sampled residents (#1, #2, #3, #4 and #5). The facility's total census was 100 according to the Resident Census and Conditions of Residents form. The facility failed to: 1. ensure a CNA and LPN who witnessed physical abuse of resident #4 immediately reported the specific details of the incident to the RN supervisor, DON or Administrator and 2. ensure that the physical abuse of resident #4 was thoroughly investigated while preventing further potential abuse while the investigation was in progress. This resulted in an Immediate Jeopardy situation which began on 12/22/12 at 12:45 p.m. when 2 facility staff witnessed a CNA hitting resident #4 on the head with a closed hand. The Immediate Jeopardy situation ended on 12/23/12 at 8:25 a.m. when the CNA was placed on 1:1 supervision by the RN supervisor. The facility Administrator was informed of the Immediate Jeopardy situation on 1/24/13 at 1:15 p.m. After removal of the Immediate Jeopardy situation, the deficiency remained at a S/S of "D". Findings: Review of the facility's abuse investigations within the last 3 months reflected an investigation into the physical abuse of resident #4 had been done. Review of the abuse investigation of resident #4 reflected documentation of a nurse's note dated 12/23/12 at 10:38 a.m. by S1 Admin which reflected on 12/22/12 at approximately 2:00 p.m. she was called by S3 RN. The RN reported that she had been informed by S5 LPN that S6 CNA was heard raising her voice to a resident. She also reported that S7 CNA had informed her that S5 LPN had something to report to her. Further review reflected S1 Admin counseled S6 CNA over the telephone for speaking in a loud voice. She reminded the CNA that she realized she spoke in loud tones but she needed to be quieter and more calm towards the resident. Further review reflected on 12/23/12 at approximately 8:00 a.m., S3 RN called S1 Admin again to report that upon further investigation, it was determined that S6 CNA had hit the resident on the side of her head with a closed fist on 12/22/12. The RN stated that the report she had received from S7 CNA that morning was that she and S5 LPN were sitting at the nurses' station desk on 12/22/12 and that when S5 LPN had reported that she had heard S6 CNA's loud voice, S7 CNA had actually seen S6 CNA hit the resident. S7 CNA reported that she assumed S5 LPN saw the CNA hit the resident as well and had reported it to S3 RN at that time but the LPN didn't. Further review reflected when notified that S6 CNA had actually hit the resident on 12/22/13, the Admin assigned S4 RN to supervise S6 CNA until the investigation could be completed. S3 RN then notified the DON. The Admin and DON arrived on site within 30 minutes to question S5 LPN, S7 CNA and the resident. The resident confirmed that she had been hit on the left side of the head with a closed fist. The resident was assessed for injury and S6 CNA was terminated. Review of S7 CNA's witness statement dated 12/23/12 reflected " on 12/22/12, I S7 CNA, observed S6 CNA go in resident #4's room and S6 CNA placed her left hand on resident #4's upper back and her right hand on the bottom part on resident #4's lower back and then she tried to get resident #4 off the bed but didn't. She turned resident #4 to face her and resident #4 was fussing saying she wanted to lay down. That's when S6 CNA hit resident #4 on the left side of her head with a closed hand fist. Then, S6 CNA turned and pulled the curtain close for about 10 seconds, the pulled the curtain open and went to the door and closed it. I don't know what happened after that because I got up and left." Review of S5 LPN's statement dated 12/23/12 reflected "on 12/22/12 resident #4 was getting into bed. S6 CNA went into resident #4's room and began yelling at her for getting into bed. S6 CNA then raised her right closed hand at resident #4 and with her other hand she pulled the curtain closed. I then seen her closed hand come down in a striking motion through the shadow from the curtain. Resident #4 then yelled stop hitting me. I went into the room to see what was going on. S6 CNA then began fussing at me for letting resident #4 back in bed. I then told resident #4 she could lay down if she wanted to. Resident #4 then began pointing at her head and said right here. I asked what about right here? She said right here, right here is where she hit me. I then went and reported the incident to S3 RN." Review of the resident's nurses' notes reflected there was no documentation by S5 LPN regarding the resident being hit by the CNA. Interview on 1/23/13 at 12:35 p.m. with S3 RN revealed that she was the RN supervisor on 12/22/12 and 12/23/12. She stated that on 12/22/12, S5 LPN reported that S6 CNA seemed to be in a bad mood and was not being friendly to the residents. She stated that the CNA was known to talk in a very loud tone of voice but she did notify S1 Admin of the LPN's report. The Admin spoke with the CNA on the telephone and counseled her about using a softer tone when speaking to the residents. Further interview revealed that the next morning, S7 CNA informed S3 RN that she thought the LPN had reported that S6 CNA had "bopped" the resident on the head the day before. S3 RN immediately called the Admin and assigned S4 RN to supervise S6 CNA until the Admin and DON arrived. Further interview with S3 RN confirmed that S5 LPN did not report that S6 CNA had hit the resident. She also stated that S7 CNA stated that she thought the LPN had witnessed the CNA hitting the resident and would report it, but she may have been looking down when it happened. Interview on 1/23/13 at 12:50 p.m. with S4 RN revealed that she was working as the treatment nurse on 12/22/12 and 12/23/12. She stated that she was not aware of an incident involving the resident until she arrived to work on 12/23/12 at about 8:00 a.m. She stated that when she entered the facility that morning, S3 RN called her into the office with her and S7 CNA. S3 RN called the Admin and reported to her that S7 CNA had informed her that S6 CNA had hit resident #4 the day before. She stated that S6 CNA was working the floor and S3 RN immediately sent her to supervise the CNA 1:1 as she continued to work. She stated it was about 15 minutes before she joined S6 CNA and another CNA as they made their rounds. Interview on 1/23/13 at 1:10 p.m. with S7 CNA revealed that on 12/22/12 she was sitting at the nurses' station desk with S5 LPN about an arms length from her. She stated S6 CNA ran into the resident's room and began to speak loudly to her. She could not understand what the CNA was saying but did hear the resident telling her that she did not tell her what to do. She stated she saw the CNA hit the resident and then heard the resident telling her not to hit her before the CNA closed the door. Further interview revealed that she told S5 LPN that she needed to go into the room and see what was going on, and the LPN immediately went into the room. She stated that she thought the LPN had seen the CNA hit the resident but she was eating and may not have. She also stated that she and the LPN never discussed the incident with each other. She stated that she did not ask the LPN if she saw the CNA hit the resident. Further interview with S7 CNA revealed that after the incident she went straight to S3 RN and told her that S5 LPN had something to report to her but did not give the RN any details. She stated that she did not tell the RN that the CNA had hit the resident because she thought the LPN would report it. She stated the next morning she heard that S6 CNA had received counseling from the Admin about her tone of voice with the residents. She realized that the LPN must not have seen the CNA hit the resident so she went at that time to report it to S3 RN. Observation on 1/23/13 at 1:25 p.m. revealed the nurses' station was clearly visible from the resident's room. Telephone interview on 1/23/13 at 2:05 p.m. with S5 LPN revealed that she was eating lunch on 12/22/12 at the nurses' station when she saw S6 CNA enter the resident's room and begin to yell at her to get out of the bed. She stated the CNA raised one hand up and pulled the curtain closed with the other. The sun was coming through the curtain and she was able to see the shadow of the CNA's hand as it came down towards the shadow of the resident's head. She stated she did not actually see the CNA hit the resident but it appeared through the curtain that she did. She went into the resident's room and the resident told her that the CNA had hit her on the head. She stated that she went immediately to S3 RN and reported to her that the CNA was screaming at the resident and had hit her. Further interview revealed that S6 CNA was called to the office by S3 RN on 12/22/12. She stated that the CNA returned from the office and continued working with the resident. She stated that after the CNA returned from the office, her attitude had not improved. She stated the CNA would make comments to her that she didn't care who she called and that she would do whatever she wanted. S5 LPN stated that she felt like the CNA was flaunting the fact that she had not gotten in trouble. Further interview revealed that she wondered why the CNA was still working with the resident but she decided that it was because she did not actually see the CNA's hand making contact against the resident's head. She stated that another CNA, whose name she couldn't remember, had also seen the resident being hit and she thought that she would be reporting it also. She confirmed that she and S7 CNA did not discuss the resident being hit by S6 CNA. Interview on 1/23/13 at 2:00 p.m. with S1 Admin confirmed that she had been called 12/22/12 by S3 RN to report that S6 CNA was talking too loudly to a resident. She counseled the CNA over the telephone with the RN present. She stated the next morning S3 RN called her to inform her that the CNA had hit the resident the day before. She immediately assigned S4 RN to 1:1 supervision with S6 CNA until she arrived at the facility and conducted an investigation. Upon completion of investigation, the physical abuse was substantiated and the CNA was terminated. Further interview with S1 Admin revealed she had reviewed the statement by S5 LPN and should have questioned it since the LPN documented that she had seen the CNA hit the resident and reported it to S3 RN. She stated that the LPN must have thought she told the RN but she hadn't because she felt sure the RN would've contacted her immediately. She also confirmed that S7 CNA did not tell the RN about the CNA hitting the resident on 12/22/12. She also confirmed that S5 LPN and S7 CNA did not confirm what they had seen with each other, or what would be reported when the incident occurred. Further interview on 1/23/13 at 2:10 p.m. with S3 RN confirmed the LPN did not report the CNA hitting the resident, and the CNA was allowed to continue working until her shift was over. Review of the Punch Detail Report for S6 CNA reflected she worked from 0600 (6:00 a.m.) until 2306 (11:06 p.m.) on 12/22/12 and from 0618 (6:18 a.m.) until 0942 (9:42 a.m.) on 12/23/12. Interview on 1/24/13 at 11:15 a.m. with S1 Admin revealed an inservice had been done that morning to address being specific with reporting resident abuse and protecting residents. She confirmed that the facility's policies were not followed for reporting the abuse and protecting the resident. Further interview on 1/24/13 at 12:00 p.m. with S3 RN revealed that S5 LPN's witness statement did not match what the LPN had reported to her on 12/22/12. She stated she was not made aware of the CNA hitting the resident until the morning of 12/23/12 when S7 CNA asked her if the LPN had reported that the CNA hit the resident. Further interview on 1/24/13 at 12:40 p.m. with S7 CNA confirmed she saw the CNA hit the resident on 12/22/12 at approximately 12:45 p.m. Review of the inservice dated 1/24/13 at 0715 (7:15 a.m.) reflected S1 Admin and S2 DON had conducted an inservice regarding elderly abuse reporting, being specific on what staff witnesses and immediately reporting it, immediately protecting the victim from abuse and communication in reporting abuse. Further review reflected inservices were scheduled at 2:00 p.m. and 3:00 p.m. on the same subjects.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit abuse of residents for 1 (#4) of 5 sampled residents (#1, #2, #3, #4 and #5). The facility's total census was 100 according to the Resident Census and Conditions of Residents form. The facility failed to: 1. ensure components of the facility's Abuse Identification, Protection and Reporting policy were followed regarding promptly reporting any incident or suspected incident of resident abuse, 2. ensure components of the facility's Protection of Residents during Abuse Investigations policy were followed regarding protecting residents from harm during an abuse investigation, 3. ensure components of the facility's Abuse Protection and Prevention Program were followed for timely and thorough investigations of all reports and allegations of abuse and 4. ensure staff immediately reported all instances of abuse of a resident to the appropriate staff. This resulted in an Immediate Jeopardy situation which began on 12/22/12 at 12:45 p.m. when 2 facility staff witnessed a CNA hitting resident #4 on the head with a closed hand. The Immediate Jeopardy situation ended on 12/23/12 at 8:25 a.m. when the CNA was placed on 1:1 supervision by the RN supervisor. The facility Administrator was informed of the Immediate Jeopardy situation on 1/24/13 at 1:15 p.m. After removal of the Immediate Jeopardy situation, the deficiency remained at a S/S of "D". Findings: Review of the facility's Abuse Identification, Protection and Reporting policy reflected that all personnel must promptly report any incident or suspected incident of resident abuse. The policy also reflected that the person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the charge nurse with the following information: a. the name of the resident(s) involved, b. the date and time that the incident occurred, c. where the incident took place, d. the name(s) of the person(s) committing the incident, if known, e. the name(s) of any witnesses to the incident, f. the type of abuse committed, and g. other information requested by the charge nurse. Further review reflected that upon receiving reports of physical (or sexual) abuse, the charge nurse should immediately examine the resident and the findings recorded in the resident's medical record. Also, the charge nurse must obtain a written, signed and dated statement from the person reporting the incident. Review of the facility's Protection of Residents during Abuse Investigations policy reflected that during abuse investigations, residents would be protected from harm by the following measures: a. employees accused of participating in the alleged abuse should be immediately reassigned to duties that did not involve resident contact or suspended without pay until the findings of the investigation had been reviewed by the Administrator and b. should the employee(s) be reassigned to non-resident care duties, such assignment would not be any part of the building which the resident frequented. Review of the facility's Abuse Protection and Prevention Program policy reflected the abuse prevention program included timely and thorough investigations of all reports and allegations of abuse. Review of the facility's abuse investigations within the last 3 months reflected an investigation into the physical abuse of resident #4 had been done. Review of the abuse investigation of resident #4 reflected documentation of a nurse's note dated 12/23/12 at 10:38 a.m. by S1 Admin which reflected on 12/22/12 at approximately 2:00 p.m. she was called by S3 RN. The RN reported that she had been informed by S5 LPN that S6 CNA was heard raising her voice to a resident. She also reported that S7 CNA had informed her that S5 LPN had something to report to her. Further review reflected S1 Admin counseled S6 CNA over the telephone for speaking in a loud voice. She reminded the CNA that she realized she spoke in loud tones but she needed to be quieter and more calm towards the resident. Further review reflected on 12/23/12 at approximately 8:00 a.m., S3 RN called S1 Admin again to report that upon further investigation, it was determined that S6 CNA had hit the resident on the side of her head with a closed fist on 12/22/12. The RN stated that the report she had received from S7 CNA that morning was that she and S5 LPN were sitting at the nurses' station desk on 12/22/12 and that when S5 LPN had reported that she had heard S6 CNA's loud voice, S7 CNA had actually seen S6 CNA hit the resident. S7 CNA reported that she assumed S5 LPN saw the CNA hit the resident as well and had reported it to S3 RN at that time but the LPN didn't. Further review reflected when notified on 12/23/12 that S6 CNA had actually hit the resident on 12/22/12, the Admin assigned S4 RN to supervise S6 CNA until the investigation could be completed. S3 RN then notified the DON. The Admin and DON arrived on site within 30 minutes to question S5 LPN, S7 CNA and the resident. The resident confirmed that she had been hit on the left side of the head with a closed fist. The resident was assessed for injury and S6 CNA was terminated. Review of S7 CNA's witness statement dated 12/23/12 reflected " on 12/22/12, I S7 CNA, observed S6 CNA go in resident #4's room and S6 CNA placed her left hand on resident #4's upper back and her right hand on the bottom part on resident #4's lower back and then she tried to get resident #4 off the bed but didn't. She turned resident #4 to face her and resident #4 was fussing saying she wanted to lay down. That's when S6 CNA hit resident #4 on the left side of her head with a closed hand fist. Then, S6 CNA turned and pulled the curtain close for about 10 seconds, the pulled the curtain open and went to the door and closed it. I don't know what happened after that because I got up and left." Review of S5 LPN's statement dated 12/23/12 reflected "on 12/22/12 resident #4 was getting into bed. S6 CNA went into resident #4's room and began yelling at her for getting into bed. S6 CNA then raised her right closed hand at resident #4 and with her other hand she pulled the curtain closed. I then seen her closed hand come down in a striking motion through the shadow from the curtain. Resident #4 then yelled stop hitting me. I went into the room to see what was going on. S6 CNA then began fussing at me for letting resident #4 back in bed. I then told resident #4 she could lay down if she wanted to. Resident #4 then began pointing at her head and said right here. I asked what about right here? She said right here, right here is where she hit me. I then went and reported the incident to S3 RN." Review of the resident's nurses' notes reflected there was no documentation by S5 LPN regarding the resident being hit by the CNA. Interview on 1/23/13 at 12:35 p.m. with S3 RN revealed that she was the RN supervisor on 12/22/12 and 12/23/12. She stated that on 12/22/12, S5 LPN reported that S6 CNA seemed to be in a bad mood and was not being friendly to the residents. She stated that the CNA was known to talk in a very loud tone of voice but she did notify S1 Admin of the LPN's report. The Admin spoke with the CNA on the telephone and counseled her about using a softer tone when speaking to the residents. Further interview revealed that the next morning, S7 CNA informed S3 RN that she thought the LPN had reported that S6 CNA had "bopped" the resident on the head the day before. S3 RN immediately called the Admin and assigned S4 RN to supervise S6 CNA until the Admin and DON arrived. Further interview with S3 RN confirmed that S5 LPN did not report that S6 CNA had hit the resident. She also stated that S7 CNA stated that she thought the LPN had witnessed the CNA hitting the resident and would report it, but she may have been looking down when it happened. Interview on 1/23/13 at 12:50 p.m. with S4 RN revealed that she was working as the treatment nurse on 12/22/12 and 12/23/12. She stated that she was not aware of an incident involving the resident until she arrived to work on 12/23/12 at about 8:00 a.m. She stated that when she entered the facility that morning, S3 RN called her into the office with her and S7 CNA. S3 RN called the Admin and reported to her that S7 CNA had informed her that S6 CNA had hit resident #4 the day before. She stated that S6 CNA was working the floor and S3 RN immediately sent her to supervise the CNA 1:1 as she continued to work. She stated it was about 15 minutes before she joined S6 CNA and another CNA as they made their rounds. Interview on 1/23/13 at 1:10 p.m. with S7 CNA revealed that on 12/22/12 she was sitting at the nurses' station desk with S5 LPN about an arms length from her. She stated S6 CNA ran into the resident's room and began to speak loudly to her. She could not understand what the CNA was saying but did hear the resident telling her that she did not tell her what to do. She stated she saw the CNA hit the resident and then heard the resident telling her not to hit her before the CNA closed the door. Further interview revealed that she told S5 LPN that she needed to go into the room and see what was going on, and the LPN immediately went into the room. She stated that she thought the LPN had seen the CNA hit the resident but she was eating and may not have. She also stated that she and the LPN never discussed the incident with each other. She stated that she did not ask the LPN if she saw the CNA hit the resident. Further interview with S7 CNA revealed that after the incident she went straight to S3 RN and told her that S5 LPN had something to report to her but did not give the RN any details. She stated that she did not tell the RN that the CNA had hit the resident because she thought the LPN would report it. She stated the next morning she heard that S6 CNA had received counseling from the Admin about her tone of voice with the residents. She realized that the LPN must not have seen the CNA hit the resident so she went at that time to report it to S3 RN. Observation on 1/23/13 at 1:25 p.m. revealed the nurses' station was clearly visible from the resident's room. Telephone interview on 1/23/13 at 2:05 p.m. with S5 LPN revealed that she was eating lunch on 12/22/12 at the nurses' station when she saw S6 CNA enter the resident's room and begin to yell at her to get out of the bed. She stated the CNA raised one hand up and pulled the curtain closed with the other. The sun was coming through the curtain and she was able to see the shadow of the CNA's hand as it came down towards the shadow of the resident's head. She stated she did not actually see the CNA hit the resident but it appeared through the curtain that she did. She went into the resident's room and the resident told her that the CNA had hit her on the head. She stated that she went immediately to S3 RN and reported to her that the CNA was screaming at the resident and had hit her. Further interview revealed that S6 CNA was called to the office by S3 RN on 12/22/12. She stated that the CNA returned from the office and continued working with the resident. She stated that after the CNA returned from the office, her attitude had not improved. She stated the CNA would make comments to her that she didn't care who she called and that she would do whatever she wanted. S5 LPN stated that she felt like the CNA was flaunting the fact that she had not gotten in trouble. Further interview revealed that she wondered why the CNA was still working with the resident but she decided that it was because she did not actually see the CNA's hand making contact against the resident's head. She stated that another CNA, whose name she couldn't remember, had also seen the resident being hit and she thought that she would be reporting it also. She confirmed that she and S7 CNA did not discuss the resident being hit by S6 CNA. Interview on 1/23/13 at 2:00 p.m. with S1 Admin confirmed that she had been called 12/22/12 by S3 RN to report that S6 CNA was talking too loudly to a resident. She counseled the CNA over the telephone with the RN present. She stated the next morning S3 RN called her to inform her that the CNA had hit the resident the day before. She immediately assigned S4 RN to 1:1 supervision with S6 CNA until she arrived at the facility and conducted an investigation. Upon completion of investigation, the physical abuse was substantiated and the CNA was terminated. Further interview with S1 Admin revealed she had reviewed the statement by S5 LPN and should have questioned it since the LPN documented that she had seen the CNA hit the resident and reported it to S3 RN. She stated that the LPN must have thought she told the RN but she hadn't because she felt sure the RN would've contacted her immediately. She also confirmed that S7 CNA did not tell the RN about the CNA hitting the resident on 12/22/12. She also confirmed that S5 LPN and S7 CNA did not confirm what they had seen with each other, or what would be reported when the incident occurred. Further interview on 1/23/13 at 2:10 p.m. with S3 RN confirmed the LPN did not report the CNA hitting the resident, and the CNA was allowed to continue working until her shift was over. Review of the Punch Detail Report for S6 CNA reflected she worked from 0600 (6:00 a.m.) until 2306 (11:06 p.m.) on 12/22/12 and from 0618 (6:18 a.m.) until 0942 (9:42 a.m.) on 12/23/12. Interview on 1/24/13 at 11:15 a.m. with S1 Admin revealed an inservice had been done that morning to address being specific with reporting resident abuse and protecting residents. She confirmed that the facility's policies were not followed for reporting the abuse and protecting the resident. Further interview on 1/24/13 at 12:00 p.m. with S3 RN revealed that S5 LPN's witness statement did not match what the LPN had reported to her on 12/22/12. She stated she was not made aware of the CNA hitting the resident until the morning of 12/23/12 when S7 CNA asked her if the LPN had reported that the CNA hit the resident. Further interview on 1/24/13 at 12:40 p.m. with S7 CNA confirmed she saw the CNA hit the resident on 12/22/12 at approximately 12:45 p.m. Review of the inservice dated 1/24/13 at 0715 (7:15 a.m.) reflected S1 Admin and S2 DON had conducted an inservice regarding elderly abuse reporting, being specific on what staff witnesses and immediately reporting it, immediately protecting the victim from abuse and communication in reporting abuse. Further review reflected inservices were scheduled at 2:00 p.m. and 3:00 p.m. on the same subjects.

Based on interview and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources to effectively and efficiently attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 1 of 5 sampled residents (#1, #2, #3, #4 and #5). The facility's total census was 100 according to the Resident Census and Conditions of Residents form. The facility failed to: 1. ensure the facility's staff was aware of, and implemented measures in its policies to protect a resident (#4) from physical abuse and 2. ensure the facility's policies were implemented to ensure a resident's (#4) physical abuse was immediately reported to the RN supervisor, DON or Admin, and thoroughly investigated. This resulted in an Immediate Jeopardy situation which began on 12/22/12 at 12:45 p.m. when 2 facility staff witnessed a CNA hitting resident #4 on the head with a closed hand. The Immediate Jeopardy situation ended on 12/23/12 at 8:25 a.m. when the CNA was placed on 1:1 supervision by the RN supervisor. The facility Administrator was informed of the Immediate Jeopardy situation on 1/24/13 at 1:15 p.m. After removal of the Immediate Jeopardy situation, the deficiency remained at a S/S of "D". Findings: Review of the facility's Abuse Identification, Protection and Reporting policy reflected that all personnel must promptly report any incident or suspected incident of resident abuse. The policy also reflected that the person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the charge nurse with the following information: a. the name of the resident(s) involved, b. the date and time that the incident occurred, c. where the incident took place, d. the name(s) of the person(s) committing the incident, if known, e. the name(s) of any witnesses to the incident, f. the type of abuse committed, and g. other information requested by the charge nurse. Further review reflected that upon receiving reports of physical (or sexual) abuse, the charge nurse should immediately examine the resident and the findings recorded in the resident's medical record. Also, the charge nurse must obtain a written, signed and dated statement from the person reporting the incident. Review of the facility's Protection of Residents during Abuse Investigations policy reflected that during abuse investigations, residents would be protected from harm by the following measures: a. employees accused of participating in the alleged abuse should be immediately reassigned to duties that did not involve resident contact or suspended without pay until the findings of the investigation had been reviewed by the Administrator and b. should the employee(s) be reassigned to non-resident care duties, such assignment would not be any part of the building which the resident frequented. Review of the facility's Abuse Protection and Prevention Program policy reflected the abuse prevention program included timely and thorough investigations of all reports and allegations of abuse. Review of the facility's abuse investigations within the last 3 months reflected an investigation into the physical abuse of resident #4 had been done. Review of the abuse investigation of resident #4 reflected documentation of a nurse's note dated 12/23/12 at 10:38 a.m. by S1 Admin which reflected on 12/22/12 at approximately 2:00 p.m. she was called by S3 RN. The RN reported that she had been informed by S5 LPN that S6 CNA was heard raising her voice to a resident. She also reported that S7 CNA had informed her that S5 LPN had something to report to her. Further review reflected S1 Admin counseled S6 CNA over the telephone for speaking in a loud voice. She reminded the CNA that she realized she spoke in loud tones but she needed to be quieter and more calm towards the resident. Further review reflected on 12/23/12 at approximately 8:00 a.m., S3 RN called S1 Admin again to report that upon further investigation, it was determined that S6 CNA had hit the resident on the side of her head with a closed fist on 12/22/12. The RN stated that the report she had received from S7 CNA that morning was that she and S5 LPN were sitting at the nurses' station desk on 12/22/12 and that when S5 LPN had reported that she had heard S6 CNA's loud voice, S7 CNA had actually seen S6 CNA hit the resident. S7 CNA reported that she assumed S5 LPN saw the CNA hit the resident as well and had reported it to S3 RN at that time but the LPN didn't. Further review reflected when notified on 12/23/12 that S6 CNA had actually hit the resident on 12/22/12, the Admin assigned S4 RN to supervise S6 CNA until the investigation could be completed. S3 RN then notified the DON. The Admin and DON arrived on site within 30 minutes to question S5 LPN, S7 CNA and the resident. The resident confirmed that she had been hit on the left side of the head with a closed fist. The resident was assessed for injury and S6 CNA was terminated. Review of S7 CNA's witness statement dated 12/23/12 reflected " on 12/22/12, I S7 CNA, observed S6 CNA go in resident #4's room and S6 CNA placed her left hand on resident #4's upper back and her right hand on the bottom part on resident #4's lower back and then she tried to get resident #4 off the bed but didn't. She turned resident #4 to face her and resident #4 was fussing saying she wanted to lay down. That's when S6 CNA hit resident #4 on the left side of her head with a closed hand fist. Then, S6 CNA turned and pulled the curtain close for about 10 seconds, the pulled the curtain open and went to the door and closed it. I don't know what happened after that because I got up and left." Review of S5 LPN's statement dated 12/23/12 reflected "on 12/22/12 resident #4 was getting into bed. S6 CNA went into resident #4's room and began yelling at her for getting into bed. S6 CNA then raised her right closed hand at resident #4 and with her other hand she pulled the curtain closed. I then seen her closed hand come down in a striking motion through the shadow from the curtain. Resident #4 then yelled stop hitting me. I went into the room to see what was going on. S6 CNA then began fussing at me for letting resident #4 back in bed. I then told resident #4 she could lay down if she wanted to. Resident #4 then began pointing at her head and said right here. I asked what about right here? She said right here, right here is where she hit me. I then went and reported the incident to S3 RN." Review of the resident's nurses' notes reflected there was no documentation by S5 LPN regarding the resident being hit by the CNA. Interview on 1/23/13 at 12:35 p.m. with S3 RN revealed that she was the RN supervisor on 12/22/12 and 12/23/12. She stated that on 12/22/12, S5 LPN reported that S6 CNA seemed to be in a bad mood and was not being friendly to the residents. She stated that the CNA was known to talk in a very loud tone of voice but she did notify S1 Admin of the LPN's report. The Admin spoke with the CNA on the telephone and counseled her about using a softer tone when speaking to the residents. Further interview revealed that the next morning, S7 CNA informed S3 RN that she thought the LPN had reported that S6 CNA had "bopped" the resident on the head the day before. S3 RN immediately called the Admin and assigned S4 RN to supervise S6 CNA until the Admin and DON arrived. Further interview with S3 RN confirmed that S5 LPN did not report that S6 CNA had hit the resident. She also stated that S7 CNA stated that she thought the LPN had witnessed the CNA hitting the resident and would report it, but she may have been looking down when it happened. Interview on 1/23/13 at 12:50 p.m. with S4 RN revealed that she was working as the treatment nurse on 12/22/12 and 12/23/12. She stated that she was not aware of an incident involving the resident until she arrived to work on 12/23/12 at about 8:00 a.m. She stated that when she entered the facility that morning, S3 RN called her into the office with her and S7 CNA. S3 RN called the Admin and reported to her that S7 CNA had informed her that S6 CNA had hit resident #4 the day before. She stated that S6 CNA was working the floor and S3 RN immediately sent her to supervise the CNA 1:1 as she continued to work. She stated it was about 15 minutes before she joined S6 CNA and another CNA as they made their rounds. Interview on 1/23/13 at 1:10 p.m. with S7 CNA revealed that on 12/22/12 she was sitting at the nurses' station desk with S5 LPN about an arms length from her. She stated S6 CNA ran into the resident's room and began to speak loudly to her. She could not understand what the CNA was saying but did hear the resident telling her that she did not tell her what to do. She stated she saw the CNA hit the resident and then heard the resident telling her not to hit her before the CNA closed the door. Further interview revealed that she told S5 LPN that she needed to go into the room and see what was going on, and the LPN immediately went into the room. She stated that she thought the LPN had seen the CNA hit the resident but she was eating and may not have. She also stated that she and the LPN never discussed the incident with each other. She stated that she did not ask the LPN if she saw the CNA hit the resident. Further interview with S7 CNA revealed that after the incident she went straight to S3 RN and told her that S5 LPN had something to report to her but did not give the RN any details. She stated that she did not tell the RN that the CNA had hit the resident because she thought the LPN would report it. She stated the next morning she heard that S6 CNA had received counseling from the Admin about her tone of voice with the residents. She realized that the LPN must not have seen the CNA hit the resident so she went at that time to report it to S3 RN. Observation on 1/23/13 at 1:25 p.m. revealed the nurses' station was clearly visible from the resident's room. Telephone interview on 1/23/13 at 2:05 p.m. with S5 LPN revealed that she was eating lunch on 12/22/12 at the nurses' station when she saw S6 CNA enter the resident's room and begin to yell at her to get out of the bed. She stated the CNA raised one hand up and pulled the curtain closed with the other. The sun was coming through the curtain and she was able to see the shadow of the CNA's hand as it came down towards the shadow of the resident's head. She stated she did not actually see the CNA hit the resident but it appeared through the curtain that she did. She went into the resident's room and the resident told her that the CNA had hit her on the head. She stated that she went immediately to S3 RN and reported to her that the CNA was screaming at the resident and had hit her. Further interview revealed that S6 CNA was called to the office by S3 RN on 12/22/12. She stated that the CNA returned from the office and continued working with the resident. She stated that after the CNA returned from the office, her attitude had not improved. She stated the CNA would make comments to her that she didn't care who she called and that she would do whatever she wanted. S5 LPN stated that she felt like the CNA was flaunting the fact that she had not gotten in trouble. Further interview revealed that she wondered why the CNA was still working with the resident but she decided that it was because she did not actually see the CNA's hand making contact against the resident's head. She stated that another CNA, whose name she couldn't remember, had also seen the resident being hit and she thought that she would be reporting it also. She confirmed that she and S7 CNA did not discuss the resident being hit by S6 CNA. Interview on 1/23/13 at 2:00 p.m. with S1 Admin confirmed that she had been called 12/22/12 by S3 RN to report that S6 CNA was talking too loudly to a resident. She counseled the CNA over the telephone with the RN present. She stated the next morning S3 RN called her to inform her that the CNA had hit the resident the day before. She immediately assigned S4 RN to 1:1 supervision with S6 CNA until she arrived at the facility and conducted an investigation. Upon completion of investigation, the physical abuse was substantiated and the CNA was terminated. Further interview with S1 Admin revealed she had reviewed the statement by S5 LPN and should have questioned it since the LPN documented that she had seen the CNA hit the resident and reported it to S3 RN. She stated that the LPN must have thought she told the RN but she hadn't because she felt sure the RN would've contacted her immediately. She also confirmed that S7 CNA did not tell the RN about the CNA hitting the resident on 12/22/12. She also confirmed that S5 LPN and S7 CNA did not confirm what they had seen with each other, or what would be reported when the incident occurred. Further interview on 1/23/13 at 2:10 p.m. with S3 RN confirmed the LPN did not report the CNA hitting the resident, and the CNA was allowed to continue working until her shift was over. Review of the Punch Detail Report for S6 CNA reflected she worked from 0600 (6:00 a.m.) until 2306 (11:06 p.m.) on 12/22/12 and from 0618 (6:18 a.m.) until 0942 (9:42 a.m.) on 12/23/12. Interview on 1/24/13 at 11:15 a.m. with S1 Admin revealed an inservice had been done that morning to address being specific with reporting resident abuse and protecting residents. She confirmed that the facility's policies were not followed for reporting the abuse and protecting the resident. Further interview on 1/24/13 at 12:00 p.m. with S3 RN revealed that S5 LPN's witness statement did not match what the LPN had reported to her on 12/22/12. She stated she was not made aware of the CNA hitting the resident until the morning of 12/23/12 when S7 CNA asked her if the LPN had reported that the CNA hit the resident. Further interview on 1/24/13 at 12:40 p.m. with S7 CNA confirmed she saw the CNA hit the resident on 12/22/12 at approximately 12:45 p.m. Review of the inservice dated 1/24/13 at 0715 (7:15 a.m.) reflected S1 Admin and S2 DON had conducted an inservice regarding elderly abuse reporting, being specific on what staff witnesses and immediately reporting it, immediately protecting the victim from abuse and communication in reporting abuse. Further review reflected inservices were scheduled at 2:00 p.m. and 3:00 p.m. on the same subjects. Findings:

Based on interview and record review the facility failed to ensure services were provided in accordance with a resident's written plan of care for 1 of 35 stage 2 sampled residents (#131) by failing to : 1. follow admit physician's orders [REDACTED]. 2. follow the resident's written plan of care to offer a replacement if the resident consumed less than 75% of the meal. 3. failed to follow the facility's policy to offer and encourage a supplement if the resident ate less than 50% of their meal. Resident #131 weighed 115.3 lbs. upon admission to the facility on [DATE]. Review of the admission physician orders [REDACTED]. No nutritional supplements were given three time a day between meals for the month of June 2011. No supplements were offered for the 29 meals in which the resident ate 75% or less during the month of June 2011. No documentation that any supplements were offered between 6/1/11 and 7/1/11. The next weight for resident # 131 was obtained 1 month later. Documentation reflected the resident weighed 94.1 lbs. on 7/1/11. These failed practices resulted in actual harm when the resident experienced a 17.2% weight loss (21.2 lbs.) from June 1, 2011 - July 1, 2011. After the 7/1/11 weight was obtained, the resident was placed on a nutritional supplement TID between meals, [MEDICATION NAME] daily was started on 6/30/11, and her weights were to be monitored weekly. The resident's weight documentation was as follows: 7/4/11 - 94.1 lbs; no weight documented for the week of 7/11/11; 96.3 lbs on 7/18/11; 99.8 lbs on 7/25/11; 98.4 lbs on 8/1/11; 99.8 lbs on 8/8/11; 100.1 lbs on 8/15/11; no weight documented on 8/22/11 or 8/29/11. Findings: Review of resident #131's record reflected an admit weight of 115.3 lbs. on 6/1/11. Admission [DIAGNOSES REDACTED]. The resident was weighed on July 1, 2011 (one month later) and was noted to weigh 94.1 lbs. This was a total weight loss of 21.2 lbs (17.2%). Review of the admit physician's orders [REDACTED]. evidenced the supplement was given as ordered. Interview with S3 LPN on 9/1/11 at 1:11 p.m. confirmed the 6/1/11 order for a Supplement TID between meals had not been given as ordered. Interview with S2 DON on 9/1/11 at 1:22 p.m. confirmed the 6/1/11 order for a Supplement TID between meals that was never given was an oversite, and should have been caught by the pharmacist. Review of the Comprehensive Care Plan with an onset date of 6/8/11 reflected the facility identified the resident's actual altered nutrition problem. The Care Plan reflected the resident's problem of nutrition altered: less than body requirements related to inability to eat regular textured foods. Care plan approaches included to monitor the % of meals eaten and offer replacement if the resident consumed 75% or less and to provide between meal feedings as necessary. Review of facility policy reflected if a resident ate less than 50% of their meal, a supplement would be offered and encouraged. Review of the CNA flowsheets for the month of June, 2011 reflected the resident consumed 75% or less for 13 meals, 50% or less for 11 meals, and 25% or less for 5 meals. This was a total of 29 out of 90 meals offered during the month of June, 2011 in which the resident ate 75% or less. In addition, there was no documentation of meal consumption for 4 meals on 6/2/11 and 6/17/11. There was no documentation which reflected replacement meals or between meal feedings were offered. Interview with S2 DON on 9/2/11 at 9:30 A.M. confirmed there was no documentation which reflected when the resident ate 75% or less, they offered another food choice, gave the resident another food choice, or ensured between meal feedings were offered. She stated the facility did not document offering another food choice on any resident. She stated the nurses were responsible for monitoring how much the resident's ate and whether a supplement was offered and/or consumed.

Based on interview and record review the facility failed to ensure a resident maintained acceptable parameters of nutritional status such as body weight for 1 of 3 sampled residents identified for weight loss since admission (#131) out of a total of 35 Stage 2 residents. The facility's total census was 102 according to the Resident Census and Conditions of Resident Form. The facility failed to: 1. follow physician's orders [REDACTED]. 2. notify the MD of the RD's recommendations for nutritional supplements, Prostat for decreased [MEDICATION NAME], to monitor the resident's labs, weight, and oral intake 3. follow the resident's written plan of care to offer a replacement if the resident consumed less than 75% of the meal. 4. follow the facility's policy for offering and encouraging supplements to residents who ate less than 50% of meal. Review of documentation reflected the resident weighed 115.3 lbs. upon admission to the facility on [DATE]. Review of the admission physician orders [REDACTED]. The next documented weight for the resident was 1 month later. Documentation reflected the resident weighed 94.1 lbs. on 7/1/11. The resident experienced a 21.2 lbs. weight loss (17.2% weight loss) from June 1, 2011 - July 1, 2011. Further record review reflected laboratory testing was completed on 6/2/11. The laboratory findings revealed the following low test results: [MEDICATION NAME] 2.1 (normal 3.5-5.2 g/dL), [MEDICATION NAME] 2.8 (normal 3.0-3.2 g/dL), Calcium 8.2 (normal 8.6 - 10.2 mg/dL) and Total Protein 4.91 (normal 6.60-8.70 g/dL). These failed practices resulted in actual harm when the resident lost 21.2 lbs, a 17.2% weight loss from June 1 - July 1, 2011. Findings: Review of resident #131's record reflected an admit weight of 115.3 lbs. on 6/1/11. Admission [DIAGNOSES REDACTED]. The resident was weighed on July 1, 2011 (one month later) and was noted to weigh 94.1 lbs. This was a total weight loss of 21.2 lbs (17.2%). Review of the admit physician's orders [REDACTED]. evidenced the supplement was given as ordered. Interview with S3 LPN on 9/1/11 at 1:11 P.M. confirmed the 6/1/11 order for a Supplement TID between meals had not been given as ordered. Interview with S2 DON on 9/1/11 at 1:22 p.m. confirmed the 6/1/11 order for a Supplement TID between meals that was never given was an oversite, and should have been caught by the pharmacist. Review of the Comprehensive Care Plan with an onset date of 6/8/11 reflected the facility identified the resident's actual altered nutrition problem. The Care Plan reflected the resident's problem of nutrition altered: less than body requirements related to inability to eat regular textured foods. Care plan approaches included to monitor the % of meals eaten and offer replacement if the resident consumed 75% or less and to provide between meal feedings as necessary. Review of facility policy reflected if a resident ate less than 50% of their meal, a supplement would be offered and encouraged. Review of the CNA flowsheets for the month of June, 2011 reflected the resident consumed 75% or less for 13 meals, 50% or less for 11 meals, and 25% or less for 5 meals. This was a total of 29 out of 90 meals offered during the month of June, 2011 in which the resident ate 75% or less. In addition, there was no documentation of meal consumption for 4 meals on 6/2/11 and 6/17/11. There was no documentation which reflected replacement meals or between meal feedings were offered. Interview with S2 DON on 9/2/11 at 9:30 A.M. confirmed there was no documentation which reflected when the resident ate 75% or less, they offered another food choice, gave the resident another food choice, or ensured between meal feedings were offered. She stated the facility did not document offering another food choice on any resident. She stated the nurses were responsible for monitoring how much the resident's ate and whether a supplement was offered and/or consumed. Further record review reflected laboratory testing was completed on 6/2/11. The laboratory findings revealed the following low test results: [MEDICATION NAME] 2.1 (normal 3.5-5.2 g/dL), [MEDICATION NAME] 2.8 (normal 3.0-3.2 g/dL), Calcium 8.2 (normal 8.6 - 10.2 mg/dL) and Total Protein 4.91 (normal 6.60-8.70 g/dL). Review of the 6/2/11 laboratory results revealed it contained a stamp which indicated the laboratory results were "faxed" on 6/2/11. The results did not indicate who the results were faxed to or whether or not the intended receiver actually received and/or reviewed the results. Review of Dietary Progress Notes dated 6/10/11 reflected the S4 RD saw the resident and made recommendations. The RD's recommendations included health shakes on meal trays, yogurt on the lunch and dinner trays, to consider Prostat for the low [MEDICATION NAME] and protein levels and to monitor the resident's laboratory results, weight, and oral intake. Review of the Physician order [REDACTED]. Further review of the Dietary Progress Notes on 6/23/11 the RD had documented the resident's sacral wound was healing and her appetite was good. There was no documentation concerning the RD's 6/10/11 recommendations. Review of a progress note dated 6/29/11 by the FNP reflected the resident was frail, thin, had swallowing problems, some weight loss, and a cachectic abdomen. Interview with S4 RD on 9/2/11 at 10:48 A.M. revealed she usually noticed if physician orders [REDACTED]. S4 RD confirmed it was not until July, 2011 that the resident started receiving a Supplement TID. Further interview with the S4 RD confirmed she communicated her recommendation(s) to the facility by folding over her documented notes containing the recommendation(s) and by telling the nurse her recommendation(s). Interview with S1 Administrator on 9/2/11 at 10:50 A.M. revealed the RD's process for making recommendation(s) and notifying the facility of her recommendation(s) was to fold (flag) her dietary note which alerted the nurse to call the physician and to get an order for [REDACTED]. S1 Administrator revealed that if the RD recommendations had been followed by the facility the resident would have been placed on the weight watchers list and weekly weights would have been done and the resident would have been discussed during the weekly staffing meetings. Further interview with S4 RD on 9/2/11 at 12:01 P.M. revealed she did not provide the facility with a list of high risk residents and the facility did not provide her with a list of high risk residents. Interview with S2 DON on 9/2/11 at 2:30 P.M. confirmed the resident was not discussed in the weekly staffing meetings for the month of June 2011. After the 7/1/11 weight was obtained, the resident was placed on a nutritional supplement TID between meals on 7/1/11, [MEDICATION NAME] daily was started on 6/30/11, and her weights were to be monitored weekly. The resident's weight documentation were as follows: 7/4/11 - 94.1 lbs; no weight documented for the week of 7/11/11; 96.3 lbs on 7/18/11; 99.8 lbs on 7/25/11; 98.4 lbs on 8/1/11; 99.8 lbs on 8/8/11; 100.1 lbs on 8/15/11; no weight documented on 8/22/11 or 8/29/11.

Based on interview and record review the facility failed to ensure a resident's physician was notified of the RD's recommendations for 1 of 3 sampled residents identified for weight loss since admission (#131) out of a total of 35 Stage 2 residents. The facility's total census was 102 according to the Resident Census and Conditions of Resident Form. The facility failed to: 1. notify the MD of the RD's recommendations for nutritional supplements, Prostat for decreased [MEDICATION NAME], to monitor the resident's labs, weight, and oral intake 2. Notify the MD of the resident's poor oral intake 3. Notify the MD of the admission laboratory testing results Review of documentation reflected the resident was admitted to the facility on [DATE] weighing 115.3 lbs. The next documented weight was on 7/1/11 when the resident was noted to weigh 94.1 lbs. This was a weight loss of 21.2 lbs or 17.2% in 1 months time. Further record review reflected laboratory testing was completed on 6/2/11. The laboratory findings revealed the following low test results: [MEDICATION NAME] 2.1 (normal 3.5-5.2 g/dL), [MEDICATION NAME] 2.8 (normal 3.0-3.2 g/dL), Calcium 8.2 (normal 8.6 - 10.2 mg/dL) and Total Protein 4.91 (normal 6.60-8.70 g/dL). These failed practices resulted in actual harm when Resident #131 experienced a 17.2% weight loss from June 1 - July 1, 2011. Findings: Review of resident #131's record reflected the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Further review reflected an admit weight of 115.3 lbs. on admission. The resident was weighed on July 1, 2011 (one month later) and was noted to weigh 94.1 lbs. This was a weight loss of 21.2 lbs or 17.2% in 1 months time. Further record review reflected laboratory testing was completed on 6/2/11. The laboratory findings revealed the following low test results: [MEDICATION NAME] 2.1 (normal 3.5-5.2 g/dL), [MEDICATION NAME] 2.8 (normal 3.0-3.2 g/dL), Calcium 8.2 (normal 8.6 - 10.2 mg/dL) and Total Protein 4.91 (normal 6.60-8.70 g/dL). Review of the 6/2/11 laboratory results revealed it contained a stamp which indicated the laboratory results were "faxed" on 6/2/11. The results did not indicate who the results were faxed to or whether or not the intended receiver actually received and/or reviewed the results. Review of Dietary Progress Notes dated 6/10/11 reflected the S4 RD saw the resident and made recommendations. The RD's recommendations included health shakes on meal trays, yogurt on the lunch and dinner trays, to consider Prostat for the low [MEDICATION NAME] and to monitor the resident's laboratory results, weight, and oral intake. Review of the Physician order [REDACTED]. Review of the Dietary Progress Notes on 6/23/11 the RD had documented the resident's sacral wound was healing and her appetite was good. There was no documentation concerning the RD's 6/10/11 recommendations. Further review of documentation in the resident's record revealed there was no additional laboratory testing ordered after the 6/2/11 laboratory results were received. Interview with S4 RD on 9/2/11 at 10:48 A.M. revealed she usually noticed if physician orders [REDACTED]. S4 RD confirmed it was not until July, 2011 that the resident started receiving a Supplement TID. Further interview with the S4 RD confirmed she communicated her recommendation(s) to the facility by folding over her documented notes containing the recommendation(s) and by telling the nurse her recommendation(s). S4 RD confirmed that if the Dietary Note had not been folded (flagged) then it must have been an oversite. Interview with S1 Administrator on 9/2/11 at 10:50 A.M. revealed the RD's process for making recommendation(s) and notifying the facility of her recommendation(s) was to fold (flag) her dietary note which alerted the nurse to call the physician and to get an order for [REDACTED]. S1 Administrator revealed that if the RD recommendation(s) had been followed by the facility the resident would have been placed on the weight watchers list and weekly weights would have been done and the resident would have been discussed during the weekly staffing meetings. Further interview with S4 RD on 9/2/11 at 12:01 P.M. revealed she did not provide the facility with a list of high risk residents and the facility did not provide her with a list of high risk residents. Interview with S2 DON on 9/2/11 at 2:30 P.M. confirmed the resident was not discussed in the weekly staffing meetings for the month of June 2011.